What to Expect from CBT

General Philosophy

CBT (Cognitive Behavior Therapy) can be used to treat a broad range of presenting problems, including difficulties with mood, anxiety, eating, interpersonal relationships, anger management, emotion regulation, substance abuse, pain, and psychosis. The strategies utilized in CBT have been derived from learning theory, which are tailored to specific presenting problems.  Additionally, CBT is an empirically supported treatment, which means it has been tested and shown to be effective in large studies.  There is extensive scientific research supporting both foundational learning theory and the practice of CBT.

Defining Features of CBT

• Therapy tends to be time-limited and goal-oriented. A client and therapist may decide to work together for a few months and then evaluate their progress. This does not mean that treatment cannot continue after this time, but specific goals are set for each phase of therapy with the intent that a client’s goal is to “become” his or her own therapist and not remain in therapy long-term.
• CBT is a present-focused approach. Understanding what is contributing to and maintaining a problem in the “here and now” is the most important aspect of CBT. The client’s past and early learning experiences are considered relevant in CBT models to understand what will be helpful for clients in the present.
• CBT models do not assume a single cause for a problem or assume that identifying the initial cause of a problem is necessary for treatment to be successful.  CBT recognizes that a combination of biological/genetic, psychological (i.e., thoughts, feelings, behaviors) and social (e.g., interpersonal relations, environmental) factors may contribute to and maintain a presenting problem.
• CBT has been demonstrated to be effective as a stand-alone treatment.  However, a client may consider consulting with a psychiatrist or other health professional regarding the benefits of medication (see CBT versus medication).
• CBT therapists work collaboratively with clients to formulate goals in therapy that are aligned with what scientific research shows is effective for a presenting problem. This philosophy is also implemented in sessions. The therapist and client work together by forming an opinion (i.e., hypothesis) on what is maintaining a specific problem and identifying possible strategies for addressing it. The therapist and client then engage in a process of testing this hypothesis by engaging in new ways of thinking and acting. The process in which the therapist and client work together to gather evidence is called “collaborative empiricism.” The client is an active participant in this process and is frequently encouraged to gather evidence to determine what works best for them.

What Happens During and Between Therapy Sessions?

• Therapy sessions tend to be relatively structured, meaning that an agenda is set to make sure that certain material is covered in each session. There is, of course, flexibility regarding the content and format of sessions and the agenda is set collaboratively by the client and therapist. However, most sessions will involve some discussion of current mood and difficulties, a review of homework and progress on the work from the prior session, learning a new skill or discussion of a particular issue, and setting a plan for work to be completed before the next session.
• Homework is a key component of CBT. The goal of therapy is to teach clients new skills to manage their difficulties more effectively, so much of the work happens outside of sessions as clients try to practice these skills in their day-to-day life. Homework is usually very practical, and involves trying out new behaviors, thinking strategies, etc., rather than the kind of homework associated with classroom learning. There are no tests in CBT!
• Consistent with the scientific approach that characterizes CBT, the client and therapist gather ‘data’ to learn about the client’s problems and potential solutions. Assessment is common in CBT and may involve completing questionnaires or self-monitoring exercises to see how symptoms are changing over the course of treatment. Examples of self-monitoring exercises include tracking changes in mood, self-critical thoughts, or unwanted behaviors, such as binge eating. Data are used to inform whether a particular approach is working for you and to inform changes to the plan.

Common Treatment Strategies

There are numerous techniques used in CBT, so the list below is by no means exhaustive. Depending on the needs of the client, therapy is likely to involve some of the following:

Responses to unhelpful thinking:

• ‘Cognitive restructuring’ involves trying to re-evaluate the negative thinking patterns that maintain unhelpful beliefs about oneself, the world, and relating to others. For instance, a person with social phobia could be taught to challenge his or her assumption that social rejection is inevitable.
• Strategies to promote more effective problem solving and decision making.
• ‘Mindfulness’ techniques help clients gain some distance from their negative thinking so they can recognize that our thoughts do not have to determine how we behave.

Responses to unhealthy behaviors:

• Clients and therapists collaboratively develop a plan for how to gradually re-enter situations they have been avoiding (e.g., because of fear in anxiety disorders, or low motivation in depression). Clients learn how to gain a sense of control and predictability in situations that previously seemed overwhelming.
• Activities that provide a sense of pleasure or mastery are planned to promote a more enjoyable and fulfilling life.
• Training in new skills may be provided, such as how to communicate more effectively, be assertive, or enhance social interactions.

Responses to painful feelings:

• Clients are sometimes taught strategies for how to accept or tolerate painful emotions that cannot be changed or avoided.
• For feelings and situations that can be successfully changed in the moment, clients are taught strategies to do so.
• Relaxation exercises may be included to help reduce overall stress.
• Strategies to manage intense emotions, such as ways to deal with intense anger or urges to harm oneself, are taught.