Cognitive behavioral therapy

Definition

Cognitive behavioral therapy is a common type of mental health counseling (psychotherapy). With cognitive behavioral therapy, you work with a mental health counselor (psychotherapist) in a structured way, attending a limited number of sessions. By helping you become aware of inaccurate or negative thinking, cognitive behavioral therapy allows you to view challenging situations more clearly and respond to them in a more effective way.

Cognitive behavioral therapy can be a very helpful tool in treating mental illnesses such as anxiety or depression. But, not everyone who benefits from cognitive behavioral therapy has a mental health condition. It can be a very effective tool to help anyone learn how to better manage stressful life situations.

Why it's done

Cognitive behavioral therapy is used to treat a wide range of issues. It's often the preferred type of psychotherapy because it can quickly help you identify and cope with specific concerns. It generally requires fewer sessions than other types of therapy and is done in a structured way that deals directly with specific challenges.

Cognitive behavioral therapy is a useful tool to address emotional challenges. For example, it may help you:

• Manage symptoms of mental illness, either by itself or with other treatments such as medications
• Prevent a relapse of mental illness symptoms
• Treat a mental illness when medications aren't a good option, such as during pregnancy
• Learn techniques for coping with stressful life situations, such as problems at work
• Identify ways to manage emotions, such as anger
• Resolve relationship conflicts and learn better ways to communicate
• Cope with grief, such as after the loss of a loved one
• Overcome emotional trauma related to abuse or violence
• Cope with a medical illness, such as chronic fatigue syndrome or cancer
• Manage chronic physical symptoms, such as pain, insomnia or fatigue

Mental health conditions that may improve with cognitive behavioral therapy include:

• Sleep disorders
• Sexual disorders
• Depression
• Bipolar disorders
• Anxiety disorders
• Phobias
• Eating disorders
• Substance abuse disorders
• Personality disorders
• Schizophrenia

In some cases, cognitive behavioral therapy is most effective when it's combined with other treatments, such as antidepressants or other medications.

Risks

In general, there's little risk in cognitive behavioral therapy. Because it can explore painful feelings and experiences, however, you may feel emotionally uncomfortable at times. Because psychotherapy sometimes involves emotional discussions, you may cry, get upset or feel angry during a session. You may also feel physically drained after a challenging session. Your therapist is trained to help you cope with these feelings and emotions.

Some forms of psychotherapy, such as exposure therapy, may require you to confront situations you'd rather avoid — such as airplanes if you have a fear of flying. This can lead to temporary stress or anxiety. But the coping skills you learn should help you later on to manage and conquer negative feelings and fears.

How you prepare

You might decide on your own that you want to try cognitive behavioral therapy. Or a doctor, relative, friend, employer or someone else may suggest psychotherapy to you. Here's how to get started:

• Find a therapist. You can find a therapist on your own — looking through the phone book or on the Internet, for instance. Or you can get a referral from a doctor, health insurance plan, friend or other trusted source. Many employers offer counseling services or referrals through employee assistance programs (EAPs). Before selecting a therapist, check credentials. Your therapist should be a licensed counselor, psychologist or other mental health provider experienced in cognitive behavioral therapy.
• Understand the costs. If you have health insurance, contact your health plan to be sure you understand what coverage it offers for psychotherapy. Some health plans cover only a certain number of therapy sessions a year. Also, talk to your therapist about fees and payment options.
• Review your concerns. Before your first appointment, spend some time thinking about what issues you'd like to work on. While you also can sort this out with your therapist, having some sense in advance may provide a starting point.

What you can expect

It's likely that you'll go to a therapist's office for cognitive behavioral therapy sessions. A therapist may have an office in a medical clinic, an office building or a home office. Therapy can also take place in a hospital if you've been admitted for treatment. You'll probably meet weekly with your therapist for one-on-one sessions that last 45 to 60 minutes. Cognitive behavioral therapy may also be done in groups — either with family members or with people who have similar issues.

Your first therapy session
Your first session is usually a time for the therapist to gather information about you and to determine what concerns you'd like to work on. The therapist may ask you to fill out forms about your current and past physical and emotional health. This information helps the therapist gain a deeper understanding of your situation. Your therapist will also want to know whether you might benefit from other or additional treatment, such as medications. It might take a few sessions for your therapist to fully understand your situation and concerns, and to determine the best approach or course of action.

The first session is also an opportunity for you to interview your therapist to see if his or her approach and personality are going to work for you. Make sure you understand:

• His or her approach
• What type of therapy is appropriate for you
• The goals of your treatment
• The length of each session
• How many therapy sessions you may need

If you don't feel comfortable with the first psychotherapist you see, try someone else. Having a good "fit" with your therapist can help you get the most benefit from cognitive behavioral therapy.

In general, conversations with your therapist are confidential. However, in certain situations a therapist may be required by law to report serious concerns to authorities — such as threatening to commit suicide, threatening to harm another person or admitting to abusing a child. Talk to your therapist about any worries you might have regarding confidentiality.

During therapy
For cognitive behavioral therapy, you and your therapist will most likely sit facing each other during sessions. Your therapist will encourage you to talk about your thoughts and feelings and what's troubling you. Don't worry if you find it hard to open up about your feelings. Your therapist can help you gain more confidence and comfort.

Cognitive behavioral therapy is generally focused on specific problems, using a goal-oriented approach. Each session may have a specific agenda to guide discussion. As you go through the cognitive behavioral therapy process, your therapist may ask you to do "homework" — activities, reading or practices that build on what you learn during your regular therapy sessions. Along with homework, your therapist will likely encourage you to apply what you're learning in your daily life.

Steps in cognitive behavioral therapy
Although there are different ways to do cognitive behavioral therapy, it typically includes these steps:

• Identify troubling situations or conditions in your life. These may include such issues as a medical condition, divorce, grief, anger or symptoms of a specific mental illness. You and your therapist may have to spend some time deciding what problems and goals you want to focus on.
• Become aware of your thoughts, emotions and beliefs about these situations or conditions. Once you've identified the problems you want to work on, your therapist will encourage you to share your thoughts about them. This may include observing what you tell yourself about an experience (your "self-talk"), your interpretation of the meaning of a situation, and your beliefs about yourself, other people and events. Your therapist may suggest that you keep a journal of your thoughts.
• Identify negative or inaccurate thinking. To help you recognize patterns of thinking and behavior that may be contributing to your problem, your therapist may ask you to pay attention to your physical, emotional and behavioral responses in different situations.
• Challenge negative or inaccurate thinking. As you continue to examine your thought patterns, your therapist may encourage you to test the validity of your thoughts and beliefs. This may include asking yourself whether your view of a situation is based on fact or based on an inaccurate perception of what's going on. This step can be difficult. You may have long-standing ways of thinking about your life and yourself. Many thought patterns are first developed in childhood. Thoughts and beliefs that you've held for a long time feel normal and correct, so it can be a challenge to recognize inaccuracies or negative tendencies in your thinking. With practice, helpful thinking and behavior patterns will become a habit, and won't take as much effort.

Your therapist's approach will depend on your particular situation and preferences. Your therapist may combine cognitive behavioral therapy with another therapeutic approach — for example, interpersonal therapy, which focuses on your relationships with other people.

Length of psychotherapy
Cognitive behavioral therapy is generally considered short-term therapy — about 10 to 20 sessions. You and your therapist can discuss how many sessions may be right for you. Factors to consider include:

• The type of disorder or situation
• The severity of your symptoms
• How long you have had your symptoms or have been dealing with your situation
• How quickly you make progress
• How much stress you're experiencing
• How much support you receive from family members and other people

Results

Cognitive behavioral therapy may not cure your condition or make an unpleasant situation go away. But overall, it's an effective treatment. It can give you the power to cope with your situation in a healthy way and to feel better about yourself and your life.

Getting the most out of cognitive behavioral therapy
Cognitive behavioral therapy isn't effective for everyone. But you can take steps to get the most out of your therapy and help make it a success, including:

• Approach therapy as a partnership. Therapy is most effective when you're an active participant and share in decision making. Make sure you and your therapist agree about the major issues and how to tackle them. Together, you can set goals and gauge progress over time.
• Be open and honest. Success with psychotherapy depends on your willingness to share your thoughts, feelings and experiences, and on being open to new insights and ways of doing things. If you're reluctant to talk about certain things because of painful emotions, embarrassment or fears about your therapist's reaction, let your therapist know about your reservations.
• Stick to your treatment plan. If you feel down or lack motivation, it may be tempting to skip psychotherapy sessions. Doing so can disrupt your progress. Attend all sessions and give some thought to what you want to discuss.
• Don't expect instant results. Working on emotional issues can be painful and often requires hard work. It's not uncommon to feel worse during the initial part of therapy as you begin to confront past and current conflicts. You may need several sessions before you begin to see improvement.
• Do your homework between sessions. If your therapist asks you to read, journal or do other activities outside of your regular therapy sessions, follow through. Doing these homework assignments is important because they help you apply what you've learned in the psychotherapy sessions.
• If psychotherapy isn't helping, talk to your therapist. If you don't feel that you're benefiting from therapy after several sessions, talk to your therapist about it. You and your therapist may decide to make some changes or try a different approach.