What Is Cognitive Behavioral Therapy?

Cognitive behavioral therapy – more commonly referred to as CBT – focuses on the way people think and act to help them with their emotional and behavioral problems.

Many of the effective CBT practices we discuss in this book should seem like everyday good sense. In our opinion, CBT does have some very straightforward and clear principles and is a largely sensible and practical approach to helping people overcome problems. However, human beings don’t always act according to sensible principles, and most people find that simple solutions can be very difficult to put into practice sometimes.

CBT can maximize on your common sense and help you to do the healthy things that you may sometimes do naturally and unthinkingly in a deliberate and self-enhancing way on a regular basis.

Scientifically-tested methods

The effectiveness of CBT for various psychological problems has been researched more extensively than any other psychotherapeutic approach. CBT’s reputation as a highly effective treatment is based on continued research. Several studies reveal that CBT is more effective than medication alone for the treatment of anxiety and depression. As a result of research like this, briefer and more intense treatment methods have been developed for particular anxiety disorders, such as panic, anxiety in social settings, or feeling worried all the time.

As scientific research of CBT continues, more is being discovered about which aspects of the treatment are most useful for different types of people and which therapeutic interventions work best with different types of problems.

Research shows that people who engage in CBT for various types of problems — in particular, for anxiety and depression — stay well for longer. This means that people treated with CBT relapse less often than those treated with other forms of psychotherapy, or those who take medication only. This positive result is likely due in part to the educational aspects of CBT — people who have CBT receive a lot of information that they can use to become their own therapists.

More and more physicians and psychiatrists refer their patients for CBT to help them overcome a wide range of problems, with good results. These problems include the following:

• Addiction
• Anger problems
• Anxiety
• Body dysmorphic disorder
• Body image problems
• Chronic fatigue syndrome
• Chronic pain
• Depression
• Eating disorders
• Gender identity and sexuality issues
• Obsessive-compulsive disorder
• Panic disorder
• Personality disorders
• Phobias
• Post-traumatic stress disorder
• Psychotic disorders
• Relationship problems
• Social anxiety

CBT skills and techniques can be applied to most types of psychological difficulties, so give them a try, whether or not your particular problem is specifically discussed in this article.

Understanding CBT

Cognitive behavioral therapy is a school of psychotherapy that aims to help people overcome their emotional problems.

• Cognitive means mental processes like thinking. The word cognitive refers to everything that goes on in your mind including dreams, memories, images, thoughts, and attention.
• Behavior refers to everything that you do. This includes what you say, how you try to solve problems, how you act, and avoidance. Behavior refers to both action and inaction; for example, biting your tongue instead of speaking your mind is still a behavior, even though you are trying not to do something.
• Therapy is a word used to describe a systematic approach to combating a problem, illness, or irregular condition.

A central concept in CBT is that you feel the way you think. Therefore, CBT works on the principle that you can live more happily and productively if you’re thinking in healthy ways.

Combining science, philosophy, and behavior

CBT is a powerful treatment because it combines scientific, philosophical, and behavioral aspects into one comprehensive approach to understanding and overcoming common psychological problems.

• Getting scientific. CBT is scientific not only in the sense that it has been tested and developed through numerous scientific studies, but also in the sense that it encourages clients to become more like scientists. For example, during CBT, you may develop the ability to treat your thoughts as theories and hunches about reality to be tested (what scientists call hypotheses) rather than as facts.
• Getting philosophical. CBT recognizes that people hold values and beliefs about themselves, the world, and other people. One of the aims of CBT is to help people develop flexible, non-extreme, and self-helping beliefs that help them adapt to reality and pursue their goals.

Your problems are not all just in your mind. Although CBT places great emphasis on thoughts and behavior as powerful areas to target for change and development, it also places your thoughts and behaviors within a context. CBT recognizes that you’re influenced by what’s going on around you and that your environment makes a contribution toward the way you think, feel, and act. However, CBT maintains that you can make a difference in the way you feel by changing unhelpful ways of thinking and behaving — even if you can’t change your environment. Incidentally, your environment in the context of CBT, includes other people and the way they behave toward you. Your living situation, your culture, workplace dynamics, or financial concerns are also features of your larger environment.

• Getting active. As the name suggests, CBT strongly emphasizes behavior. Many CBT techniques involve changing the way you think and feel by modifying the way you behave. Examples include gradually becoming more active if you’re depressed and lethargic, or facing your fears step by step if you’re anxious. CBT also places emphasis on where you focus your attention. Mental behaviors, such as worrying and chewing over negative events, can be helped by learning to focus your attention in a more helpful direction.

Progressing from problems to goals

A defining characteristic of CBT is that it gives you the tools to develop a focused approach. CBT aims to help you move from defined emotional and behavioral problems toward your goals of how you’d like to feel and behave. Thus, CBT is a goal-directed, systematic, problem-solving approach to emotional problems.

Making the thought–feeling link

Like many people, you may assume that if something happens to you, the event makes you feel a certain way. For example, if your partner treats you inconsiderately, you may conclude that she makes you angry. You may further deduce that her inconsiderate behavior makes you behave in a particular manner, such as sulking or refusing to speak to her for hours (possibly even days; people can sulk for a very long time!).

We illustrate this common (but incorrect) causal relationship with the following formula. In this equation, the A stands for a real or actual event — such as being rejected or losing your job. It also stands for an activating event that may or may not have happened. It could be a prediction about the future, such as, "I’m going to get the sack," or a memory of a past rejection, such as "Hilary will dump me just like Judith did ten years ago." C stands for consequence, which means the way you feel and behave in response to an actual or activating event.

A (actual or activating event) = C (emotional and behavioral consequence)

CBT encourages you to understand that your thinking or beliefs lie between the event and your ultimate feelings and actions. Your thoughts, your beliefs, and the meanings that you give to an event produce your emotional and behavioral responses.

So, in CBT terms, your partner does not make you angry and sulky. Rather, your partner behaves inconsiderately, and you assign a meaning to her behavior, such as "She’s doing this deliberately to upset me, and she absolutely should not do this," thus making yourself angry and sulky. In the next formula, B stands for your beliefs about the event and the meanings you give to it.

A (actual or activating event) + B (beliefs and meanings about the event) = C (emotional and behavioral consequence)

This is the formula or equation that CBT uses to make sense of your emotional problems.

Emphasizing the meanings you attach to events

The meaning you attach to any sort of event influences the emotional responses you have to that event. Positive events normally lead to positive feelings of happiness or excitement, whereas negative events typically lead to negative feelings like sadness or anxiety.

However, the meanings you attach to certain types of negative events may not be wholly accurate, realistic, or helpful. Sometimes, your thinking may lead you to assign extreme meanings to events, leaving you feeling disturbed.

For instance, Tilda meets up with a nice man that she’s contacted via a dating app. She quite likes him on their first date and hopes he’ll contact her for a second meeting. Unfortunately, he doesn’t. After two weeks of eagerly checking her phone, Tilda gives up and becomes depressed. The fact that the chap failed to ask Tilda out again contributes to her feeling bad. But what really leads to her acute depressed feelings is the meaning she’s derived from his apparent rejection, namely, "This proves I’m old, unattractive, past it, and unwanted. I’ll be a sad singleton for the rest of my life."

As Tilda’s example shows, drawing extreme conclusions about yourself (and others, and the world at large) based on singular experiences can turn a bad distressing situation into a deeply disturbing one.

Psychologists use the word disturbed to describe emotional responses that are unhelpful and cause significant discomfort to you. In CBT terminology, disturbed means that an emotional or behavioral response is hindering rather than helping you to adapt and cope with a negative event.

For example, if a potential girlfriend rejects you after the first date (event), you may think, "This proves I’m unlikeable and undesirable," (meaning) and feel depressed (emotion).

CBT involves identifying thoughts, beliefs, and meanings that are activated when you’re feeling emotionally disturbed. If you assign less extreme, more helpful, more accurate meanings to negative events, you are likely to experience less extreme, less disturbing emotional and behavioral responses.

Thus, on being rejected after the first date (event), you could think, "I guess that person didn’t like me that much; oh well — they’re not the one for me" (meaning) and feel disappointment (emotion).

You can help yourself to figure out whether or not the meanings you’re giving to a specific negative event are causing you disturbance by answering the following questions:

• Is the meaning I’m giving to this event unduly extreme? Am I taking a fairly simple event and deriving very harsh conclusions about myself (and/or others and/or the future) from it?
• Am I drawing global conclusions from this singular event? Am I deciding that this one event defines me totally, or that this specific situation indicates the course of my entire future?
• Is the meaning I’m assigning to this event loaded against me? Does this meaning lead me to feel better or worse about myself? Is it spurring me on to further goal-directed action or leading me to give in and curl up?

If your answer to these questions is largely ‘yes’, then you probably are disturbing yourself needlessly about a negative event. The situation may well be negative, but your thinking is making it even worse.

Acting out

The ways you think and feel also largely determine the way you act. If you feel depressed, you’re likely to withdraw and isolate yourself. If you’re anxious, you may avoid situations that you find threatening or dangerous. Your behaviors can be problematic for you in many ways, such as the following:

• Self-destructive behaviors, such as excessive drinking or using drugs to quell anxiety, can cause direct physical harm.
• Isolating and mood-depressing behaviors, such as staying in bed all day or not seeing your friends, increase your sense of isolation and maintain your low mood.
• Avoidance behaviors, such as avoiding situations you perceive as threatening (attending a social outing, using a lift, speaking in public), deprive you of the opportunity to confront and overcome your fears.

The ABCs of CBT

When you start to get an understanding of your emotional difficulties, CBT encourages you to break down a specific problem you have using the ABC format, in which

• A is the activating event. An activating event means a real external event that has occurred, a future event that you anticipate occurring or an internal event in your mind, such as an image, memory or dream.

The A is often referred to as your "trigger."

• B represents your beliefs, thoughts, personal rules, the demands you make (on yourself, the world and other people) and the meanings that you attach to external and internal events.
• C represents the consequences, including your emotions, behaviors, and physical sensations that accompany different emotions.

This figure shows the ABC parts of a problem in picture form.

Writing down your problem in ABC form — a central CBT technique — helps you differentiate among your thoughts, feelings, behaviors, and the trigger event.

Consider the ABC formulations of two common emotional problems, anxiety and depression. The ABC of anxiety may look like this:

• A: You imagine failing a job interview.
• B: You believe, "I’ve got to make sure that I don’t mess up this interview; otherwise, I’ll prove that I’m a failure."
• C: You experience anxiety (emotion), butterflies in your stomach (physical sensation), and drinking to calm your nerves (behavior).

The ABC of depression may look like this:

• A: You fail a job interview.
• B: You believe, "I should’ve done better. This means that I’m a failure."
• C: You experience depression (emotion), loss of appetite (physical sensation), staying in bed and avoiding the outside world, and drinking to quell your depressed feelings (behavior).

You can use these examples to guide you when you are filling in an ABC form on your own problems. Doing so will help ensure that you record the actual facts of the event under A, your thoughts about the event under B, and how you feel and act under C.

Developing a really clear ABC of your problem can make it much easier for you to realize how your thoughts at B lead to your emotional/behavioral responses at C.

Characterizing CBT

Here’s a quick reference list of key characteristics of CBT:

• Emphasizes the role of the personal meanings that you give to events in determining your emotional responses.
• Was developed through extensive scientific evaluation.
• Focuses more on how your problems are being maintained rather than on searching for a single root cause of the problem.
• Offers practical advice and tools for overcoming common emotional problems.
• Holds the view that you can change and develop by thinking things through and by trying out new ideas and strategies.
• Can address material from your past if doing so can help you to understand and change the way you’re thinking and acting now.
• Shows you that some of the strategies you’re using to cope with your emotional problems are actually maintaining those problems.
• Strives to normalize your emotions, physical sensations, and thoughts rather than to persuade you that they’re clues to "hidden" problems.
• Recognizes that you may develop emotional problems about your emotional problems — for example, feeling ashamed about being depressed.
• Highlights learning techniques and maximizes self-help so that, ultimately, you can become your own therapist.