Cognitive behavioral therapy is a psychological treatment that can turn intrusive thoughts into constructive thoughts, loosening the unhealthy grip of negative thinking on your mind. Proven by evidence-based research, it has helped many people bounce back from depression, anxiety, phobias, addiction, anger, and other mental health issues.
The most significant benefit of cognitive behavioral therapy is the skills to manage stressful situations and build healthy mental habits.
Let’s find out how cognitive behavioral therapy can help you achieve this.
What is Cognitive Behavioral Therapy (CBT)?
Cognitive behavioral therapy posits that thoughts, feelings, and behaviors are interconnected. Changing one is likely to change the others. The therapist works with patients to identify and change negative thought patterns.
The process helps you address unproductive behaviors that result from a distorted perception of reality. By doing so, the patient’s emotional well-being is believed to improve. This therapy is evidence-based: research has proved that it is effective for a wide range of psychological disorders and many different patients.
Benefits of Cognitive Behavioral Therapy
Develop Healthier Thought Patterns
Cognitive behavioral therapy works mainly with your thought patterns that influence your behaviors and responses to stressful situations.
Let’s look at the CBT model below.
The CBT model (Source: Wikipedia)
The core beliefs about yourself, other people, and the future are in the middle of the triangle. Your core beliefs form the foundation of how your thoughts, feelings, and behaviors are connected.
Core beliefs are only sometimes evident; figuring them out is part of CBT. What is more noticeable are the triggers – such as an unfortunate event – and your reactions to that event. They are the tip of the iceberg, and your core beliefs form the bottom of the iceberg.
For example, the trigger could be losing your job, and you respond by not getting out of bed. To figure out the core belief underneath, the cognitive behavioral therapist would ask you laddering questions (see below for Step 3: examine negative thoughts).
These questions encourage you to peel back the layers of meanings to get to the core belief, which, for instance, could be that you believe you are a failure.
Then, the cognitive behavioral therapist works with you to examine your core beliefs and how truthfully they reflect your reality. Together, you work to identify how your core beliefs, whether justified or not, shape your thoughts, behaviors, and feelings. If the core beliefs strayed far from your reality, the therapist would help you to remedy them. You can see truth for what it is: neither too negative nor too positive.
Ultimately, the therapy lets you let go of misperceptions, instilling a balanced perspective that life is neither hell nor heaven but somewhere in between, and you can learn skills to improve it.
Effective Short-Term Treatment
CBT is an effective short-term treatment for relatively mild issues in which the patients still have control over their cognitive functions – they need to learn techniques or skills to manage their problems better.
For example, Abe suffers from depression and finds being alone in the evening difficult. In his second CBT session, he tells the therapist that he wants to visit his grown children who live in town but does not want to impose on them. The therapist asks Abe about his visits to the children before his depression. He recalls that he just came over without even calling them, and they have always been happy to see him.
The therapist then encourages Abe to call one of his children, of which he chooses the son, once a week, to prove to himself that they are happy to see him. She asks him to visualize the call: how his son would likely invite him over for dinner. Abe agrees to put calling his son on his Action Plan. His Action Plan lists specific things he is committed to doing that week, such as washing the kitchen sink for 10 minutes to improve his condition gradually.
By his 10th session, Abe is discussing his temp work in construction and filling out a job application for customer service roles. He has shown much improvement in just a few months with CBT.
Structured and practical exercises to improve skills
CBT involves learning practical skills to manage your daily tasks and relationships. You work with the therapist to set specific weekly goals, such as walking for 20 minutes when you experience the most intrusive thoughts. The skill to be honed may be the ability to stem negative thoughts from flooding your brain.
In the session, you will report your progress and reflect on the exercises. Depending on how you do it, the therapist can work with you to identify practical solutions to help you improve.
More Affordable and Accessible
Thanks to the rich research and readily quantifiable nature of CBT, it has become very popular and is covered by many insurance. It is also recommended for therapy skeptics or people with self-stigma about therapies. It is because CBT is more about learning practical skills rather than digging deep into the scary places of your psyche. Therefore, CBT can be the first line of treatment when you want to start therapy.
Key Cognitive Behavioral Therapy Techniques
These techniques are skills or habits that must be built and maintained. Before you can wield these skills, you must go through trials and errors. Practice makes perfect.
In this article, we lay out two standard CBT techniques, and you may be able to do this yourself:
- Identify and challenge negative thoughts
- Behavioral experiment
Identifying and Challenging Negative Thoughts
This technique enables you to recognize and change unhelpful thought patterns and behaviors to alleviate emotional distress. It is a step-by-step guide that works towards developing constructive thoughts and behaviors, allowing you to cope better with adverse events and feelings.
Step 1: develop awareness
Pay attention to your thoughts, inner dialogue, and emotions. Keeping a thought journal may help: Whenever you notice yourself feeling upset, anxious, or down, describe the thoughts and feelings you are experiencing. Naming the feelings helps make them less intense and more manageable.
Keep the thought journal as a reminder, or use an app with a reminder function such as Clarity – CBT Thought Diary, Daylio, or Day One.
Practicing mindfulness is helpful here: mindfulness is an exercise in detaching yourself from your thoughts. For example, if you think you are a failure, you are not – this is just a thought you can choose to keep or let go. Journaling encourages you to give the ideas a physical form – such as a written statement on paper – thus creating a sense of distance from the thoughts.
Ultimately, this step helps you realize you are not your thoughts.
Step 2: Categorize your thoughts into cognitive distortions
If you diligently record your thoughts, you will have amassed many thoughts after a week. Now, sort them into different types of cognitive distortions or thinking patterns that lead to negative behaviors or emotions.
When you are under the sway of cognitive distortion, you will have automatic thoughts that grip your mind without your full awareness of its influence. Intuitive thinking would infuse overwhelming anxiety or hopelessness into you; it would also compel you to take regrettable actions or react in a way that goes against your values or best interests.
See five common cognitive distortions and their related automatic thoughts below.
Cognitive Distortion 1: All-or-Nothing Thinking
Polarized or black-and-white thinking, no middle ground.
Automatic thoughts:
“If I fail the exam, I’m a failure.”
“I can’t finish everything; I won’t do anything.”
“Everything is terrible; nothing good ever happens.”
“It’s always going to be like this.”
“You are always…..; you never……”
Cognitive distortion 2: Catastrophizing
Expecting the worst possible outcome in a situation, even without any evidence.
Automatic thoughts:
“My partner is late getting home; they must be having an affair.”
“I wasn’t invited to that event; I must be a social outcast.”
“If I don’t get this promotion, my entire career is over.”
“My stomach hurts; it’s cancer.”
Cognitive distortion 3: Personalization
Taking responsibility for events beyond your control or assuming that external events are directly related to you.
Automatic thoughts:
“My friend is upset, so it must be my fault. I must have done something to upset them.”
“Everyone at the party looked at me strangely; they must be talking about or judging me.”
“If I think positively about someone, they will like me more.”
“My parents got divorced, and I was just a kid. It must have been my fault.”
Cognitive Distortion 4: Mind Reading
Believing you know what others think, usually assuming they have negative thoughts about you.
Automatic thoughts:
“My friends didn’t respond to my text promptly; they must be mad at me or think I’m annoying.”
“I saw my co-workers whispering in the break room, and I’m sure they were talking about my mistakes at work.”
“She didn’t smile when I entered the room, so she must not like me.”
“I need to act a certain way, or people will think I’m weird.”
Cognitive Distortion 5: Should Statements
Using “should,” “must,” or “ought to” statements that impose unrealistic expectations on yourself or others.
Automatic thoughts:
“I must always control my emotions and never feel anxious.”
“My partner should always know what I need without me having to say anything.”
“I must never feel angry; it’s not acceptable.”
“I should have my entire life figured out by now.”
You may or may not realize that whenever you have these automatic thoughts – they are called’ automatic’ for a reason. It is precisely why the CBT technique is so helpful: it helps you slow down and observe your thinking. Ultimately, it enables you to know your mind with crystal clarity.
The list above is incomplete. Other cognitive distortions include:
- Overgeneralization: “My last two relationships ended badly, so I must be unlovable.”
- Discounting the positive: “When people say I did a good job, they’re just being polite; they don’t mean it.”
- Emotional reasoning: “I feel so anxious about flying; therefore, it must be hazardous, and I shouldn’t get on the plane.”
- Selective attention: After a fun evening with friends, one negative interaction or comment is the only thing you remember, overshadowing the overall positive experience.
- Comparison: “My friend has a perfect relationship, while I’m still single; I wish I had what they have.”
Step 3: Examine negative thoughts with laddering questions
Upon identifying an automatic thought, ask yourself the laddering questions below. Imagine this process as the rungs on a ladder (hence the word ‘laddering’) that leads you to your core belief.
Ask any of the laddering questions below to dig deeper into an automatic thought and uncover your core beliefs:
- What if this thought was true? What would it mean?
- What does this thought say about how I view the world, friends, or family?
- What is the worst thing that this thought may say? Why is it so bad?
- What thoughts do I have about myself that would make this thought so terrible?
These questions should lead you from one thought to another. Keep going – ask the same question for each thought. After 5 or 6 of these thoughts, you would likely arrive at the core beliefs that permeate your life.
Let’s take an example.
Automatic thought (Catastrophizing): “My partner is late getting home; they must be having an affair.”
Laddering questions:
If they were having an affair, what would it mean to me?
Response: They don’t love me anymore.
If they didn’t love me, what would it mean to me?
Response: They would leave me.
If they would leave me, what would it mean to me?
Response: I would be all alone.
If I were alone, what would it mean to me?
Response: No one cares about me.
If no one cared about me, what would it mean to me?
Response: I don’t deserve love.
“I don’t deserve love” seems like the core belief in this case. Usually expressed in short, definitive statements (3 to 5 words), core beliefs are fundamental assumptions (not truths) about yourself and others. Still, they hold a powerful influence over your actions, feelings, and thoughts.
Step 4: Challenge negative thoughts
Knowing that the thought comes from a core belief means you are much more aware of its influence on your actions and feelings. Now, you can start challenging the idea to see if it holds any truth.
See some example questions to challenge the five common cognitive distortions below.
All-or-Nothing Thinking:
“Is it true that everything has to be perfect, or can there be shades of gray?”
“What evidence is there that this situation is all good or bad?”
Catastrophizing:
“What is the worst that could realistically happen in this situation?”
“Have similar situations turned out as badly as you’re imagining?”
Mind Reading:
“Do you have concrete evidence or facts that support your belief about what others are thinking?”
“Could there be alternative explanations for their behavior or expressions?”
Personalization:
“Is it possible that this situation has nothing to do with you?”
“What other factors might influence the outcome that aren’t related to you?”
Should Statements:
“Why do you believe things ‘should’ or ‘must’ be a certain way?”
“What are the consequences of holding onto these rigid beliefs?”
In answering these questions, you should evaluate the evidence and conduct experiments to test the validity of the thought. See below for behavioral experiments.
Many people need support in this step because it is hard to challenge a thought you believe to be true. Our brains are instinctively lazy, so when a belief has cemented into our minds, it takes mental energy and critical thinking to recognize it, let alone challenge it.
Behavioral experiment
This technique involves experimenting to gather evidence that supports or refutes your automatic thoughts, core beliefs, or predictions about a stressful situation.
In a session, you will work with the therapist to design an experiment that exposes you to a stressful situation related to the chosen issue.
The issue can be a thought or a core belief you think is true. If you have done the above technique of ‘identifying and challenging negative thoughts,’ you can pick one for this experiment. It could be a fear or anxiety that would carry the most meaning to you if proven.
For example, in this behavioral experiment case study, the therapist is helping the patient – Adeline – work on her social anxiety. The experiment is: she will go to a party at her cousin’s house and test out the predictions she makes about it.
The therapist encouraged her to commit to the experiment. Specifically, Adeline must push herself out of her comfort zone, go to the party, and talk to people she doesn’t know.
Step 1: make predictions
The therapist gives Adeline a handout to guide her through the experiment (see the table below).
They talk about the negative images or thoughts that may occur to Adeline at the party. Notice how the therapist asks the question, “What would be so bad about that?” to encourage Adeline to dig deeper into the specifics of what she thinks would happen:
- How would she feel?
- What would she do?
- How would she look like?
- What would happen if she talked to someone?
Step 2: rate the feelings
The therapist asks Adeline to rate the strength of her feelings on a scale from 1 to 10: “How anxious would she feel about …..?”.
Step 3: look for evidence
Then, the therapist encourages Adeline to look for objective evidence at the party. She should ignore ambiguous evidence.
At the end of this experiment design, Adeline’s handout looks like this:
Prediction
Rating of feelings
Experiment
Objective evidence
Results
Conclusion
I won’t talk to anyone.
10/10
Talk to 2 – 3 strangers.
Do people walk away when I start talking to them?
Step 4: do the experiment
Adeline will have to go to the party, do what has been written down, and collect the objective evidence.
Step 5: Record the result
In the Results column, Adeline must jot down the facts – unambiguous and objective evidence. Then, she must reflect on the entire experiment:
- What lessons has she learned from it?
- How has the experiment affected her mood and thinking?
Adeline will report these results to the therapist in their next session. It is believed that the next time her anxiety keeps her from a social event, this experiment can remind her that it will not be as bad as she thinks.
Other CBT techniques
In addition to these skills, CBT also uses other standard techniques:
- Cognitive restructuring
- Mindfulness
- Problem solving
- Goal setting
- Managing tasks
How to Find and Pay for a Cognitive Behavioral Therapist
Major health insurers provide coverage for CBT, such as UnitedHealthcare, Cigna, Aetna (CVS Health), Humana, Kaiser Permanente, and Blue Cross Blue Shield. Contact your health insurance provider for the specifics that apply to your plan. Also, contact your physician for their opinions on whether CBT would work for you and suggestions for suitable therapists.
You can also reach out to these professional organizations for expert help in navigating the mental health system:
- The Substance Abuse and Mental Health Services Administration (SAMHSA)
- The National Alliance on Mental Illness (NAMI)
- The Association for Behavioral and Cognitive Therapies (ABCT)
CBT is available in-person or online by video, audio, or text messaging. If remote therapy may work for you, consider general websites such as BetterHelp and Talkspace or counseling for specific needs such as Pride Counselling, Teen Counselling, Therapy for Black Girls, and Faithful Counselling.
If you are worried you can’t afford the entire treatment, some former CBT patients suggest price renegotiation after some initial meetings. Once the therapist knows you and your hardship, they are more compassionate in offering you a discount. In addition, off-peak hours and loss of employment are two other reasons that may compel the therapists to provide a lower price on a sliding scale.
Another tip for cheaper CBT counseling is to go for a therapist trainee at local universities or hospitals. A supervising professor will watch your sessions, and they will set you back for only a fraction of the regular price.
The cognitive behavioral therapist Judith Beck says that her most challenging client is someone who has tried several therapies but has yet to complete them. Commitment is vital to any treatment, especially for CBT. The good thing is that CBT is short-term; treatments often take less than three months. The specific exercises, action plans, and therapy notes are highly structured and interconnected to raise your competency.
Get Dr. Ali Mattu’s valuable advice on how to start therapy as a beginner, including:
- how to get cheaper therapy
- how to choose a therapist that’s right for you.
Is Cognitive Behavioral Therapy Right for You?
Dr. Judy Ho recommends CBT to people who are a little resistant to therapies in general, carrying a little self-stigma, because a lot of CBT revolves around learning skills. It is educational and practical for mild conditions and temporary situations.
CBT does not dive deep into the historical root of your problems (like psychodynamic therapy), but rather, it helps you cope with daily life. A former patient has described CBT as like a bandage: it does not heal the wound but keeps those wounds from getting infected or tearing open.
CBT does not work on your emotions directly. It mainly targets your thinking and behaviors, which are believed to affect your emotions. If you want to work with your feelings, especially when dealing with extreme pain and suffering, then Dialectical Behavioral Therapy (DBT) would likely be a better fit. DBT and CBT complement each other in providing a more well-rounded treatment.
Finally, CBT treatment tends to be short, ranging from 6 to 12 sessions, so it is likely unsuitable for severe mental health disorders. CBT may only be part of a more significant treatment program for these cases.
