Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy is based on the idea that it is not only events that affect how we feel, but also how we interpret them and what we do in response. For example, if you think "everyone will judge me," you may feel anxious and avoid a party, which then confirms the belief and keeps the anxiety going.

CBT helps break these cycles. It focuses on the present and on specific goals, rather than spending most of the time exploring the past, although past experiences may be discussed when relevant. It is collaborative: the therapist and client work together as a team, and the client gradually becomes their own therapist.

Cognitive behavioural therapy, as it is spelled in the UK, Ireland, Australia and other countries, is offered in many formats, including individual sessions, groups, online programs and guided self-help.

A course of CBT usually follows a clear structure. After an assessment, you and your therapist develop a shared understanding of your difficulties, sometimes called a formulation, and agree on goals. Sessions then focus on learning and practicing skills.

Key ingredients include:

• Identifying patterns linking thoughts, emotions, body sensations and behaviors
• Testing unhelpful thoughts against evidence
• Changing behaviors that keep problems going, such as avoidance
• Practicing new skills between sessions
• Reviewing progress and adjusting the plan

CBT is typically short-term, often between several weeks and a few months, depending on the problem and its complexity. Sessions are usually weekly. Between sessions, clients often complete exercises, which is one of the reasons CBT can be effective: change happens in daily life, not only in the therapy room.

CBT techniques vary depending on the problem, but common ones include:

• Thought records: writing down situations, thoughts, feelings and alternative perspectives
• Cognitive restructuring: identifying thinking traps, such as catastrophizing or mind reading, and finding more balanced views
• Behavioral activation: scheduling meaningful and enjoyable activities, especially for depression
• Exposure: gradually facing feared situations to reduce anxiety
• Behavioral experiments: testing predictions in real life
• Problem-solving: breaking problems into manageable steps
• Relaxation and breathing techniques

CBT worksheets are tools used to structure these exercises, and many are available in self-help books. They are most helpful when used with guidance, as a therapist can tailor them to your situation.

CBT for anxiety is one of its best-known applications. It is a recommended treatment for generalized anxiety, panic disorder, social anxiety, phobias and health anxiety, often using exposure to help people face fears rather than avoid them.

Exposure and response prevention (ERP) is a form of CBT designed for obsessive-compulsive disorder. It involves gradually facing triggers for obsessions while resisting compulsions, so the brain learns that anxiety reduces without rituals.

Specialized forms of CBT exist for many conditions, including depression, PTSD (trauma-focused CBT), insomnia (CBT-I), eating disorders (CBT-E), psychosis (CBTp) and chronic pain. Related approaches, sometimes called third-wave therapies, include acceptance and commitment therapy, dialectical behavior therapy and mindfulness-based cognitive therapy.

CBT works well for many people, particularly those who want a practical, structured approach and are willing to practice skills between sessions. It is effective for children, teenagers, adults and older adults when adapted appropriately.

It may be less suitable as the only approach for some complex, long-standing difficulties, where longer-term or integrative therapy may help more. Some people prefer therapies that focus more on relationships or exploring the past. A good therapist will discuss options with you.

CBT can be combined with medication when a psychiatrist recommends it, for example for moderate to severe depression or OCD. The most important factor is finding a therapist you feel comfortable working with.

CBT is provided by psychologists, clinical psychologists, psychotherapists, licensed counselors and other mental health professionals with specific training. When choosing a therapist, it is reasonable to ask about their training in CBT and experience with your concern.

In a first session, the therapist will ask about your difficulties, their history and your goals, and explain how CBT works. You might begin tracking thoughts or behaviors before the next session. Over time, sessions become more focused on practicing skills and preparing for life after therapy, including a plan to prevent relapse.