What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) refers to several different methods of therapy that are dramatically different from standard “talk” therapy. Since the 1950s, a number of therapists have felt that psychoanalysis via talking things out is a lengthy process that can scarcely achieve its goals without years of patient/therapist work. Therapists who looked at talk therapy as proposed by Freud and then modified by others suggested that patients had essentially two problems, whatever difficulties in life they encountered, and the way they approached those difficulties from a thinking perspective.

For a number of people, a problem in life was made worse by the way in which people thought about and reacted to the problem. Thus therapists worked toward developing concrete ways of changing behavior and thought patterns around problems. The end goal was to help people rid themselves of the negative aspects of problem management from a thought/emotion/behavior perspective.

Eventually these various early thoughts on how people approached difficult situations from a cognitive perspective manifested into cognitive behavioral therapy of today. From the 1980s onward, the writings of people like Dr. David Burns, and the work of Aldo Pucci, Michael Mahoney, Marsha Linehan and Arthur Freeman, among many others, have helped to shape how cognitive behavioral therapy is practiced in a therapeutic setting.

The therapeutic work of cognitive behavioral therapy differs from traditional talk therapy because it requires a significant amount of homework on the part of the patient, and because it is time-limited, taking about 16-18 therapy sessions for a patient to master the practice. People using this method of therapy often use a workbook in which they record situations, parse emotional reactions and attempt to identify “core beliefs” that may not be true and may drive the person toward negative emotional reactions or behavior when faced with crisis. A common workbook in this practice is the book Mind Over Mood: Change How You Feel By Changing the Way You Think, by Dennis Greenberger and Christine Padesky. Individual therapists may prefer other books or worksheets.

Cognitive behavioral therapy is instruction-based therapy, which teaches the patient to begin to think critically and dialectically about thoughts and behaviors arising during difficult situations. Difficult situations may be defined in diverse fashion. A person who gets panic attacks after talking to family members would evaluate what thoughts appear to be contributing to panic, and how rational, logical or truthful these thoughts are. Using worksheets like those in Mind Over Mood, patients learn to rate their emotional state, (panic, anger, depression, or others) before analyzing their thoughts, and then to rate it again after questioning their thoughts. They also look for “hot thoughts” that drive reaction, and learn to question the validity of these hot thoughts.

Once a person has learned the basic method of cognitive behavioral therapy, they review work with a therapist, usually once a week. This review focuses on the work done, and looks toward more work that can be done in order to be able to create a more thinking approach to high emotions and difficult situations. The end goal is to use thinking to unlearn and replace negative emotions, thoughts and reactions with more positive ones.

There is only so much that can be accomplished with cognitive behavioral therapy. Even those who become skilled at evaluating how learned behaviors or thoughts of the past make situations worse, may not always be able to control these behaviors just by thinking about them and trying to replace them. People with true mental illness such as depression, panic disorder, or bipolar conditions may need additional support of medication. CBT alone can make matters frustrating, because even with logical parsing and questioning of ideas, a person may not be able to fully rid themselves of extremely negative emotions that are chemically based.

Trust between patient and therapist is exceptionally important, especially as patients begin to look at some core beliefs that are very difficult, and because these beliefs may bring up past trauma or circumstances that a patient must then think about and parse through. Some people are unwilling to go this deep in assessing trauma or core beliefs grounded in a difficult or traumatic past, and if they’re unwilling to do the homework, they won’t get much from CBT. Sometimes therapists combine CBT with traditional talk therapy, first establishing trust, then teaching a method for reordering thinking, and finally working with patients over months or years to help reiterate CBT methods.