Updated: Dec 31, 2021
Learn all the key concepts of CBT, one of the most effective mental health treatments ever.
In the 1960s, a doctor named Aaron Beck made a groundbreaking discovery that would later seem obvious. He found that many people don’t think very nice things about themselves.
Humans often have thoughts like:
“I’ll fail at everything I try.”
“There’s something inherently wrong with me.”
These beliefs then lead to all kinds of life problems. They cause people to feel discouraged, anxious, depressed, and to behave in ways that seem to make their lives more difficult, rather than easier.
Dr. Beck worked with his patients to find ways to challenge these unhelpful thoughts. To everyone’s surprise at the time, it worked—really well. CBT was born.
Cognitive behavioral therapy, or CBT, is a type of mental health treatment and set of techniques that help people challenge negative thoughts.
By changing patterns of thinking about themselves and the world, people can better deal with, and sometimes overcome, daily challenges as well as mental health problems.
I’ve created a series of worksheets that are based on the most effective CBT techniques for anxiety and PTSD specifically. You can check them out here.
CBT is also sometimes called cognitive behavior therapy (rather than “behavioral”) or simply, cognitive therapy.
The therapy strategies involved are also helpful for everyday stress and problems, and many people use them outside of mental health treatment.
This guide will take a closer look at CBT. You’ll get an idea of the basic premise, specific techniques, and areas where it's grown. It will also include next steps you can take, either for yourself or as a mental health professional.
How CBT Works
The most basic idea of CBT is fairly simple. It’s often explained with a tool called the CBT triangle (see the diagram below). The triangle shows how our thoughts (especially patterns of thoughts) lead to certain feelings, which lead to certain behaviors.
Over time, this often negative pattern leads to ongoing problems.
Here’s an example.
Laura believes that she’s not capable of being in a happy relationship. That’s her thought.
A friend, Tony, asks Laura out. They go out on a date, but Laura feels self-conscious and embarrassed. This brings up feelings of shame, because of her underlying beliefs about herself. Shame and embarrassment are her feelings.
The more Laura thinks about the date later, the more horrified she becomes. Even though Tony texts her, she thinks it’s just out of politeness.
She texts Tony back and says it was nice to hang out, but obviously this isn’t going to work out. This is her behavior.
No matter what Tony says in the text, Laura may not be able to see anything positive. She may continue to avoid situations where she could meet someone new, and simply give up, despite wanting a relationship deep down. This is Laura’s pattern.
Laura’s situation has nothing to do with being desirable, or if she’s capable of having a happy relationship. It has to do with her thoughts and feelings about herself and the situation.
So what can she do about it?
Laura may need to change her patterns of thinking. Sometimes this process is simple. Just looking at alternatives about a situation can make things more clear.
In other cases, it may take more time. If Laura has felt this way for years, she may need to work through it a bit longer. She will also need to challenge her assumptions. This is where CBT comes in.
With CBT, Laura may change her pattern to look something like this.
Laura has the initial thought that she can’t be happy in a relationship. Tony texts her, and she has the urge to cut things off. Then she remembers that she is working on changing her thoughts. She thinks perhaps she’s jumping to conclusions.
Laura feels calmer about the situation, and even a bit hopeful (her feeling) since she’s been questioning her initial beliefs.
Instead of dismissing Tony, Laura takes more time to look at the text. She reads it to a friend, who says it sounds like Tony is hinting at asking her out again.
Laura changes her response, or her behavior, considerably. She texts Tony back and says she had a good time. Tony also enjoyed the date, and asks if she wants to go out again the next night.
Laura begins to reconsider her beliefs. Maybe this is worth trying, she thinks.
By challenging her assumptions about herself and others, Laura is able to change her pattern. She decided to try something entirely new, which put into question her previous beliefs.
This technique, called gathering evidence, or sometimes exposure, also helps Laura view her world differently.
Mental health professionals often teach this process to patients. By working with a therapist for several weeks, people can start to think differently, which can be life-changing.
Therapists may use other techniques in CBT sessions, including mindfulness and gradual exposure. These strategies, combined with challenging automatic negative thoughts, can lead to significant life improvements.
Others learn techniques on their own, through self-help resources, and are able to put them into practice. This works particularly well for everyday challenges, like dealing with work stress, or increasing confidence.
Cognitive Behavioral Theories
Simply put, cognitive behavioral theories are based on the idea that our thoughts, beliefs, and perceptions affect our lives, even more than events themselves.
By challenging these thoughts, through thinking of things differently and testing new behaviors in the world, people can feel better and often reverse symptoms.
Have you ever wondered how two people can go through the same tragedy, and respond entirely differently? This is because each person has their own background, personality, history, biology, and way of thinking about life.
He was beloved and renowned in the field, and recently passed away at the age of 100.
He worked for decades on researching and developing the techniques used today.
Other experts confirmed Dr. Beck’s work over the years. While Dr. Beck was developing his own theory and treatment approaches, another psychologist named Dr. Albert Ellis was drawing similar conclusions.
Dr. Ellis also determined that people often held onto inaccurate thoughts, called thought distortions, or distorted thoughts. These thoughts lead people to suffer, and can lead to mental health problems like depression.
Dr. Ellis developed a similar therapy approach, called rational emotive behavioral therapy (REBT). Many of these strategies are combined with popular CBT techniques based on the same ideas.
Both REBT and CBT represented a shift from Freudian thinking at the time. They focus on making changes in the here and now, including looking at current thoughts and taking action.
Freud’s theories were quite different, and were focused on analyzing childhood experiences, without much consideration of thoughts and behaviors that are happening today.
History of CBT
The ideas of CBT began to take off in the 1970s and 80s, after two major studies confirmed it worked better than medication for depression.
Over the years, hundreds of studies would go on to confirm its effectiveness. Dr. Beck continued to expand his work, participating in multiple academic studies and writing numerous books.
"The applications of CBT to a host of psychological and medical disorders extend far beyond anything I could have imagined when I treated my first few depressed and anxious clients with cognitive therapy," said Dr. Aaron Beck.
This statement was included in the newest edition of the book Cognitive Behavior Therapy, Basics and Beyond, by daughter Judith Beck. She is the foremost leader in the field of CBT, and continues related research and training.
Areas of Expansion
Many modern therapies have been developed, or adapted, from the ideas of the original cognitive behavioral therapy. Specialized treatment models and similar therapies use the CBT model to treat multiple conditions and challenges.
Some of the many areas treated include:
PTSD (post-traumatic stress disorder)
Because of its broad application, CBT has been built upon to develop new therapies, and it has in-turn added the most helpful approaches to its arsenal.
Expansion in Recent Years
Other popular treatment models have grown out of this foundational therapy. A few of the best known include dialectical behavioral therapy (DBT), trauma-focused CBT (TF-CBT), and cognitive processing therapy (CPT).
Dr. Judith Beck (and her father) have also stressed that CBT as a whole has grown beyond just looking at treating the negatives, and that a focus on the positives is just as important (how appropriate for the pioneers of CBT).
This means that instead of just figuring out what is wrong with a person's thoughts or life, we look at what's helpful about their situation, personality, and history.
For example, perhaps our friend Laura from earlier is very creative, and is known for being a great listener. These skills can not just help her in the dating world, but can help her create a happy life with or without a new partner.
Expanding this focus on strengths, while incorporating elements of other new therapies, has helped CBT remain one of, if not the, most flexible and effective treatments ever developed in the world of mental health.
In the 1990s, the two Doctors Beck developed the Beck Institute for Cognitive Behavior Therapy to support and grow these efforts. The organization provides information and training to therapists and others around the world who use CBT techniques.
Here’s a closer look at some of the mental health conditions that CBT continues to tackle.
Treating Anxiety Disorders
Those who experience extreme anxiety often have false beliefs about certain situations or possible outcomes. My clients often say they know “logically” that something isn’t likely, but they continue to have the same fear.
For example, someone who is claustrophobic may fear that they’ll get trapped in a small space. While this is unlikely to present them with any serious danger, even if it were to happen for some reason, they suffer from a debilitating fear, or phobia.
The typical CBT treatment for this would include two main strategies. First, we would challenge the person’s assumptions in session.
Someone with claustrophobia may have unrealistic fears about becoming trapped. Plus, they may be exaggerating the danger even if this were to occur.
Let’s say they became trapped for hours in traffic, unable to get out of their car. This would be unpleasant for anyone, and excruciating for many people who fear small spaces, but how likely would it be to cause death?
And would someone really be trapped? Could they technically get out of the car and leave?
By talking through these scenarios, the person with the fear can start to reconsider their beliefs. This same technique can be applied to general anxiety disorder, another common condition.
The second part of anxiety treatment is gradual exposure, or testing of one’s assumptions. These techniques overlap somewhat.
In the case of the claustrophobia, my client and I might make a plan for them to gradually test out their fears. They might start by just sitting in their car in the driveway, or standing in a small space with a door open.
Over time, we slowly increase the difficulty of these exposure exercises, until the fear is a faint memory.
While the phobia may begin to crop up once in a while throughout life, it will no longer cause everyday stress. And if it starts to get worse, the same techniques will usually work even faster and better down the road.
Many people never struggle with the same fear again.
I find that when people are suffering from depression, cognitive processing is extremely difficult. The brain becomes determined to hold onto negative thoughts, and any amount of reframing is not effective.
Instead, I typically start with a commonly used CBT technique called behavioral activation. This is intervening at a different point in the triangle.
This may also be seen as a type of exposure, and is similar to facing anxiety fears. However, we can often start with fun, easy activities instead.
Often people with depression spend most of their time inside and isolated, if not literally under the covers. We might start with simply walking to the mailbox once a day, or making one trip to the grocery store.
Over time these simple activities will start to alleviate symptoms. Once this starts to work, it becomes easier to begin to talk through the things that are contributing to depression.
The other most common issue I treat in my practice is post-traumatic stress disorder (PTSD). It responds particularly well to CBT strategies.
There are three types of PTSD treatments that use CBT techniques. These include the following:
Prolonged Exposure Therapy (PE)
Cognitive Processing Therapy (CPT)
Trauma-Focused CBT (TF-CBT)
While each of these techniques are a bit different, they include nearly all of the same elements. I’ll review each technique below.
Education, or psychoeducation. This is how we start any treatment for PTSD, by reviewing the basics of the disorder and discussing symptoms. Education about mental health is often called “psychoeducation.”
Relaxation, or mindfulness. The plan with treatment is for most or all of the symptoms to subside. However, until that happens, relaxation techniques can help make anxiety and fears more manageable.
Processing. We’ve already touched on the idea of cognitive processing. This is an important element of this treatment as well. In the case of these targeted treatments, the processing, or discussing, will focus almost entirely on thoughts and beliefs that are specific to the trauma that’s causing the PTSD.
Exposure to the memory. In the case of prolonged exposure, as you might imagine, this technique is center stage. The participant dives into the memories and feelings they’ve been avoiding. In the other two therapies this process happens more gradually, either through the processing phase, or through specific exercises such as writing about trauma memories.
Exposure to fears. All three of these therapies include the option to practice with everyday fears relating to the trauma. For example, someone may be afraid to drive by the area where the trauma occurred, or to go into public at all. By gradually facing these fears, they begin to see that they can feel safe again.
The reason CBT works so well with PTSD is because the condition is caused by negative beliefs and a lack of confidence. Most often, the person who’s struggling believes they are somehow to blame for the trauma.
This causes them to remain in a fearful state, because they believe they won’t be able to stay safe in the future.
Through effectively challenging these fears and assumptions, the person who has survived the trauma begins to see that they can be safe in the world. The symptoms of PTSD then subside.
It’s pretty amazing, I think!
Finding a Therapist
CBT is a fairly wide field. Because there are so many branches of it, it can become confusing if you’re looking for a therapist who uses this approach. Therapists can also vary widely in their training.
Someone who uses CBT may have had a brief training course, or may have studied the craft for years. Generally, I recommend finding someone who is trained, has a few years of experience, and has had success in your specific issue.
For example, I’ve specialized in treating anxiety and PTSD. Clients who are looking for help with these areas would benefit from a therapist with my training. If they’re dealing with something else, perhaps depression, another therapist may be more helpful.
If you have options, gather information about your possible provider and ask questions. Find out what techniques they use, and ask about success from their past clients. Here are some ways to look for a CBT therapist:
Provider directories. Online listings, such as Psychology Today, Therapy Den, or Open Path list therapists and their specialties. Look for one who matches your needs.
Insurance listings. If you plan to stay within your insurance network, this is a good place to start. Contact your insurance company or look through their list of providers.
Local searches. Many therapists now make efforts to list their practice and services in local search engines. So if you type “CBT therapist,” into Google, you may get some options nearby.
SAMHSA locator. The Substance Abuse and Mental Health Services locator includes larger grant-funded and non-profit agencies that provide counseling. These are often the only organizations that provide in-network providers, however sometimes therapists carry very high caseloads and may not be available regularly. You can access the locator here.
In recent decades, experts have wondered if CBT could work outside of therapy. The conclusion is, that in many cases, it can! It doesn’t work for everyone, however in some cases, for some people, it does the trick.
These findings are important, because not everyone can access therapy, let alone CBT in particular, and self-help programs may be a helpful alternative.
One group of researchers took a look at numerous studies on CBT self-help programs. The research they looked at examined self-guided CBT programs for problems like anxiety, depression, and insomnia. They concluded the following:
Those with higher education may benefit the most from self-help CBT
It worked better for those whose problem started at an older age (versus in childhood, for example)
Those who participated more and followed the protocol most closely benefited the most
In my own practice, I’ve found that last result to be most important. Many people have trouble completing any program or developing a new habit without accountability. The structure of therapy sessions can provide that.
Another thing to consider is how set in the problem is. If someone has struggled for years with a negative belief, for example, it may take an outside person to walk them through it. However, once people get the hang of the process, they are often able to challenge thoughts on their own.
I will also note that the outside person doesn’t always have to be a therapist. A wise friend, someone else who has been through recovery work, or simply someone willing to listen can make the difference.
Often just talking through a problem or struggle can help you draw new conclusions about it.
I would suggest that people ask these questions when considering self-help options, versus professional CBT therapy (although keep in mind you can do both):
Are you in imminent danger? If you are suicidal, self-harming, or having any other symptoms that are leading to your life seeming out of control, then professonal help is always recommended.
What else have you tried? If you’ve tried other types of therapy for years and nothing has worked, then it may be worthwhile to try something different. Self-help CBT might be a great tool that makes the difference.
Have you gotten to a stuck point? Have you been able to make progress up to a point, but some things just keep bothering you? A few sessions with a CBT therapist may help.
Do you generally find self-help books and tools beneficial? If you find you can keep your interest and follow recommendations, then self-guided techniques may work well.
Common CBT Techniques
Here are some of the CBT techniques you might encounter in a therapy session, or through your own self-study.
Understanding the CBT triangle. This tool helps you learn the connection between thoughts, feelings, and behaviors.
Recognizing cognitive distortions, or negative thoughts. Common distortions include all-or-nothing thinking, or overgeneralizing. By learning that many thoughts aren’t based in fact, you can start to see things differently.
Targeted challenging of thoughts. Rather than simply discussing whatever topics come up, CBT typically focuses on specific problems and beliefs, based on your goals. If you’re struggling with confidence, for example, you would spend your time honed in on that topic.
Mindfulness. Many CBT programs now incorporate mindfulness into their protocols. This is a great technique that helps you better understand yourself and your behaviors.
Exposure techniques. Programs focused on anxiety and PTSD typically include some type of exposure option. This might include exposure to your memories, or everyday situations you fear.
Journaling, or writing narratives. Writing about your memories or current situation can help you identify negative beliefs about yourself and the world. You can then begin to challenge them.
Processing. Through talking through your thoughts, beliefs, feelings, and fears, you can better understand and often change them.
Socratic questioning. Many CBT therapists use a technique called Socratic questioning. CBT worksheets may also use a version of this, with prompts to consider certain questions. These help you draw conclusions yourself, rather than being told what to believe. This technique is particularly helpful, because it’s a tool you can keep and use for life.
Here’s a look at common CBT definitions you might encounter, on your own or in therapy. I’ve included a definition of each.
Cognitive Distortions: Beliefs that are not based in fact. They often include negative thoughts about oneself, the world, or a situation from the past. CBT tools may include a list of common cognitive distortions you can sort through.
Core Beliefs. These beliefs are also cognitive distortions, but tend to be on a deeper level. For example, “I’m a worthless person,” is a common negative core belief.
Exposure, or behavioral experiments: Trying new things to challenge negative beliefs. For example, if someone thinks they will be rejected, they might try making a new friend. Therapists may use an exposure hierarchy to help with this.
Automatic Thoughts: Thoughts that happen instantly, that we don’t generally question on our own. They are often negative and self-critical in nature.
Thought record: This is the process of recording thoughts, assumptions, beliefs, and reactions to situations. By better understanding this pattern, you can begin to change it.
Training for Therapists
Are you interested in becoming a CBT therapist, or are you a mental health professional already, interested in this specialty? Here are some training options to help you take the next step. (If you’re not already a therapist, you’ll also need to complete the education and supervision required to become licensed.)
Check out an introductory CBT class. A one or two-hour CE course can help you get a better idea of this therapy, and if it matches your clinical style. You may also pick up some basic techniques you can integrate into other modalities.
Try it for yourself. What better way to learn about a therapy than to see if it helps you? Find your own CBT therapist, or check out a self-help program to learn the basic techniques.
Take a longer certified program. If you’re ready to jump all the way in, try a more extensive course with the Beck Institute. Other specialized programs for PTSD are also available, such as CPT and TF-CBT. These require several days of training, combined with a year-long supervision where you complete cases and review them with a supervisor.
Want more? I love the option of self-help CBT, and I also enjoy helping other therapists provide this intervention. I’ve developed a series of worksheets focused on the techniques I use for anxiety and PTSD. Learn more here.
Beck Institute for Cognitive Behavior Therapy. https://beckinstitute.org/
Cognitive Behavior Therapy, Third Edition: Basics and Beyond 3rd Edition, (2021)
Coull, G., & Morris, P. G. (2011). The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: a systematic review. Psychological medicine, 41(11), 2239–2252. https://doi.org/10.1017/S0033291711000900
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1
New York Times, Dr Aaron T. Beck, Developer of Cognitive Therapy, Dies at age 100. https://www.nytimes.com/2007/07/24/obituaries/24cnd-ellis.html
New York Times, Dr. Albert Ellis, Influential Figure in Modern Psychology, Dies at 93. https://www.nytimes.com/2007/07/24/obituaries/24cnd-ellis.html