Cognitive behavioral therapy

What is CBT?
Cognitive behavioral therapy (CBT) is a form of treatment that focuses on examining the relationships between thoughts, feelings and behaviors. By exploring patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts, people with mental illness can modify their patterns of thinking to improve coping. CBT is a type of psychotherapy that is different from traditional psychodynamic psychotherapy in that the therapist and the patient will actively work together to help the patient recover from their mental illness. People who seek CBT can expect their therapist to be problem-focused, and goal-directed in addressing the challenging symptoms of mental illnesses. Because CBT is an active intervention, one can also expect to do homework or practice outside of sessions.

A person who is depressed may have the belief, “I am worthless,” and a person with panic disorder may have the belief, “I am in danger.” While the person in distress likely believes these to be ultimate truths, with a therapist’s help, the individual is encouraged to challenge these irrational beliefs. Part of this process involves viewing such negative beliefs as hypotheses rather than facts and to test out such beliefs by “running experiments.” Furthermore, people who are participating in CBT are encouraged to monitor and write down the thoughts that pop into their minds (called “automatic thoughts”). This allows the patient and their therapist to search for patterns in their thinking that can cause them to have negative thoughts which can lead to negative feelings and self-destructive behaviors.

When is CBT used as a form of therapy?
Scientific studies of CBT have demonstrated its usefulness for a wide variety of mental illnesses including mood disorders, anxiety disorders, personality disorders, eating disorders, substance abuse disorders, sleep disorders and psychotic disorders. Studies have shown that CBT actually changes brain activity in people with mental illnesses who receive this treatment, suggesting that the brain is actually improving its functioning as a result of engaging in this form of therapy.

CBT has been shown to be as useful as antidepressant medications for some individuals with depression and may be superior in preventing relapse of symptoms. Patients receiving CBT for depression are encouraged to schedule positive activities into their daily calendars in order to increase the amount of pleasure they experience. In addition, depressed patients learn how to change (“restructure”) negative thought patterns in order to interpret their environment in a less negatively-biased way. As regular sleep has been found to be very important in both depression and bipolar disorder, therapists will also target sleeping patterns to improve and regulate sleep schedules with their patients. Studies indicate that patients who receive CBT in addition to treatment with medication have better outcomes than patients who do not receive CBT as an additional treatment.

CBT is also a useful treatment for anxiety disorders. Patients who experience persistent panic attacks are encouraged to test out beliefs they have related to such attacks, which can include specific fears related to bodily sensations, and to develop more realistic responses to their experiences. This is beneficial in decreasing both the frequency and intensity of panic attacks. Patients who experience obsessions and compulsions are guided to expose themselves to what they fear in a safe and controlled therapeutic environment. Beliefs surrounding their fears (of contamination, illness, inflicting harm, etc.) are identified and changed to decrease the anxiety connected with such fears.

The same is true for people with phobias, including phobias of animals or phobias of evaluation by others (termed Social Anxiety Disorder). Those in treatment are exposed to what they fear and beliefs that have served to maintain such fears are targeted for modification. CBT is often referred to as a “first line treatment” in many anxiety disorders including generalized anxiety disorder,posttraumatic stress disorder, panic disorder, and obsessive-compulsive disorder and specific phobias.

Over the past two decades, CBT for schizophrenia has received considerable attention in the United Kingdom and elsewhere abroad. While this treatment continues to develop in the United States, the results from studies in the United Kingdom and other countries have encouraged therapists in the U.S. to incorporate this treatment into their own practices. In this treatment, often referred to as cognitive behavioral therapy for psychosis (CBT-P), patients are encouraged to identify their own delusional or paranoid beliefs and to explore how these beliefs negatively impact their lives.

Therapists will then help patients to engage in experiments to test these beliefs. Treatment focuses on thought patterns that cause distress and also on developing more realistic interpretations of events. Delusions are treated by developing an understanding of the kind of evidence that a person uses to support their beliefs and encouraging them to recognize evidence that may have been overlooked, evidence that does not support the belief. For example, a person who thinks that they are being videotaped by aliens may feel less worried when their therapist helps them to discover that there are no hidden cameras in the waiting room, or that a television remote does not contain any Alien technology within it.

CBT’s focus on thoughts and beliefs is applicable to a wide variety of symptoms. While the above summary is certainly not comprehensive, it provides an overview of the principles of CBT and how they apply to the treatment of various mental illnesses. Because CBT has excellent scientific data supporting its use in the clinical treatment of mental illness, it has achieved wide popularity both for therapists and patients alike. A growing number of psychologists, psychiatrists, social workers, and psychiatric nurses have training in CBT.

Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., July 2012