Cognitive behavioral therapy (CBT) is one of the most common and best studied forms of psychotherapy. It is a combination of two therapeutic approaches, known as cognitive therapy and behavioral therapy.
The exact treatment approaches used will depend on the illness or problem to be treated. But the basic idea behind the therapy is always the same: What we think, how we behave, and how other people make us feel are all closely related – and they all affect our wellbeing.
What is cognitive therapy?
The term cognitive comes from the Latin "cognoscere," meaning "to recognize." Cognitive therapy is about forming a clear idea of your own thoughts, attitudes and expectations. The goal is to recognize and change false and distressing beliefs. It is often not only the things and situations themselves that cause problems, but the sometimes exaggerated importance that we attach to them, too.
One example of a distressing thought pattern is when somebody immediately draws negative conclusions from a certain situation, generalizes them and applies them to other similar situations. In psychology, this generalized way of thinking is called “over-generalizing.” Another distressing way of thinking is known as “catastrophizing”: Something unsettling happens, and people immediately start worrying that it will turn into a disaster.
Such thought patterns can sometimes develop into self-fulfilling prophecies and make life difficult for those affected. If you think that other people don't like you, for instance, then you're likely to put your guard up when you're around them. As a result, they will be less friendly towards you too.
Cognitive therapy helps people learn to replace these thought patterns with more realistic and less harmful thoughts. It also helps people think more clearly and control their own thoughts better.
How does behavioral therapy work?
Behavioral therapy has its origins in “behaviorism.” This theory assumes that human behavior is learned and can therefore be changed or learned differently. Behavioral therapy aims to find out whether certain behavioral patterns make your life more difficult or make problems worse. In the second step, you work on changing those behavioral patterns.
For example, people who have developed depressive thoughts often tend to become withdrawn and give up their hobbies. As a result, they feel even more unhappy and isolated. Behavioral therapy helps to identify this pattern and find ways to become more active again.
In anxiety disorders, behavioral therapy often includes learning about things that can help you feel calmer. For example, you can learn to reduce anxiety by consciously breathing in and out deeply so that your breathing is calmer and your body can relax. When doing this, you concentrate on your breathing instead of the thing that is causing your anxiety. These kinds of techniques can help you to calm down instead of letting your anxiety overwhelm you.
Which thoughts and behavioral patterns are harmful, and which are not?
Harmful thoughts or behavioral habits can make people feel bad about themselves. Picture the following situation: You see somebody you know on the street and say hello, but they don't say hello back. Your own reaction to that very much depends on how you assess the situation:
|Thoughts||“He ignored me – he doesn’t like me anymore.”||“He didn't notice me – maybe he's having a bad day. I should give him a call and find out how he's doing.”|
|Feelings||Someone who thinks like this feels down, sad and rejected.||These thoughts don't cause any negative feelings.|
|Behavior||The consequence of this thought is to avoid this person in the future, although the assumption could be completely wrong.||This thought makes you get back in touch with the person to find out if everything is okay.|
How is CBT different from other psychological treatments?
Cognitive behavioral therapy (CBT) is problem-oriented. It focuses on working through specific current problems and finding solutions for them. Unlike psychoanalysis, for example, it doesn't mainly deal with the past. CBT is much more concerned with dealing with problems in the here-and-now. The most important thing is helping people to help themselves: They should be able to cope with their lives again without therapy as soon as possible. This doesn't mean that cognitive behavioral therapy completely ignores the influence of past events. But it mainly deals with identifying and changing current distressing thoughts and behavioral patterns.
Analytic psychotherapy, which has its origin in classic Freudian psychoanalysis, uses a different approach. Here the therapist tries to help the patient discover and understand problems and their deeper causes.
When is CBT considered?
Cognitive behavioral therapy is used to treat mental health conditions such as depression, anxiety, obsessive-compulsive disorder and addictions. But it can also be used to treat physical conditions such as chronic pain, tinnitus and rheumatism. Here it can help people to cope better with the symptoms.
To really benefit from cognitive behavioral therapy, you have to be committed and willing to put in enough effort. The therapy can only help if you actively take part in it, you are open and honest with the therapist, and also work on your problems between the sessions. This can be quite exhausting, especially with severe psychological conditions such as severe depression or anxiety disorders. For this reason, medication is sometimes used at first to relieve the worst symptoms so that psychological treatment can be started.
When trying to find the right kind of psychotherapy, the specific goals play an important role. If you would like to look deeper into the cause of your problems, CBT is probably not the right choice. It is particularly useful if you are mainly interested in tackling specific problems, and are less interested in the causes.
How does CBT work and how long does it take?
It is important that you and your therapist have a close and trusting working relationship. It can sometimes take a while to find the right therapist.
In the first session, you briefly describe your current problems and outline your expectations of the therapy. Then you define the goals of your therapy and make a therapy plan together with the therapist. The plan can be adjusted if your personal goals change over the course of therapy.
Therapy often includes writing down your own thoughts in a journal over a certain period of time. The therapist will then check the following things with you: Do you see things realistically? What happens if you behave differently than you normally do in a certain situation? In the therapy sessions, you will regularly discuss any problems you may have and progress that you have made.
Relaxation exercises, stress-reducing and pain-relieving techniques are often used in cognitive behavioral therapy, too. You also learn problem-solving strategies.
Compared to analytical psychotherapy approaches, cognitive behavioral therapy is a short-term treatment. But there is no "standard" length of treatment here. Some people already feel much better after a few sessions, while others need treatment for several months. This depends on various factors, such as the kind and severity of the problems. An individual session typically lasts about one hour. Sessions usually take place once a week. Cognitive behavioral therapy is offered in psychotherapy practices, hospitals and rehabilitation clinics. It is sometimes also offered as group therapy, or online.
Can CBT also have side effects?
Psychological treatments can have side effects, too: Facing your problems or anxieties head on may be distressing or make you feel quite "wobbly" at first, and can negatively affect relationships with other people. It is important to speak openly with your therapist about any difficulties that come up during therapy.
There is hardly any scientific research on the possible side effects of psychotherapy.
Who covers the costs?
In Germany, statutory health insurers pay for cognitive behavioral therapy to treat mental illnesses such as depression, anxiety, obsessive-compulsive disorder and addictions. The costs of cognitive behavioral therapy can also be covered for the treatment of severe psychological distress that is caused by a chronic physical illness. But it can sometimes take several weeks or months until you can see a therapist or until the insurance company approves the therapy.
In Germany, a psychotherapy practice can bill the statutory health insurer directly for two to four trial sessions at first – and up to six trial sessions for children, teenagers and people with learning difficulties. This allows the psychotherapist and client to get to know each other, find out what the problems are and whether therapy would be worthwhile. After the trial sessions, you and the therapist have to prepare an application explaining why therapy is needed. You have to submit this application to your health insurance company before therapy can begin. Besides this application, you also have to give your health insurer a medical report from your doctor stating that the symptoms aren't caused by a physical problem, and that there are no medical reasons not to have psychotherapy. The statutory health insurance company then decides whether to approve therapy based on an evaluation.
Gemeinsamer Bundesausschuss (G-BA). Richtlinie des Gemeinsamen Bundesausschusses über die Durchführung der Psychotherapie (Psychotherapie-Richtlinie). 2021.
Pschyrembel Online. 2022.
Robert Koch Institute (RKI), Statistisches Bundesamt (Destatis). Psychotherapeutische Versorgung. (Gesundheitsberichterstattung des Bundes; Heft 41). 2008.
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