Cognitive Behavioural Therapy

Cognitive Behavioural Therapy: what it is, how it works, and what it can do
On thinking, feeling, and doing; and why CBT is such an important tool

Hi!

Maybe you're about to start cognitive behavioural therapy, often abbreviated as CBT. Or you're a practitioner getting to grips with it. Or you simply want to understand what it's all about. Either way, glad you're here.

CBT is the approach most psychologists start with, and for good reason. When I began my training as a healthcare psychologist and received proper in-depth teaching on CBT for the first time, it gave me an immediate foothold. I had more to work with, a framework for understanding how difficulties develop and persist, and a set of techniques to actually do something about them. I often thought: I should have learned this much earlier. For many people with all kinds of different difficulties, CBT works well, and it's widely accessible.

In this article I'll explain what CBT is, how it works, and who it's useful for. And at the end, I'll briefly touch on an important nuance: when CBT is less effective, and what might help instead.

Thinking, feeling, and doing are connected
CBT is based on the idea that thoughts, feelings, and behaviour are strongly interconnected. How you think about something influences how you feel. How you feel influences what you do. And what you do, in turn, influences how you think and feel.

That might sound obvious, but we rarely stop to think about it. Which is a shame, because it gives us something powerful: a way to influence feelings, thoughts, and behaviour when we're struggling. It also offers something tangible in the here and now. If you're caught up in difficulties like anxiety, low mood, or tension, you don't necessarily need to dig for the deepest cause from your past. What's happening right now, in your head and in your behaviour, is at least as important. And that's exactly where CBT lets you get to work straight away.

I'll use a personal example. I've never been particularly fond of dogs. My father was always afraid of them, and I saw that from a very young age. He used to tell stories about being bitten by an aggressive dog abroad. So I learned through him: dogs are scary, stay away. As a result, I never got to have positive experiences with dogs, I always kept my distance, tense and on edge. But since spending more time around dogs (my in-laws have three) and the people in my life who have them, I've noticed that they don't bite me. In fact, that has never once happened. So I started standing closer to dogs, doing something differently. To get over that threshold, I told myself I could stay calm and that they wouldn't bite me, thinking differently. And as a result, I noticed my anxiety decrease, because what I was afraid of didn't happen, feeling differently. Now I'm no longer particularly afraid of dogs and can stay nearby without any trouble. That's how thinking, doing, and feeling are connected, and how by doing something differently, I became less anxious. A kind of mini-CBT in a nutshell.

Below I'll explain the different components in a bit more detail. Because even though it sounds simple, there's quite a lot to it.

Thinking: the cognitive side
The cognitive part of CBT focuses on the way you think. People don't always look at themselves and the world around them in a neutral way. Someone experiencing low mood might think: "I never get anything right" or "People don't like me." Someone who is anxious often overestimates how dangerous situations are and how likely the feared scenario is to occur.

In CBT, you explore together whether these kinds of thoughts are actually accurate. Not to talk them away or force them to be positive, but to test them against reality. Do they hold up? Are there other ways of looking at this situation? And what difference does it make if you try? It often turns out that thoughts are making us anxious or low, while they're not nearly as realistic as they feel.

One of the best-known tools for this is the thought record: a structured way of unpacking a situation and examining which thoughts, feelings, and behaviours are at play, and then practising more helpful alternative thoughts. I've created thought records and a sheet with reassuring thoughts that you can use for this.

Testing thoughts can happen by challenging them directly, or for example by calculating how likely it actually is that what you're afraid of will happen. But it doesn't only happen through talking. You also go out and try things in real life, like me going up to those dogs and discovering I wasn't bitten. Between sessions, these kinds of exercises are often given as homework.

Doing: the behavioural side
The behavioural part focuses on what someone does, or avoids doing, even though it would actually be helpful. Behaviour and difficulties often keep each other going. Someone who is afraid of busy places and avoids them as a result will tend to find that their anxiety grows rather than shrinks. Someone who is low in mood and gradually does less and less often becomes even lower, because there are fewer enjoyable things, less fun, and less positive energy in their life.

In CBT, you map out together which behaviours play a role in the difficulties and when they occur. This is done through a functional analysis. That might sound a bit technical, after all, isn't the behaviour getting in the way? But within CBT, the assumption is that behaviour persists, or even increases, if it feels like a kind of reward in the short term. That can be something directly pleasant, like the rush from using a substance. But the absence of something negative also counts as a reward: avoiding a presentation so you don't embarrass yourself brings immediate relief. That relief keeps the avoidance going, even though it doesn't help you move forward in the long run. Once you've mapped this out clearly together, you start practising new behaviour that does help, including outside of sessions.

Cognitive and behavioural: a powerful combination
Cognitive therapy and behavioural therapy are historically two separate traditions. Behavioural therapy is rooted in behaviourism and learning theory: behaviour is learned and can therefore be learned differently. Cognitive therapy, developed by among others Aaron Beck, added the importance of thoughts and interpretations. For a long time the two traditions worked separately, but it's now clear that they complement each other beautifully. Someone who learns to think differently often starts to act differently too. Someone who learns to act differently often starts to think differently too. That makes CBT more than the sum of its parts.

What does CBT look like in practice?
CBT is a structured therapy. Treatment consists of three phases. In the first phase, the focus is on getting to know each other, understanding what's going on, and exploring together when the difficulties occur and what they're connected to. Clear goals are established. In the second, and longest, phase, those goals are actively worked on through targeted exercises, behavioural experiments, and homework assignments. Put simply: learning to think differently and act differently, in order to feel better. In the third phase, treatment is rounded off and a plan is made for what to do if things become difficult again, to help prevent relapse.

CBT is somewhat more directive than many other forms of therapy. The therapist takes an active role: providing explanation, working towards concrete goals, and giving exercises to take away between sessions. The approach is transparent, the therapist explains how they see the situation and why a particular approach is being proposed.

Forms of CBT
CBT comes in many variants. Most people follow individual therapy, but CBT is also available in group settings, for couples, or for families. There are protocols for a wide range of difficulties, such as CBT for depression, panic attacks, and negative self-image (COMET).

There are also forms that don't follow a fixed protocol, but instead explore together how someone's difficulties relate to what they have learned throughout their life. We call this a holistic formulation: looking at the connections between what someone has experienced, what they have learned from it (such as core rules for living), how they cope with that, what difficulties they have, and what would be best to address first. From there, a functional analysis can examine which behaviours aren't helping and how they can be better understood and changed. Or a meaning analysis can explore where intense feelings come from, what triggers them, and how someone can find more calm within them.

From this broader perspective, CBT has continued to evolve, giving rise to treatments that look deeper than surface-level difficulties. Treatments that look more closely at personality development and what someone missed early in life, such as schema therapy, or at managing entrenched behavioural patterns, such as dialectical behaviour therapy (DBT), fall under what is known as the third wave of CBT. What all these variants share is their scientific foundation and their focus on the interplay of thinking, feeling, and doing.

Does it work?
Yes. CBT has an enormous evidence base and has been the subject of a great deal of research into its effectiveness. For a wide range of difficulties, from anxiety disorders and depression to eating disorders and psychosis, CBT has been shown to be effective. For a number of conditions, CBT has the added advantage that the effects are maintained after treatment ends, because people learn techniques they can continue to apply themselves.

It's worth knowing, though, that many studies focus on a particular group: people without many co-occurring difficulties, and people who manage to complete a course of treatment. For that group, CBT works very well. But clinical reality is often a little more complex.

Research shows that CBT is less effective for people with more deep-rooted patterns, such as those with personality disorders. Hutsebaut and colleagues describe why: people with personality disorders often find it difficult to trust a therapist, become emotionally dysregulated more quickly, and find it harder to sustain commitment to goals over time. Not because they don't want to, but because those are precisely the areas where they are most vulnerable.
What can happen as a result is that someone drops out, misses sessions, or finds it impossible to complete exercises. This is unfortunately sometimes quickly interpreted as a lack of motivation, when something quite different is actually going on. And yet CBT could add a great deal for people with more severe difficulties, such as those with psychotic symptoms, through protocols designed to examine and test thoughts.

The AMPS can help look more carefully at what is really happening when a CBT treatment isn't working, isn't helping, or when someone stops attending. How solid is someone's foundation? Are they able to sustain commitment to goals over time? Are they able to take on a different perspective? These questions help clarify how treatment could be made to work, and offer more direction than simply asking whether the technique was applied correctly.

What does help for this group is thinking and working according to what are known as common factors: the active ingredients shared by all effective treatments, such as a good therapeutic relationship, authentic contact, actively repairing ruptures in the working alliance, and attention to emotions and motivation. GIT-PD: Guideline-Informed Treatment for Personality Disorders, is a treatment framework that explicitly builds on these principles and can serve as an underlying structure for any form of treatment, enriching your CBT work when it isn't running smoothly. You can find more about this on the het kenniscentrum website. 

I hope this helps you look at yourself as a person with kindness, while still leaving room to reflect critically on what you do.

Kind regards,

Jente