Cognitive Behavioural Therapy (CBT) is a structured, time-limited (usually 12-16 sessions) psychotherapy that identifies and addresses persistent maladaptive thought patterns to change emotions (e.g. - depression/anxiety/trauma) and behaviours (low motivation/insomnia). It uses strategies such as goal-setting, breathing techniques, visualization, and mindfulness to decrease emotional distress and self-defeating behaviour. Treatment is generally time-limited. CBT can be delivered in a wide variety of formats, including in groups and via remote delivery (online or phone). Although most commonly used for depression and anxiety, CBT has also been specialized to treat other conditions, such as CBT for insomnia (CBT-I) for insomnia disorder, and trauma-focused CBT (TF-CBT) for post-traumatic stress disorder.
CBT techniques include identifying distortions such as overgeneralization of negative events, catastrophizing, minimizing positive events, and maximizing negative events. Patients work with therapists to identify and change cognitive distortions and avoidance behaviours that cause their symptoms. This frequently involves keeping diaries or “thought records” outside of sessions and practicing behavioural strategies learned in sessions.
The key components of CBT include:
CBT uses lots of different terminologies, and it can be helpful to spell out exactly what they mean, so both you and your patients can be speaking the same language.
Description | What to Tell Your Patient | |
---|---|---|
Feelings | • Feelings are one word (e.g. - “happy, sad, excited”) | “A person can't change their feelings, but they can change their thoughts and behaviours.” |
Thoughts | • Thoughts are sentences that run through one's mind. One can have many different thoughts about a situation. | • “Sometimes thoughts are right, but sometimes they can be wrong too” • Thus, be skeptical of your thoughts! |
Actions/Behaviours | • Actions and behaviours are the things one does, and one's behaviours. Thoughts influence actions and behaviours. | - |
Core beliefs are fundamental assumptions (not truths) that individuals have made about about themselves, others, and the world. These beliefs develop over the course of their lives. Core beliefs influence how a person sees the world around them and themselves. Core beliefs are usually so connected to a person's identity that they stop noticing them or questioning these beliefs. For example, someone in a depressive episode might think “I am a failure” and because these beliefs are not questioned and assumed to be “100% true,” the individual lives and acts as though they beliefs are real and true.
Beck's cognitive triad, also known as the negative triad, is a cognitive-therapeutic model of the three key elements of a person's belief system when going through depression. The triad involves automatic, spontaneous and seemingly uncontrollable negative thoughts about:
Thoughts can often come automatically, and CBT challenges us to think more closely about these thoughts. Some automatic thoughts are true, but many are either untrue or have just a grain of truth. CBT requires patients to use a structured method to evaluate their thinking. Otherwise, their responses to automatic thoughts can be superficial and unconvincing and will fail to improve their mood or functioning. Typical automatic thoughts (also called cognitive distortions) include:
Cognitive Distortion | Definition | Automatic Thought |
---|---|---|
All-or-nothing thinking | Viewing a situation in only two categories instead of on a continuum. | “If I’m not a total success, I’m a failure.” |
Catastrophizing | Predicting the future negatively without considering other, more likely outcomes. | “I’ll be so upset, I won’t be able to function at all.” |
Emotional reasoning | Thinking something must be true because you “feel” (actually believe) it so strongly, ignoring or discounting evidence to the contrary. | “I know I do a lot of things okay at work, but I still feel like I’m a failure.” |
Disqualifying or discounting the positive | Unreasonably telling yourself that positive experiences, deeds, or qualities do not count | “I did that project well, but that doesn’t mean I’m competent; I just got lucky.” |
Labeling | You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion. | “I’m a loser. He’s no good.” |
Magnification/minimization | When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive. | “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.” |
Mental filter (Selective abstraction) | When you have a tendency to focus on only one detail (often taken out of context) and ignore all other aspects and more important parts of a situation (e.g. - “seeing the glass as half empty”). | “Because I got one low rating on my evaluation [which also contained several high ratings] it means I’m doing a lousy job.” |
Mind reading | You believe you know what others are thinking, failing to consider other, more likely possibilities. | “He thinks that I don’t know the first thing about this project.” |
Overgeneralization | You make a sweeping negative conclusion that goes far beyond the current situation. | “[Because I felt uncomfortable at the meeting] I don’t have what it takes to make friends.” |
Personalization | You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior. | “The repairman was curt to me because I did something wrong.” |
“Should” and “must” statements | You have a precise, fixed idea of how you or others should behave, and you overestimate how bad it is that these expectations are not met. | “It’s terrible that I made a mistake. I should always do my best.” |
Tunnel vision | You only see the negative aspects of a situation. | “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.” |
Magical thinking | Believing that the course of events in the world depends on your actions and thoughts. | “I need to wash my hands 10 times each time, or else my parents will die.” |
Notice how the first two sentences don't provoke many emotions, but the third sentence is “emotional reasoning,” you might be “reading” into this feeling, thinking: “Might I be jinxing the universe by writing this down?!” This is a tough thing to overcome for individuals who struggled with the cognitive distortion of emotional reasoning every day.
It is important for the patient to have specific goals they want to achieve by the time they are finished the course of therapy. It is also important to have goals between sessions, that are more attainable and realistic. The SMART goals framework is one way of achieving that. A goal should feel 80% do-able and 20% challenging so as to strike the right balance.
S
- Specific (well defined, clear, and unambiguous)M
- Measurable (specific way to measure your progress towards the goal)A
- Attainable (something not impossible - “Do something 80% attainable and 20% hard”)R
- RealisticT
- Time (must have a start and finish date - if the goal is not time constrained, there will be no sense of urgency to achieve the goal!)Example of a SMART goal could be: “Add more structure to your day” (i.e. - make your bed, eat regular meals, have a regular sleep schedule, and make a regular schedule). Another SMART goal could be: “Have more social interaction by calling one friend each week.”
Just like how CBT is a structured-form of therapy, your sessions with your patient should also be structured and modeled on that. A typical CBT session should be structured as follows:[7]
Time | Focus | Description |
---|---|---|
Before appointment | Assess symptoms | Patient fills out a scale assessing symptoms (GAD-7, PHQ-9, Beck) |
5-10 minutes | Check-in | What happened last week? Do a “mood check”: how is this week's mood compared to last week's? |
5 minutes | Set the Agenda | Decide: what are the important things that happened that need to be problem-solved today? Prioritize the agenda if there are many problems that happened. |
5 minutes | Bridge | Connect back to the last session: what was important during the last therapy session? |
5 minutes | Homework | Review homework done over the past week. |
30 minutes | Problem Solving | Focus on the core themes of CBT and problem-solve. |
5 minutes | Wrap up | Ask patient for feedback: How did the session go? Is there anything that bothered them or that they didn’t understand? Is there anything they'd like to see changed in future sessions? Assign homework for the next session |
Homework is an integral part of CBT, and what makes CBT work. There are various types of homework assignments including:
Thought records are done outside of the CBT session, where patients record their automatic thoughts and feelings over the week:
The goal of CBT is to help your patients correct the automatic thought (sometimes called “hot thought”), by reaching balanced thoughts (e.g. - “Even though [I’m behind on my rent], I can see that [I have a solution now/and a capable person], because [I have support from my family].”) Beware though, of superficial and “fake” balance thoughts. For example, if a patient is constantly worried about having anxiety because their thought is: “I’m a terrible mom.” and her balanced thought is “but I’m a good wife.” Notice that this balanced thought doesn't actually relate to the thought. If the balancing thought does not correspond with the automatic thought, that’s a pitfall the therapist must identify!
When addressing automatic thoughts or cognitive distortions, the following questions can be helpful:
When evaluating situations that your patient brings up, here are some helpful techniques:
Socratic questioning, or the socratic method, is a key technique in CBT. You help your patient understand themselves by asking questions about their thoughts, examples include: