Cognitive Behavioral Therapy (CBT)

12-week treatment that included CBT and an antidepressant caused remission in 37% of patients. However, only 23% of patients taking antidepressants achieved remission. During remission, a patient experiences few or no symptoms of depression.

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy is a type of talk therapy (psychotherapy). It is a short-term, goal-oriented therapy and helps to identify and correct problematic thought patterns that cause mental illness. A person’s thought patterns and beliefs determine how a person behaves. This is the basis of cognitive behavioral therapy. CBT understands that a person’s negative perception of an event can cause mental illness.

CBT combines cognitive therapy and behavioral therapy. Cognitive therapy addresses a patient’s problematic thoughts and mood. Behavioral therapy focuses on the patient’s behaviors. CBT has demonstrated benefits in many mental disorders, such as depression, anxiety, and eating disorders. It is also useful in the treatment of specific disorders, namely:

Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder
Attention Deficit Hyperactivity Disorder

Notably, it may also be used in the treatment of other conditions, such as insomnia, migraines, and long-term pain conditions. Unlike casual talk therapy, cognitive behavioral therapy techniques are far more structured. During a session, you and your therapist work together to:

Identify specific problems

Set realistic goals

Achieve the goals within predetermined time points

A therapist can be a psychiatrist, psychologist, licensed professional counselor, or psychiatric nurse with CBT training.

History

Aaron T. Beck is often regarded as the father of cognitive therapy. He was an American psychiatrist who developed CBT in the 1960s. ³ Noam Chomsky, Allen Newell, and George Armitage Miller also contributed to the development of earlier forms of CBT. ⁴

Cognitive Theory of Depression

During his practice, Beck observed that depressed patients often verbally expressed their thoughts. However, they lacked logic. He noticed that many of them had inaccurate thoughts about themselves or an event. This is now known as “cognitive distortion.” He theorized that depression was more of a cognitive disorder than a mood disorder.

Combining his clinical experience and observation, he developed the cognitive theory of depression. Later, he published a study that showed his theory was both effective and result-oriented.

Developing CBT as Treatment

In 1979, together with other authors, he published Cognitive Therapy for Depression. His work was a revolution at that time. Following this, Beck developed a research-backed treatment protocol manual. This attracted other researchers who developed their own CBT treatment protocols. Within a few years, researchers combined Beck’s cognitive therapy with behavioral approaches. This led to the birth of what we now call cognitive behavioral therapy.

Currently, CBT is the most well-studied form of psychotherapy. It has many science-backed treatment protocols.

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How Does CBT Work?

CBT has two components: Cognitive Therapy and Behavioral Therapy. ⁵

Cognitive therapy helps to identify thought patterns that cause or complicate a problem. Simply put, cognitive therapy helps distinguish between “harmful” and “neutral” thought patterns. A single event can spark both harmful and neutral thoughts in a person.

For example, if a husband forgets his wife’s birthday, the wife may think:

First, he does not care. He might be cheating.
(HARMFUL)

Second, he may be busy or stressed due to his work. They can talk about it later.
(NEUTRAL)

Behavioral therapy helps to identify behavioral problems that arise from problematic thought patterns.

The situation mentioned above can cause at least two behavioral responses:

First, the wife behaves rudely or does not even talk.

Second, both discuss the matter and work together to find a solution.

Whether a person chooses harmful or neutral thoughts depends on three factors. These include automatic thoughts, problems with reasoning, and deep-rooted beliefs. Cognitive behavioral therapy is designed to resolve problems with both thoughts and behaviors.

CBT helps patients:

Identify their faulty thought patterns

Learn skills to cope with real or perceived problems.

Face their fears

Learn ways to stay calm during a crisis.

Understanding the Steps and Sessions

The steps of cognitive behavioral therapy can include:

Assessment of the patient

This helps the therapist understand the patient’s thought patterns, emotions, and situations.

Conceptualization

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Discuss

Discussion on the total number of sessions that may be needed and the length of each session.

A cognitive behavioral therapy session can involve:

One-on-one discussions between a patient and a therapist

A group discussion among group members and the therapist

There can be up to 20 weekly (or fortnightly) sessions. Typically, each session is 30 to 60 minutes long. The therapist can conduct a session in a clinic, at home, or somewhere outside.⁶During each session, the therapist first checks the patient’s mood. The patient explains progress or problems experienced during the period between two sessions. Then, they talk about specific problems they are trying to solve in the current session. Finally, they set up homework for the patient and the goals of the current session.

Effectiveness

CBT can be effective in the treatment of many psychiatric and non-psychiatric conditions:

Chronic Pain

Chronic pain refers to pain that lasts more than three months in a row. Examples include lower back pain, cancer pain, headaches, and pain due to arthritis. CBT can help reduce chronic pain by:

Enhancing coping skills
Improving fear of pain
Increasing relaxation

In patients with chronic jaw pain, four biweekly individual sessions produced 50% improvement in symptoms. This is according to a 2006 study. The same study found that structured education protocol produced only 29% improvement.¹³

Obsessive-Compulsive Disorder (OCD)

OCD is a long-term mental disorder. It causes repeated thoughts (obsessions) and consequent behaviors (compulsions). Exposure and Response Prevention (EX/RP) can help reduce compulsive behaviors. EX/RP is a type of CBT. CBT can also work for patients who do not respond to common OCD medications. In severe cases, a doctor may use a combination of CBT and medications. Estimates suggest that CBT is effective in up to four-fifths of OCD patients. However, it is less effective or ineffective in 20% of patients. ¹⁰

Anxiety

In people with anxiety disorders, CBT improves symptoms and reduces suicidal thoughts.

Weight Loss

Obesity is a global epidemic. In the United States, one in three adults is overweight. Many studies have shown that cognitive behavioral therapy aids weight loss. According to a 2012 study, 8-week individual CBT caused 2.4 kg weight loss in middle-aged women.¹⁶

Smoking Cessation During Pregnancy

CBT can be an effective tool for helping pregnant women quit smoking. Because it does not involve any medication, it poses no risk to the baby in the womb. One study found that six individual CBT sessions during pregnancy nearly doubled cessation rates. The investigators measured cessation rates three months after delivery. ⁸

Post-Traumatic Stress Disorder (PTSD)

People with PTSD have repeated nightmares and flashbacks. It is common among war veterans. According to a 2001 study, 16-20 weekly CBT sessions can reduce PTSD symptoms by about 50%. Most importantly, the effects were maintained six months after therapy.¹¹

Insomnia

Insomnia is a sleep disorder. It causes problems with falling or staying asleep. About one-fourth of Americans have short-term insomnia in a given year. ¹⁴The American Academy of Sleep Medicine recommends CBT as the primary treatment for insomnia. Most people with insomnia benefit from 4 to 6 weekly sessions, each session lasting about six hours. ¹⁵

Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is a brain disorder. It is characterized by an ongoing lack of attention, hyperactivity, and impulsivity. The symptoms typically begin during childhood and continue through adulthood. CBT is found to be effective in relieving ADHD symptoms in adolescents. In one study, researchers observed a 40% reduction in symptoms after 12 individual CBT sessions.¹²

Depression

CBT can be an effective treatment in preventing depression relapse. Relapse rates are almost half in CBT patients compared to those taking antidepressants. In one study, nearly 30% of CBT patients relapsed, whereas 60% of antidepressant-treated patients relapsed.⁶Similarly, studies show that CBT may be particularly more effective in patients who do not respond to antidepressants.⁷

Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) affects a child’s ability to communicate. It makes social interactions difficult. Symptoms may include lethargy, hyperactivity, irritability, and isolation. In the US, one in fifty-nine children has ASD and is more common in boys. ¹⁷CBT showed significant improvements in symptoms in boys with ASD. The symptoms included lethargy, hyperactivity, and irritability. This is according to a 2018 study.¹⁸ However, the study was small, and conclusions cannot be drawn.

Top 5 Misconceptions

CBT is Not Flexible

Cognitive behavioral therapy techniques have structured protocols and specific goals, but they are not rigid. CBT therapists first assess a patient’s thought patterns, emotions, and mood. Then, they discuss the prevailing problem with the patient. This is followed by a detailed plan that specifically addresses the patient’s problems. After all, CBT is a collaborative treatment. Therapists may customize a CBT protocol to meet the patient’s unique individual needs.

At the beginning of each new session, the therapist and patient discuss the progress of the previous session. This helps bridge the gap between the two sessions. Thus, CBT is not rigid and considers the individual needs of a patient in each session.

It is Only About Cognition and Behavior, Not About Emotions

Some people believe that emotions are not important in CBT. While the term “emotion” does not appear in its name, CBT is very serious about a patient’s emotions. Therapists work hard to understand the connection between thoughts, emotions, and behavior. They understand that emotions are an indispensable part of a person’s behavior and cognition.

The Past Has No Role in CBT

CBT is concerned about solving a patient’s current problem. That said, it is wrong to say it does not consider the patient’s past or childhood. CBT therapists have a deep understanding of how a person’s past can influence their present-day behavior and cognition. Unlike traditional talk therapies, cognitive behavioral therapy does not go deeper into the person’s past. However, it cares about how present-day problems may have their roots in the past.

It Has No Side Effects

Each therapy has its share of side effects. What matters the most is the severity and frequency of these effects. CBT is not free from side effects. That said, the risk is really low. Most side effects are also mild and transient. A type of CBT known as exposure therapy exposes a person to the source of anxiety. This can cause temporary stress. In some cases, cognitive behavioral therapy may increase the severity of existing problems. However, severe side effects are very rare.

It is Expensive

A single 45-minute session can cost from $175 to $290. Several factors determine the fees, such as qualification and experience of the therapist and length of a session.

Before enrolling in a session, it is important to find out if your insurance covers psychotherapy. If it does, how many sessions per year? While $200+ per session may look like a huge amount, the total cost of treatment is usually low. This is because it is a short-term therapy. A typical treatment ends with about 20 sessions. Moreover, studies have noted that combining CBT with medication may provide good value for money.

In people with depression who do not respond to medication, adding CBT can provide long-term benefits at a relatively lower cost. This is according to a recent study published in the journal The Lancet Psychiatry.¹⁹

How CBT Helps Anxiety and Depression

How CBT is Used to Treat Anxiety

CBT is effective in treating different forms of anxiety. These include PTSD, OCD, generalized anxiety, and social anxiety. It may be used alone or combined with medication.

Therapists use CBT to help patients:

Identify negative thoughts that might contribute to anxiety.
Challenge negative thoughts. Also known as cognitive restructuring, it involves analyzing the pros and cons of those thoughts. This gives a clear view of what is scary and what is not.
Shift negative thoughts to positive “realistic” thoughts. Once a person has understood what’s right and what’s not, they can work to shift their thought patterns towards positive thoughts. The therapist facilitates this transition with reassurance and calming statements.

How CBT is Used to Treat Depression

Cognitive behavioral therapy is found to be effective in treating patients with major depression. Some experts recommend it as the primary treatment for such type of depression. In severe depression, it is used in combination with antidepressants. According to the American Family Physician (AFP), CBT may be more effective than drug therapy for mild to moderate depression. ²⁰ Treating depression with either CBT, drugs, or a combination of both, depends on the patient’s choice.

When a person with depression visits a primary care physician, the physician informs the person about his options. The options are psychotherapy and drug therapy. While other forms of psychotherapy are available, CBT is the most studied. Treatment with CBT may begin first or after initial treatment when antidepressants fail. In the second case, CBT may be added as an adjunct.²¹ Notably, some physicians may recommend CBT to prevent relapse or manage residual symptoms.

Finding Resources

Finding a therapist may not be an uphill challenge, but finding the right one can be hard. With the following tips, it should be easy to find a therapist that best suits your needs:

Talk to a doctor, friend, relative, or an insurer. One can also find a therapist on the internet or through a psychological association.
Find out if your insurance covers the cost of psychotherapy sessions. Some health plans pay only for a certain number of sessions each year.
If your insurance does not cover psychotherapy, check how much you have to pay out of pocket. The fees for each 45-minute session can range from $175 to $290. Usually, you have to pay more for longer sessions.
Ask if the therapist accepts insurance.
Learn your payment options and the total cost of therapy.
Check credentials. These include education, background, certification, licensing, experience, and area of expertise.

Cognitive Behavioral Therapy (CBT)