What is Cognitive Behavior Therapy (CBT)?
Cognitive-behavior therapy (CBT) is a practical treatment that focuses on the interconnectedness between our thoughts, behaviors, and emotions.
Cognitive Therapy was developed by Dr. Aaron T. Beck to treat problems with depression and it has been shown to be an effective treatment for a range of problems.
When we filter experiences through a lens of negative thoughts, it affects how we feel and often leads to behavioral problems such as avoidance or withdrawal, which only serve to worsen how we feel.
CBT helps you identify and respond to problematic thoughts that are triggered in certain situations, the core beliefs that underlie them (e.g., I’m unworthy; incapable, or unlovable), and the unhelpful behaviors that contribute to them.
Your Thoughts & Feelings
People suffering from anxiety tend to overestimate threat and underestimate their ability to cope. Exposure-based treatments, such as those for many anxiety disorders and OCD, involve learning to intentionally embrace your fears, challenge your thinking, and learn that you can cope in order to break free of the hold that fear and avoidance have on your life.
Beyond Just Thinking
CBT also identifies problematic thought patterns, such as rumination and worry. Understanding the role that repetitive negative thinking plays in your problems and helping you develop alternative ways to handle concerns and fears is a core feature of CBT.
CBT also helps you learn skills to effectively manage a range of problems, such as problems with attention and organization, sleep difficulties, hair pulling and skin picking, or painful emotional states.
Not all CBT is directed at changing thoughts and behaviors. It’s important to distinguish when NOT to challenge thoughts and feelings but rather, accept and even embrace them instead of engaging in struggles to avoid or escape discomfort. This can be tricky business, and your therapist will guide you.
New in CBT
Advances in our field have yielded even more specific empirically-based approaches to treatment. At the SFBACCT, psychologists integrate components of these and other empirically-based treatments into individualized treatment plans for each patient.
Mindfulness involves developing an awareness of current moments with acceptance of what is and without judgment.
Acceptance and Commitment Therapy (ACT) helps you accept thoughts and feelings while committing to taking actions that are in line with your chosen life values and goals.
Dialectical Behavior Therapy (DBT) aims to strike a balance between acceptance and change strategies and helps you develop skills to regulate emotional states, increase distress tolerance, and increase interpersonal effectiveness.
How CBT Treats These Disorders
Cognitive behavior therapy (CBT) is considered to be the gold standard treatment for Selective Mutism (SM). Speaking in certain situations is identified as the feared behavior, and exposure to speaking in those situations is the treatment of choice. The therapist works with the child and family to create a fear hierarchy of behaviors that the child avoids, including verbal (duration, volume, varied voice tone, enunciation) and non-verbal (eye contact, body position and posture, facial expression) aspects of speech. Together the therapist and child set speech goals. The child and therapist then practice various aspects of speaking in situations and environments in which the child is typically mute. These are called exposure practices. After each exposure practice, the therapist and child review what the child learned and discuss how the child can practice this repeatedly outside of the session.
Research shows that caretaker involvement in treatment is crucial for the best results because frequency and duration of practice impacts treatment results. More practice typically leads to a quicker reduction in symptoms.
For very young children, the treatment focus is mainly behavioral, using successive approximations towards meeting explicit speaking goals. Successive approximation means gradually moving towards a goal (in the case of SM, a speaking goal), rewarding each effort and movement towards that goal along the way to completing the goal.
Because SM is an anxiety disorder, slightly older children and adolescents may benefit from learning cognitive strategies and skills for managing negative thoughts that serve as obstacles to speaking in certain environments or situations.
Medications, including Selective Serotonin Reuptake Inhibitors (SSRIs), have demonstrated effectiveness for children with SM. Research shows that a combination of medication with CBT has the strongest evidence for remission of SM symptoms. Often the child can discontinue use of medication after a period of engaging in typical speech in all environments.
Most children learn appropriate toileting, and the mastery of this task marks an important milestone in a child’s psychosocial development. Children who are toilet trained have learned to hold their urine or feces until they have access to a toilet or to another appropriate place to toilet. However, the child with an elimination disorder has failed to learn this important task at an appropriate time, usually after 5-years of age. Common elimination disorders include nocturnal and diurnal (night time and day time) enuresis and encopresis.
Enuresis is the intentional or involuntary discharge of urine in bed or in clothes. Although enuresis resolves over time in almost every case as the child achieves improved bladder functional capacity, even without treatment, these children can be the victims of teasing and bullying as well as delay some aspects of their psychosocial development. Certain medical conditions (seizures, sleep apnea, urinary tract infections, diabetes, and urinary tract obstructions) can contribute to enuresis, so it is essential consult the child’s pediatrician before undertaking behavioral treatment of the problem. Nocturnal enuresis can be effectively treated through classical conditioning using a urine alarm that the child wears to bed. Behavior therapy also includes working with parents to respond effectively to bed-wetting accidents and over-training to enhance the resiliency of the treatment effect. Diurnal enuresis is more complicated to treat but typically includes Kegel exercises to increase awareness and muscle control, dry pants checks with appropriate rewards for dry pants and appropriate responses to wet pants, and development of a reinforcement plan with the child and parents to enhance willingness of the child to participate in the program.
Encopresis is the involuntary loss of formed, semi-formed, or liquid stool in inappropriate places such as underwear, diapers, or pull-ups in children over four years of age. Over 90% of children referred for treatment of encopresis present with functional constipation. However, it is important that parents consult with the child’s pediatrician prior to seeking behavioral treatment for the problem. Treatment for encopresis focuses primarily on helping the child and parents comply with medical management of constipation (exercise, diet, use of stool softeners and enemas). The goal of treatment is to manage constipation adequately and for long enough that the lower colon repairs and leakage no longer occurs, as well as to teach the child appropriate toileting behaviors and health habits (diet and exercise) to manage the problem over time.
Most young children experience mild anxiety on separation from parents at school, and this anxiety decreases quickly, usually after only a few days or weeks. However, some young children experience very high anxiety when separating from primary caretakers that does not improve without treatment. Untreated separation anxiety disorder (SAD) may interfere with the child’s psychosocial development and diminish self-esteem and self-confidence.
Cognitive-behavior therapy (CBT) is an effective treatment for SAD. Because SAD tends to affect younger rather than older children, it is essential that parents participate fully in the treatment process. CBT includes teaching the child a number of tools to lessen anxiety at school drop off, working with school personnel to assist the child to transition to the school and classroom, and working with parents to encourage the child to use the tools the child has learned and to face his or her separation fears. Exposure to the fear of separation is the most effective and curative factor in helping children overcome all fears, including separation fears. The cognitive-behavioral therapist, in collaboration with the child, parents, and school personnel, develops a graduated exposure plan to assist the child to return to school in manageable steps and as quickly as possible.
GAD involves excessive and chronic anxiety and worry about a number of events or activities (health, money, family, or work), and people with GAD have little control over their worry process and tend to move from one worry to the next such that they are worrying about something most of the time. When people with GAD encounter problems, even small ones, they tend to overestimate their severity, viewing a headache as a sign of a brain tumor, for example, or an argument with their partner as a sign they are headed for divorce.
The goal of cognitive-behavior therapy (CBT) for GAD is to give the individual greater control over his or her worry process. The treatment begins with monitoring worry episodes to unpack the worry experience into its cognitive, behavioral, and physical components.
The individual learns thinking or cognitive strategies focused on the tendency to overestimate the likelihood and impact of negative events and thereby decrease the escalation of worry episodes. The individual also completes worry exposures that dampen worry by desensitizing the individual to the fear-evoking thoughts and images.
CBT also helps individuals identify beliefs about the function that worry seems to serve (also called metacognitive beliefs). For example, if you believe that worrying helps prevent negative outcomes, you might not feel motivated to decrease worry episodes. CBT increases your awareness of such metacognitive beliefs about worry so you can challenge them and break the cycle of engaging in worry loops.
Chronic worry contributes to muscle tension, headache, sleep difficulties, irritability, gastrointestinal distress, and other health-related problems. The individual then learns breathing, relaxation, and mindfulness strategies to decrease over-arousal and undercut the escalation of worry episodes.
Cognitive behavior therapy (CBT), parent training (for youth), and social skills training are all evidence-based treatments that have been demonstrated to benefit individuals with ADHD (and their families). These treatments are based on social learning, behavioral, and cognitive principles.
CBT for ADHD teaches individuals how to tolerate frustration, reduce impulsive responding, regulate emotions, and complete the steps involved in undertaking tasks by improving orientation to detail and concentration. CBT also helps individuals address negative thoughts that may cause them to give up readily, become easily angered or upset, and make poor decisions. Problem solving and learning to cope with challenges are two other major components of CBT. Furthermore, organizational skills, time management strategies, and prioritization are part of CBT for ADHD. Mindfulness and relaxation training are two other elements of CBT treatment that have been shown to be effective for helping individuals manage symptoms of ADHD.
Social skills training teaches individuals how to function optimally in social situations, including how to interact appropriately with peers, how to enter peer groups and activities, how to set developmentally appropriate boundaries and limits within relationships, and how to learn the rules of games/sports/activities to be able to participate actively. Social problem solving helps individuals solve problems that are social in nature to be able to maintain relationships when challenges arise. In addition, social skills training teaches individuals how to read social cues from peers to be able to react responsively in various social situations.
For youth with ADHD, behavioral parent training is a technique that teaches parents how to manage child behavior, improve parenting skills, and problem-solve or cope effectively with problem behaviors. Behavioral parent training involves using rewards and active ignoring to help shape problematic child behaviors into adaptive behaviors. Parent training often includes guidance to parents for schools or direct contact with teachers to help educators manage child behavior in the classroom and develop a common language between parents and educators to best support behavior changes. The school environment, program, or placement is a part of any treatment plan, and often clinicians work with parents to develop a plan with schools for academic accommodations for children and adolescents with ADHD.
In addition to behavioral treatments, there is strong evidence for the effectiveness of stimulant medications in managing symptoms of ADHD. There is slightly less strong but sufficient evidence for atomoxetine, extended-release guanfacine, and extended-release clonidine. Psychiatrists, primary care physicians, or developmental pediatricians should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects.
The goal of Panic Control Treatment is to develop skills for reducing the frequency and intensity of panic attacks, and reduce avoidance and related interference associated with the fear of triggering a panic attack.
One of the first steps is to monitor your symptoms to identify the components of a panic attack. While it often seems like panic comes on all at once and without provocation, when you break down the components of your symptoms, you learn that there is a sequence of thoughts, behaviors, and physiological sensations that comprise the reaction.
By acquiring the facts about panic symptoms, you learn that many of your fears about panic sensations are not accurate, and that panic attacks are an adaptive, safe, reaction that actually assists in preparing you for fighting in or fleeing from dangerous situations.
In breathing retraining you will learn to modify respiration, using diaphragm muscles, and reducing respiration rate and flow to gain control over hyperventilation that is responsible for generating panic sensations. A new development in this area is the use of capnometry, which provides you with immediate feedback about your respiration that can be useful for enhancing this part of treatment. To learn more about breathing retraining and Freespira click HERE.
You will also learn to restructure your thoughts about panic, which involves developing new ways to think about your body’s physiological sensations so you can learn to accept and not fear them.
Finally, in exposure, you will gradually confront the situations you have been avoiding that trigger sensations (situational exposure), and intentionally generate panic symptoms you have been avoiding using a set of exercises (known as interoceptive exposures) specifically designed for this purpose. The goal of exposure is to generate new learning to change the reactions you have to panic sensations, first in isolation and then in the context of feared situations. The goal is not to never feel anxious or have panic sensations, but instead, to learn not to fear sensations and know you can handle them when they occur.
The goals of cognitive behavioral sex therapy are to enhance sexual satisfaction and pleasure by changing maladaptive sexual thoughts and behaviors. Treatment is conducted in individual or couple format, depending on the case, and is individually tailored to meet your specific needs. Typically, plans for treatment include learning about commonly-held myths and misconceptions about sex and developing an adequate understanding of sexual anatomy physiology. You work on developing healthy and adaptive attitudes about sex. You learn how to identify and modify specific negative automatic thoughts about sex using cognitive restructuring.
Since many couples have problems finding adequate time for sexual activity, and avoid trying because of a fear of failure, you learn to develop skills for scheduling and planning intimate time together. This includes specific behavioral homework assignments during which you carry out a series of graduated, home-based techniques to reduce anxiety about performance during sex and increase your focus on pleasure. These are called sensate-focus exercises, and often involve expanding sexual repertoire to minimize boredom and maximize interest and arousal. You work on developing improved sexual communication skills by identifying and modifying inefficient or ineffective patterns of interaction pertaining to sex. When appropriate, you may be referred to other clinicians for further assessment and treatment of problems that can interfere with normal sexual response and with sex therapy, such as general relationship problems, individual psychological problems such as depression or anxiety, or medical problems.
When applicable, you may also discuss integrating the use of response-enhancing medications such as Viagra or Levitra into your plan.
The primary behavior treatment for Tics and Tourette’s is called the Comprehensive Behavioral Intervention for Tics (CBIT). CBIT has been shown to be effective in reducing tic severity and teaching individuals a successful management strategy for their symptoms. The treatment focuses on training individuals to increase awareness of tics and to do a competing behavior when they feel the urge to tic. This is sometimes referred to as Habit Reversal Training (HRT). Additionally, CBIT involves making environmental changes and changes to activities that help reduce the total number of tics. This aspect of the treatment is often called the functional intervention. While tics have a neurological basis, tics are also sensitive to the environment in which they occur. Treatment works to recognize how and what environments impact tics, and how to make successful environmental changes.
Treatment for agoraphobia includes a number of cognitive and behavioral interventions. Behavioral interventions are exposure-based (Exposure Therapy) and focus on doing the activities that one is avoiding, such as leaving one’s house or entering specific situations. When working in Exposure Therapy, individuals often break down larger goals into smaller steps. By putting these steps in a hierarchy from least anxiety-provoking to most anxiety-provoking, individuals can systematically practice moving towards their larger goals. Ultimately, the goal is for individuals to know they can face feared situations and places at any point on their hierarchy. Cognitive interventions focus on working with thinking patterns that can fuel anxiety and avoidance. Individuals learn and develop strategies to respond to problematic cognitions that play a role in their anxiety and avoidance behaviors.
Additional interventions can include relaxation training, acceptance and commitment therapy (ACT), and mindfulness training. These tools improve an individual’s ability to sit with anxiety and uncomfortable emotions while maintaining motivation.
Agoraphobia can often present with symptoms of panic attacks and panic disorder. When this is the case, the agoraphobia treatment plan is integrated into panic treatment.
Body Focused Repetitive Behaviors (BFRBs) such as Trichotillomania (Hair Pulling) and Skin Picking
The treatment goal for problems with body focused repetitive behaviors (BFRBs) is learning how to reduce and manage your symptoms. Symptoms typically don’t remit permanently, but with increased awareness of problem components and a willingness to practice strategies regularly, patients can reduce symptoms.
Treatment begins with detailed self-monitoring of the problem behavior, including its antecedents and consequences. Monitoring increases self-awareness of problem components and guides the selection of interventions.
Habit Reversal Training (HRT) has been used for many years to increase awareness of precursors to engaging in BRFBs and situations where the behaviors are likely to occur, develop relaxation skills to reduce feelings that trigger pulling or picking, practice responses that are incompatible with pulling and picking (habit reversal), and increase social support to enhance motivation.
In recent years, a comprehensive model for behavioral treatment of trichotillomania (ComB) has expanded upon the interventions in HRT by identifying problem components across five domains: sensory, cognitive, affective, motoric, and place. Interventions are individually tailored to address problems within these domains. For example, interventions may include using sensory substitutes such as toys to fidget with, talking back to problematic thoughts, learning emotion and arousal regulation strategies, using stimulus control strategies (e.g., covering mirrors, removing tweezers), and blocking automatic motor responses (e.g., wearing gloves, changing hand positions). Creative solutions are encouraged to help individualize strategies.
Acceptance-based strategies, such as those used in Acceptance and Commitment Therapy (ACT) and emotion-regulation strategies from Dialectic Behavior Therapy (DBT) are also beneficial when learning to manage problems with BFRBs.
Exposure and Response Prevention (ERP) is considered to be the gold standard for treatment of OCD. It involves facing intrusive thoughts, urges, or images and situations that trigger them and NOT using compulsions. Initially, your anxiety is likely to increase as you face your fears rather than try to avoid or escape from the discomfort they provoke, but if you stay with your feelings, you learn something new (e.g., you can handle them without using compulsions). You learn to lean in toward the uncertainty and doubt that obsessions trigger and break free from the cycle of using compulsions in response to feelings of distress.
Monitoring your obsessions and compulsions is a first step toward identifying your particular ERP practices. Creating a hierarchy of feared situations and obsessions and ranking them from least (0) to most (100) anxiety provoking (called Subjective Units of Distress or SUDS) can serve as a guide when selecting ERP practices. While you may start with easier practices before embracing more difficult ones, the goal of treatment is to learn that you can handle any obsession, wherever it ranks on your hierarchy and in whatever situation it occurs, without using compulsions as a way to find temporary relief from distress. Initially, practices may be well-planned with your therapist but eventually you will practice response prevention to spontaneous triggers on your own throughout the day.
Diligent practice between sessions is a key to successful treatment, and your therapist will help you plan how to do this. Most practices will be in vivo, meaning real-life (e.g., touching objects that feel contaminated and not washing, leaving the house without engaging in checking rituals), but when real-life practices aren’t possible for some obsessions (e.g., “a loved one might die because of something I did in the past”), imaginal exposures will help you face your fears through imagined scenarios. With repeated practice, your confidence in your ability to face your fears will grow.
Recovery does not mean that you’ll never be bothered by obsessions again, but it does mean that if you continue practicing leaning in toward obsessions and tolerating the anxiety they trigger instead of using compulsions, you are likely to become free from the grip of OCD.
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the frontline treatment for insomnia and other sleep disorders. It has also been shown to be a very effective transdiagnostic treatment across mood and anxiety disorders. CBT-I uses strategies such as sleep monitoring, behavior modification and cognitive interventions to change dysfunctional sleep patterns and habits.
The first step in treating sleep difficulties with CBT-I is to identify the underlying causes of insomnia. This involves completing a thorough clinical interview with the therapist and utilizing a sleep diary to evaluate sleep patterns and other factors that influence falling and staying asleep. Specific patterns of thoughts and behaviors are identified and addressed in ongoing treatment.
A CBT-I treatment plan generally combines psychoeducation about improving “sleep hygiene” behaviors, relaxation training and cognitive therapy. More complex cases may utilize sleep restriction or stimulus control. Sleep restriction may be appropriate for individuals who have difficulty falling asleep. Stimulus control involves strategies such as learning to leave the bed if awake for more than twenty minutes and to move to a quiet place to read or relax until sleepy.
The goal of CBT-I is to gently reshape sleep habits and thoughts about sleep, and to increase confidence in one’s ability to fall and stay asleep without medication. CBT-I has been widely studied and demonstrated to be highly effective. It is a time-limited treatment that can be effective in as a few as 4-5 sessions.
Cognitive behavioral therapy (CBT) for social anxiety is an empirically validated treatment that provides individuals with cognitive and behavioral skills to manage and reduce anxiety related to social situations. CBT for social anxiety incorporates psychoeducation about the mechanisms that underlie problems in social anxiety (e.g., fear of evaluation, escape and avoidance behaviors, attentional focus towards threat and self-evaluation) and how they work to perpetuate problems; cognitive strategies to identify and respond to unhelpful thoughts and beliefs that are triggered in social situations or in anticipation of them; and behavioral strategies to help you build confidence in your ability to tolerate anxiety and engage in social situations.
Your therapist will work you to identify thoughts that are triggered in social situations (e.g., I’ll embarrass myself and not be able to handle it), the core beliefs that might underlie them, (e.g., I’m not capable; I’m unlikeable) and the unhelpful behaviors that contribute to them (escape, avoidance, “safety behaviors” to avoid showing anxiety). You’ll learn how to identify and challenge your anxious thoughts and develop more helpful and accurate responses. You’ll learn how thoughts and expectations trigger a cascade of physiological and behavioral symptoms that reinforce negative self-beliefs. For example, the more you escape, avoid, or use behaviors to hide anxiety in social situations, the more you feed the belief that anxiety (or showing anxiety) is threatening and that you must escape or avoid it. You’ll work with your therapist to identify scenarios and situations where your symptoms are triggered and plan graded exposures to build tolerance and confidence that you can handle them. You’ll conduct “behavioral experiments” to test your beliefs about potential catastrophic consequences of challenging your fears.
Cognitive behavior therapy (CBT) for depression is an evidence based treatment that involves identifying and responding to thoughts and behaviors that contribute to and maintain depression. You’ll learn to monitor your mood and situations that trigger automatic thoughts, underlying beliefs, and problematic behaviors.
Automatic thoughts are the immediate thoughts that run through our minds, and they often contain distortions, especially when we feel depressed. For a list of common distortions, click here. These distortions in our thinking can affect the way we feel and what we do. Cognitive restructuring interventions are used to identify and modify distorted cognitions in order to develop a more balanced perspective.
In the cognitive model of depression, schemas are defined as underlying cognitive structures that form early in life and affect how we interpret situations. The content of schemas can include core negative beliefs about ourselves (e.g., I’m incompetent, worthless), others (e.g., Others are untrustworthy, judgmental), the world (e.g., The world is dangerous, unpredictable) and the future (e.g., The future is bleak, hopeless). When we encounter situations that trigger these underlying beliefs, we filter our experiences through them, which can result in distorted automatic thoughts, negative emotions, and problematic behaviors. Identifying these schemas and evaluating their accuracy supports more helpful and accurate beliefs.
Behavioral experiments are used to help assess the validity of problematic beliefs and change unhelpful thoughts and behaviors.
Strategies to reduce repetitive negative cycles of rumination are also used in the treatment of depression.
Behavioral Activation (BA) in CBT targets the problematic behaviors of avoidance and withdrawal, which often occur in depression, by helping individuals increase their activity levels and opportunities for more positive reinforcement. Activity Scheduling is used to plan activities, especially those that provide a sense of mastery and accomplishment, pleasure, and social support.
Relapse prevention is an important element of treatment. You and your therapist will review what you have learned and the skills that you have developed in treatment and plan for how to handle possible setbacks.
The goal of CBT for specific phobia is to reduce avoidance and distress associated with with phobic triggers. One of the first steps is monitoring your reactions when you face fear-provoking triggers (or thoughts, images, or other representations of the triggers), and to break them down into a sequence of thoughts, behaviors, and physiological reactions that can be addressed one step at a time. You will also learn about the adaptive nature of the fear response, and how and when it becomes a problem.
Another step in the process is developing skills in cognitive restructuring, which involves establishing new ways to think about the fear-provoking triggers, and your body’s responses to those triggers, so you can learn to accept and not fear them.
Finally, during exposure, you will gradually and in a carefully planned manner confront the triggers you have been avoiding (situational exposure), and intentionally generate anxious physical symptoms that have been associated with the triggers (interoceptive exposure). This includes generating a Fear and Avoidance Hierarchy, which sets the stage for tackling your phobia in a stepwise manner, starting with the least anxiety-provoking challenges first. The goal of exposure is to reduce anxious reactivity, and to generate new learning to change the responses you have to your phobic triggers and your physical reactions so that you may become free of the constraints of the phobia and live without the associated distress and avoidance.