Cognitive Behavioral Therapy: An In-Depth View

Authored by Bradley R. Brenner, Ph.D., Jeremey Steglitz, Ph.D., & Jaclyn Lopez Witmer, Psy.D.

A person diagnosed with depression, severe mental illness, anxiety disorder, drug or alcohol dependence, or a number of other mental health issues could undergo treatment for many years and, in fact, could undergo treatment for a long time with very little success. Finding an effective therapy treatment is a highly personal experience that is usually different for everyone. But one type of treatment that has garnered some pretty amazing results is Cognitive Behavioral Therapy (CBT). CBT has been studied as focused, effective psychotherapy that has proven helpful in managing many symptoms of mental illness, especially depression and anxiety.

What Is CBT?

CBT can be described as a collaborative, “time-limited, structured approach used to treat a variety of mental health disorders. It aims to alleviate distress by helping patients to develop more adaptive cognitions (or thoughts) and behaviors.” CBT, unlike other forms of psychotherapy, readily lends itself to scientific study, making it the “most widely researched and empirically supported psychotherapeutic methods.”

CBT can be both short-term treatment for symptom-reduction (CBT for insomnia, as an example, is typically a 6-12 week treatment), or it can be longer-term to address underlying beliefs and schema that can often maintain someone’s distress or unfulfilling relationships. CBT is meant to focus on specific goals and take an active approach to address them. The overall goal is to change patterns of thinking and behaving that may contribute to the problems or difficulties that lead someone to seek therapy. Using these types of treatment approaches is meant to indirectly change the way a person feels since our thoughts and behaviors directly impact our emotions.

The History of Cognitive Behavioral Therapy

Cognitive-behavioral therapy was developed by Aaron Beck in the 1960s. He was, at that time, a University of Pennsylvania psychiatrist who studied and practiced psychoanalysis. Psychoanalysis was the most widely used type of mental health treatment then and was viewed as the international gold standard to help people via talk therapy. Dr. Beck attempted to scientifically validate some of the concepts of psychoanalytic methods for treating depression.

But he was surprised when his experiments failed. He found that his patients seemed to have an internal dialogue, not brought forth for discussion by traditional psychoanalytic techniques. Instead, they kept it to themselves. Given that, he was unable to address their thoughts and beliefs in a therapy session in a manner he believed would be helpful.

Spurred by his curiosity and his desire to find novel methods to help his patients, he began work on developing a new course of treatment, helping patients to speak more directly about their inner thoughts. His aim was to change underlying emotions and beliefs about themselves and the way they believe the world works. He found that when they were able to do this, the results were more favorable and long-lasting. He first labeled his new therapy method “cognitive therapy,” which later became known as “cognitive behavior therapy,” or its shorthand CBT. Since then, the method has been widely studied and practiced with people dealing with a variety of mental health issues and is one of the most effective treatments available today.

How Does CBT Work?

Dr. Beck realized the importance of the link between thoughts and emotions. He discovered that everyone has an internal dialogue or automatic thought processes that fill in the gaps with emotion-filled phrases and ideas that they might not even be aware of. Most of the time, the automatic thoughts of people suffering from depression, Seasonal Affective Disorder (SAD), or other mental health problems are negative, which is what CBT was created to address. It has been found that a person can learn to identify and voice these thoughts when given the right tools. For example, a patient might start thinking to him or herself, “I wonder if my brother is annoyed with me. He hasn’t been talking much lately. I wonder if he is mad at me for being late to the game on Friday.” These internal thoughts are filled with emotions that might trigger anxiety, sadness, anger, or other distressing feelings. CBT invites a patient to nonjudgmentally investigate these thoughts and explore their accuracy based on what he or she can observe.

In this way, a patient and therapist work together. As a team, they identify and help the patient internalize new interpretations of familiar situations, thereby helping patients become less stuck and more cognitively flexible.

When a patient decides to start therapy, they will be introduced to the CBT process, which usually begins with an initial assessment to find out if it is the appropriate treatment for a given person and their current struggles. Then, the focus shifts to identifying particularly problematic struggles and patterns in a patient’s life. The therapist may even ask the patient to keep a journal and do some self-reflection as early as the first session. The patient will then be led toward behavioral changes and thought modification.

The therapist and patient will work together to explore the accuracy of the patient’s thought processes about herself, other people, and the world around her. Negative thoughts are not necessarily replaced with more positive thoughts, though they can be. The key to CBT is compassionately examining the accuracy of the patient’s thinking and incorporating alternative, more realistic internal talk.  

Another focus of CBT is the patient’s behaviors and coping strategies. Together, the patient and therapist will explore how the patient responds behaviorally to certain situations or thoughts, the benefits and drawbacks of those behavioral reactions, and how the patient can learn and incorporate new, healthier behaviors and coping skills that will lessen psychological distress in the long-term.

As therapy progresses, time will be spent discussing how the patient can put new ways of thinking and reacting into practice, understanding and resolving any obstacles to implementing the new tools, and addressing any emerging issues the patient has noticed. CBT is a highly collaborative process and, like all other types of psychotherapies, depends largely on the quality of the therapeutic relationship, which is ideally built on trust, honesty, and compassion.

Where Is CBT Conducted?

CBT can be conducted in any place where other types of therapy are conducted, usually in a therapist’s office or hospital setting. When addressing highly specific fears, like the fear of leaving one’s home (agoraphobia), for example, initial sessions will likely take place in their homes.

Length of CBT Treatment

Treatment time is not the same for every patient. It largely depends on their circumstances and particular mental health struggles. However, most CBT therapy lasts anywhere from five to 20 sessions, often conducted on a weekly basis. Individual therapy sessions typically last 45 minutes to an hour. However, when a therapist is conducting exposure therapy, which is a specific type of behavioral therapy within CBT developed to address different forms of anxiety and trauma, including Obsessive Compulsive Disorder and PTSD, the sessions might last longer. This is to allow a patient’s anxiety levels to decrease after being exposed to things and situations that cause them extreme anxiety. An example of this would be a patient who, when he or she walks into a restaurant, experiences social anxiety and cannot engage with other people.

The initial sessions of CBT are spent evaluating whether or not it’s the appropriate treatment for the patient and his/her/their specific situation. Skilled therapists often recommend a mix of Cognitive Behavioral Therapy with other forms of therapy such as psychodynamic, interpersonal, or other effective approaches that help patients in other ways. Highly effective therapists recognize that everyone’s life and situation are different and adapt therapy to best suit their current needs.

These factors make a specific timeframe for treatment difficult to state with any level of certainty. Each person and situation is unique, and the length of therapy is something that should be an ongoing discussion with your therapist.

The Popularity of CBT

What makes CBT so popular is that, quite simply, it works. It is a focused treatment option that is relatively simple to follow, easy to test, and well-researched. There are now more than 325 clinical trials of CBT addressing its effectiveness with various disorders and different populations. The therapy has scientific proof of its ability to create significant, life-altering changes in less time than other treatments, and it seems to work in any age group.

It has even been found to be more effective than medication in treating adults with mild to moderate depression and surprisingly effective for patients with schizophrenia.

Because of its effectiveness and status among the medical profession, CBT has become a primary treatment option listed in guidelines for many types of psychiatric conditions. It also falls neatly within the medical way of viewing mental health conditions. Because of that, CBT is widely taught in medical schools and, therefore, most physicians and other health professionals are familiar with it, increasing its popularity even more.

Criticism of CBT

There are some who raise legitimate criticisms for the approach as “too mechanistic.” From their perspective, CBT fails to address the patient and their experiences as a whole and is too narrowly focused on symptoms. They also point out that early iterations of Cognitive Behavioral Therapy “lacked a strong link to cognitive psychology and neuroscience.” Vigorous research has continued since it was first developed and it has become one of the most studied and scientifically validated forms of talk therapy. So, while CBT was first developed based mainly on clinical observations from within a therapist’s office during its early years, its theories have been modified and improved over many decades.

These modifications have led to something considered a “third wave” of CBT. Many researchers and healthcare practitioners have found the need to extend its utility to other specific mental health concerns or to incorporate new discoveries in cognitive science or other forms of therapy to improve its viability. This has brought about new approaches to the therapy that addresses the patient more wholly.

Why are Negative Thoughts So Relevant To a Person’s Mental Health?

Most people recognize that negative thoughts are important to minimize, but few fully realize their powerful role in creating significant problems in life. CBT is based on the theory that “it’s not events themselves that upset us, but the meanings we give them.” In other words, negative thoughts can cloud actual events in a way that makes them seem worse than they actually were or are. They can mold our ideas into thought or behavioral patterns that create negative outcomes or at least into the perception of negative outcomes, thereby reinforcing the belief that the negative thoughts were true, to begin with.

In Beck’s theory of the negative thought process, he suggested that most of these thought processes are established during their childhood and adolescent years. In adulthood, this makes them largely automatic ways of thinking, which makes them particularly powerful since they come to be accepted as the truth. For example, if a child mostly receives affection when doing well in a basketball game, they might develop a thought pattern that makes them believe they must always excel in everything they do for anyone to love them. This can be detrimental when things happen that are out of their control or when they do not succeed. When they fail, for example, these old negative thoughts lead them to believe they are defective and unloveable.

How CBT combats negative thoughts

At its core, CBT aims to change negative thoughts and patterns by helping a person to recognize that the patterns are happening in the first place. In other words, people learn about the process of emotion regulation  When used by a skilled and warm therapist, CBT will help someone nonjudgmentally assess their thoughts.

Following that, a patient comes to the realization that these beliefs are skewed and over-exaggerated and, ultimately, harmful to their well-being. For instance, it might help a person with depression look more closely at the thought processes underlying how they perceive past experiences and find a link between that and how they react to anything similar in the present. The desired outcome is that they will then be able to develop a more realistic perspective and examine their reactions and automatic thought processes more closely in any number of situations.

What Is The Difference Between CBT and DBT?

DBT, or dialectical behavior therapy, is a method often confused with CBT, so it’s important to know the difference. DBT is a very specific form of Cognitive Behavioral Therapy that builds on the foundations of CBT and integrates other psychotherapy methods and schools of thought. It utilizes both individual and group therapy to help patients learn to use the strategies they have learned in therapy. It was developed to regulate emotions and behavior, increase mindfulness, tolerate distressing events, and improve relationships.

It was initially created to address the urgent needs of suicidal patients who were diagnosed with BPD (borderline personality disorder). It has since been found helpful in treating other mental health concerns such as PTSD (post-traumatic stress disorder), eating disorders, substance use disorders, and depression. This therapy, which draws from Zen Buddhism and classical behavioral therapy, operates by coaching patients to integrate healthier behaviors into their everyday lives while increasing their self-acceptance.

How Is CBT Different From Other Types of Psychotherapy?

Psychotherapy is an umbrella term for many types of talk therapy, and CBT is one type. What differentiates CBT from other forms of therapy is its emphasis on bringing into focus and examining automatic (usually negative) thought patterns. The approach is typified by a nonjudgmental, scientific-like examination of thought patterns and assessing their validity and impact.

Usually, CBT focuses on the present with less focus on the past. Other forms of psychotherapy, such as psychodynamic psychotherapy, tend to examine past experiences and their meaning for current struggles. And depending on the patient’s preferences and current struggles, CBT, unlike other forms of therapy, tends to be more directly guided by the therapist with certain predetermined goals in mind.

As a whole, psychotherapy (again, CBT is one type of psychotherapy) is effective and helps people to reduce their symptoms and to increase a sense of well-being. The most important element that determines the effectiveness of all types of psychotherapy is that the therapist and patient develop a positive and warm working relationship. In the research literature on the effectiveness of psychotherapy, this is often referred to as the therapeutic alliance.  The shorthand way to think of this concept s  “do I fit well with my therapist?”

CBT and Anxiety: A Look at Children, Adolescents, and Older Adults

Anxiety can be effectively treated with CBT. A specific type of CBT, called exposure therapy, involves gradually exposing a patient to a situation that causes them anxiety. The exposure is gradual, limited, and repeated. The purpose is to not only desensitize a patient to stressful stimuli by which their stress levels begin to decrease, but also to introduce something called inhibitory learning, where the patient’s brain begins to learn that the initially threatening stimuli are relatively safe.

In children and adolescents, studies have indicated that about 60 percent greatly reduce their anxiety levels after going through exposure therapy. These effects were shown to last in the long-term with young patients experiencing improved levels of anxiety many years after treatment.

Anxiety is also an often-ignored, but significant problem in older adults. With some minor adjustments, CBT for older adults has been found to be very helpful in the treatment of anxiety.

CBT, Depression, and PTSD: A Look at Military Personnel

Patients with severe depression can benefit from CBT. Though the therapy has been used effectively on a number of mental health conditions, depression is perhaps the most studied. CBT is used to help patients develop more realistic thoughts about themselves, making it beneficial for patients suffering from depression. One such study focused on treating Veterans of the US Military.

Major Depressive Disorder, or MDD, is one of the most highly diagnosed mental disorders among military personnel and Veterans. Because CBT has been such a successful treatment for civilians, the Department of Veterans Affairs highly recommends it for its members. The VA developed guidelines for some common differences Veterans and civilians might face and what those differences might mean when using CBT with active military personnel and Veterans.

Interestingly, while CBT did prove effective, it was shown to be a little less effective on military personnel. One theory for this is that because so many Veterans also suffer from PTSD (Post Traumatic Stress Disorder), they may have developed certain avoidance or numbing techniques that interfere with CBT’s overall effectiveness. Other factors that differ between military personnel and the civilian population are gender and age. Of Veterans diagnosed with a severe mental illness or trauma, approximately 90 percent are men and the average age is 57. This differs from the civilian population, in which women and younger individuals are diagnosed more frequently with mental health problems.

The conclusion of the study was that PTSD is a more complex mental illness to treat; therefore, it requires much more research to be conclusive. In fact, CBT has been modified to specifically address PTSD and other traumas, and these newer CBT-based therapies, including Cognitive Processing Therapy and Prolonged Exposure Therapy, have been shown to be effective at reducing PTSD symptoms and improving the overall quality of life among diverse groups of military Veterans.

CBT Misconceptions

Over time, misconceptions about CBT have developed. Among those misconceptions, two concerns stand out and have been addressed by research.

1. Concerns about CBT’s sustainability for severe depression

Several clinical trials have been conducted that prove CBT to be an effective treatment for all forms of depression, from mild to severe. It has been shown to be just as effective as medication. For severe depression, a combination of CBT and medication tends to be the most effective treatment option. For mild to moderate depression, CBT alone holds significant promise.

2. Concerns about whether or not CBT adds any benefit above what can be accomplished with just medication.

Medication is sometimes used at the beginning stages of treatment and it has been shown to magnify the effectiveness of CBT. Generally, medication is used in small dosages and it is not used long-term or with every patient. Studies do indicate, however, that combined medication and CBT therapy work better than medication alone, especially when symptoms are more severe.

Key Elements of CBT

The main intention of CBT is to give patients the cognitive and behavioral tools to become their own therapists. By helping them understand how to recognize their own thoughts and behavior patterns that are keeping them stuck, therapists are teaching patients to self-identify unhelpful patterns. Patients are then taught to test their perceptions and expectations to come up with the most helpful course of action for themselves.

The treatment can be short-term (though not always) and is intended to build a patient’s self-esteem and problem-solving capacities but it’s not meant to leave them flailing alone in their struggles. The idea is that they will learn the necessary skills to compassionately analyze their own thoughts, feelings, and behaviors, and to seek further help from a mental health professional when needed.

CBT Techniques

CBT has its own set of techniques. One such technique is “guided discovery,” which was developed by Christine Padesky in 1993. This method involves a therapist attempting to see things from the patient’s point of view and help the patient “expand their thinking to become aware of their underlying assumptions, and discover alternative perspectives and solutions for themselves.”

This technique can involve a line of questioning designed to help patients reach their own conclusions without giving them direct answers. These questions will highlight a patient’s perspectives and allow them to see things outside themselves, which lends itself to another CBT technique called restructuring.

Cognitive restructuring involves helping the patient evaluate the observable evidence for and against a certain thought or belief that is driving someone’s distress. For example, a patient’s long-standing belief that he is a failure would be gently examined by both therapist and patient by exploring the evidence for and against that belief, gently chipping away at the patient’s inaccurate conviction that he is a failure.

Another technique of CBT is behavioral activation, which involves planning and committing to meaningful activities, such as exercise or eating dinner with a friend, counteracting the natural withdrawal, isolation, and avoidance that comes with depression and anxiety. Behavioral activation is based on the idea that values-based behavior can lead to mood improvement; even engaging in “half-smiles” has been shown to slightly lift depression.

CBT is also based on practice or repetition, what some CBT therapists call “homework.” Since CBT is a skills-based therapy and gradually encourages patients to become their own guide, patients tend to see the greatest improvements when they apply what they learned or discovered in session to their lives between sessions. This is also important because a CBT treatment plan is not a one-size-fits-all approach; some skills will be more helpful for some patients versus others, so it becomes even more important for patients to practice skills between sessions to figure if it might be helpful for them.

CBT: Concluding Thoughts

Cognitive Behavioral Therapy is one of the most recognized major forms of psychotherapy with decades of clinical and research support. It is a highly accepted mainstream first treatment option for many mental health challenges. It is effective, and in the hands of a skilled, warm, and authentic therapist in NYC, it can significantly decrease symptoms and help to increase well-being and to develop stronger, more resilient mental health, giving the patient a much better quality of life.

If you’re interested in Cognitive Behavioral Therapy in NYC we welcome you to get personalized access to one of our expert, warm therapists in NYC.