Cognitive behavioral therapy (CBT) techniques
Cognitive behavioral therapy (CBT) techniques are by far the most popular type of therapy in the United States. CBT is also the most well-researched. While it is often touted as a cure-all for every problem facing humankind (hint: it’s not), it does have an impressive track record of success for many difficulties. Let’s take a deep dive into CBT and provide you with all you need to know about this highly effective type of therapy.
What is CBT?
CBT is semi-brief structured psychotherapy that focuses on changing maladaptive thoughts and behaviors that lead to negative outcomes. The core assumption behind CBT is that individuals have developed unhelpful thinking and behavior patterns that cause them a variety of problems. The job of the therapist is to help identify those thinking patterns and motivate the client to change.
You can expect up to six months of weekly sessions, although many clients will stay for longer. Because it is a relatively brief therapy, especially when compared to traditional psychodynamic therapy, insurance companies may start questioning treatment that goes on much past six months. While there is no manual, CBT does have a specific focus. A therapist will actively employ CBT techniques to move the client toward the completion of their goals. In other words, it will not be an unstructured client-led treatment, but more of a collaboration where the therapist acts as a guide.
CBT has evolved quite a bit since Aaron Beck and Albert Ellis first introduced the concept in the 1960s. Several other therapies with CBT roots have emerged, most notably dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT). As it has broadened, the definition of CBT has likewise expanded. Concepts that the early pioneers of CBT never dreamed of, including emotion regulation, mindfulness meditation, and (gasp!) acceptance of negative thoughts have become cornerstones of CBT and its related therapies.
The goals of CBT
To understand the goals of CBT and CBT techniques, you need to comprehend the basics of its theory. In brief, here is what you need to know: thoughts lead to feelings which, in turn, lead to behavior. And behavior fuels more thoughts, acting as a feedback loop. This interaction between thoughts, feelings, and behavior is the underlying principle of all CBT. Of course, clients will have their particular areas of concern, but the broad objectives for everyone undertaking traditional CBT will reflect this theory. Therapists employing classic CBT techniques can expect to assist their clients in working toward the following goals:
- Change distorted thoughts. According to CBT, cognitive distortions—also known as thinking errors—are the beginning of almost all our troubles. Individuals will have developed core beliefs that are constantly repeated in their minds. The goal is to identify those distortions and replace them with more realistic thoughts. For example, a client may believe “I am the worst human being on earth.” Unless they are a serial killer, this is unlikely to be true. They could replace their negativity with a more objective thought, such as “Yes, I have done some bad things but I try to be a good person most of the time.” More realistic thoughts will lead to emotions that are more suitable for the situation and appropriate behavior.
- Adopt beneficial behaviors. Many clients (and therapists) consistently do things that make their problems worse. Not only do they need to learn to stop performing those behaviors, but there are a myriad of beneficial activities they could do instead. For example, let’s say a highly anxious person has five cups of coffee every morning. Instead of overloading their system with a stimulant, they could practice relaxation exercises and help reduce their anxiety.
- Convey how thoughts, feelings, and behaviors are connected. One of the most crucial aspects of CBT is that it highlights the importance of the mind-body connection. Everything affects everything else. And although that usually starts with realistic thinking, behavior can also play an integral role in evoking positive emotions.
- Have clients become their own therapists. Although it may not be good for the therapy business, the overall goal of CBT is to have clients employ CBT techniques on their own. Through education, homework, and problem-solving, clients learn what they need to do to help themselves feel better in the present and how to sustain it long-term. A host of workbooks and online tools make it easy for clients to practice CBT techniques outside of a therapist’s office. It is no wonder it has become one of the most popular self-help options for those looking to avoid the cost, inflexibility, and/or discomfort of traditional therapy.
Who can benefit from CBT?
Purveyors of CBT techniques are likely to tell you that it can help with almost any problem. And while there may be some truth to that, it has more empirical support in treating certain disorders. CBT was developed with depression and anxiety in mind and it has consistently shown it reduces anxiety and depressive symptoms in most people. What’s more, CBT has proven the premiere treatment for many hard-to-treat disorders. For example, dialectical behavior therapy is the gold standard for borderline personality disorder. In addition, the most recognized treatments for post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD) are CBT driven and emphasize the use of exposure. It has also been used successfully for eating disorders and substance abuse.
It should also be noted that CBT techniques are not just for people with diagnosed psychiatric disorders. Their many resources can help with non-clinical problems, such as everyday stress and anger management. While a therapist might combine CBT techniques to best serve their client, many of the tools can be used individually to improve less severe areas of difficulty. For instance, a CBT technique like role-playing can help someone prepare for a presentation or interview at work. And journaling can help anyone recognize problematic habits.
20 CBT techniques you can actually use
In CBT, journaling is more than just scribbling down whatever is on your mind. It has a specific purpose. Clients record their thoughts and actions to identify patterns that may be harmful. Keeping a thought record, for instance, is a form of therapeutic journaling. Thought records ask you to record your thoughts and subsequent feelings when you encounter a specific situation.
Cognitive restructuring is the logical next CBT technique after journaling. After clients identify thought patterns in their thought records, they will be asked to evaluate their rationality and challenge them with more realistic thinking. The process of cognitive restructuring is the heart of CBT and can be done for most problems.
Conduct a behavioral experiment
This is an effective technique to combat anxiety. Anxious clients will be reluctant to do certain activities because they are afraid of what might happen. Usually, their fears are unfounded. Ask the client to predict what will happen and then encourage them to conduct an experiment and try it. They are likely to find that the outcome is more positive than expected and they will be motivated to take more risks in the future.
Exposure is one of the basic behavioral CBT techniques. It is especially helpful for anxiety disorders, PTSD, and OCD. The premise is that the client cannot overcome their anxiety through avoidance. They must confront what they fear in order to learn that it will not harm them. Most therapists recommend an incremental process of exposure so as to not overwhelm the client, although some problems may indicate the need for a “flooding” approach.
Relaxation techniques are primarily used to reduce anxiety symptoms but they are a generally good stress buster. The easiest and most commonly used is deep abdominal breathing, such as those done in yoga. Another commonly used CBT technique is progressive muscle relaxation. Relaxation techniques can be used as a preventative exercise to keep baseline anxiety down or in the moment to reduce anxiety in stress-provoking situations.
Imagery can be used as a relaxation CBT technique but also to shift mood and institute calm. The client is asked to imagine a place where they feel safe and happy. It might be a place where they have fond memories (their “happy place”) or somewhere they always dreamed of going.
Role-playing is a classic CBT technique to help someone prepare for a situation where they feel unsure and have anxiety. In role-playing, the individual enacts the same behavior that they will soon encounter to get themselves ready to face it in a real environment. Role-playing can be used for almost anything, from practicing for a difficult confrontation with a loved one or performing new behaviors to learning to cope with a phobia.
Brainstorming is not just a CBT technique. You have probably used it in school or at work as a way to come up with ideas. The most important part of brainstorming is the lack of judgment. You consider every option, whether it might work or not. After brainstorming, you are ready to evaluate your choices. What are the pros and cons? Will this work in your given situation? How will I implement it? This step-by-step process helps anyone who has made poor choices. It is especially helpful for those people who act impulsively, such as those with attention-deficit hyperactivity disorder (ADHD).
Thought stopping is a CBT technique used for people who constantly worry and have difficulty turning off their minds. A common way to implement it is to wear a rubber band around your wrist and flick yourself when you find yourself ruminating. The brief sting takes your focus off your worries and helps you break the chain of rumination.
Worry time is another CBT technique to help prevent rumination. It is especially helpful if your anxiety keeps you from falling asleep. About an hour before you are ready for bed, take about 10-15 minutes (keep a timer) and write down all your worries. Then stop when your time is up. You are asked not to worry anymore until you have “worry time” again the next day.
Mood thermometers are often used with individuals to gauge how they feel in a group setting or as part of anger management. Usually, a “thermometer” is drawn on a worksheet and, like a thermometer, it has different levels that signify increasing degrees of a particular emotion. For example, children in an anger management group might be asked to reveal how angry they are by pointing to the different degrees of the thermometer. It helps individuals visualize the differences in the intensity of their emotions.
Similarly, feelings charts are used to help people identify their feelings. You might be surprised how many people have difficulty recognizing that they feel more than just a few emotions. Feelings charts usually list at least 16 different emotions with corresponding drawings of faces that exhibit said feelings. Not only do these charts help people identify their present feelings but they often give a name to other feelings that people had difficulty describing. Feelings charts are especially helpful with children and populations that have a limited vocabulary or difficulty identifying and expressing feelings.
Activity scheduling is a behavioral technique that helps your clients engage in something that you know will be good for them. There are plenty of behaviors that are beneficial that we avoid for various reasons. But when you put those activities on a schedule it makes them much harder to ignore. For example, let’s say you have a client that has been avoiding exercise that was recommended by their doctor. You can have them put those workouts in their schedule while they are in session. They may still find a way to avoid it but they will—at the very least—be forced to think about it.
Distraction is not going to cure any problem but it is a highly useful CBT technique to help cope with a variety of concerns. There are many instances where it is better to distract than engage in harmful behavior. For example, distraction can help someone avoid participating in addictive behavior when they have an urge. Or, someone can distract rather than get into an angry exchange with their partner. Sometimes, distraction is exactly what you need to buy enough time to make a better decision.
Successive approximation is a fancy way of describing the process where you break up a task into more manageable parts. This makes it seem less overwhelming to the client and more likely they will take it on and complete it.
Self-monitoring is an essential behavioral CBT technique used to help clients keep track of their behavior. Most commonly used for eating disorders and weight management, it involves writing down data at different times of day to better understand behavior patterns. For example, someone with an eating disorder might keep track of what they eat each day and at what times.
Reframing is the bread and butter of cognitive therapy. It refers to the therapist giving the client a different (and usually more positive) way to look at a situation. For example, a client might complain about how their mother is interfering in their romantic relationship. A therapist might then reframe the situation by remarking about how nice it is that their mother cares enough to want to be so involved in their life.
You can’t mention a list of CBT techniques without mindfulness meditation. Mindfulness is a mainstay of many CBT therapists (and is integral to DBT and ACT) and has been shown to reduce both anxiety and depressive symptoms.
What is the worst that can happen?
This is a simple cognitive technique that is a single question. When a client has apprehension in performing a behavior, it is often because they have an overly negative view about the consequences of that action. By asking “what is the worst that can happen,” you get them to think about whether the consequences are actually as bad as they fear and likely encourage them to perform the behavior.
Affirmation is positive self-talk. Using affirmation, the client is encouraged to give themselves daily messages that serve to motivate them and boost their self-esteem (e.g., “ I can do it”) The key is to keep the affirmations realistic. If the client doesn’t believe what they are saying, it won’t work.
The Downsides of CBT and CBT techniques
Despite its many advantages, CBT techniques are not for everyone. Here are instances when you might recommend a client see another type of therapist:
- Clients who just want to come to therapy and talk about whatever is on their minds might find CBT techniques a bit more challenging than they were expecting. This becomes especially apparent when they resist completing homework, either visibly or in a passive-aggressive way.
- Certain clients can’t accept that thoughts always precede emotions. This is not an illegitimate point. Many clients (and therapists) have a much easier time identifying their feelings than the thoughts that go with them. It may take significant work to recognize certain thoughts, but if clients won’t buy into the theory behind CBT, it is going to be an uphill battle.
- CBT can be a cold process for certain clients. For some, the focus might seem to be on the identification of thoughts and behaviors rather than on the person. A perceptive therapist can allay some of those concerns with an empathetic approach but some may see CBT techniques as overly structured and mechanical.
- Clients with psychotic symptoms, such as those with schizophrenia, will have a difficult time with traditional CBT techniques. It makes sense. How do you realistically evaluate your thoughts when you aren’t thinking rationally? The cognitive part of CBT involves looking for evidence that your thoughts are realistic. How do you do that when you have delusions, hallucinations, and/or fragmented thinking? Having said that, behavioral interventions and emotion regulation may hold some promise in treating certain aspects of psychotic disorders.
- In the same vein, the cognitive aspects of classic CBT may not be the right treatment for certain personality disorders. This is especially true for cluster B disorders, such as narcissistic, histrionic, and borderline personality disorder. When Marsha Lineman created DBT for borderline personality disorder, she recognized that people with that disorder might have difficulty with CBT’s cognitive component. Therefore, she focused more on tangible behavioral skills (e.g., meditation) that help regulate emotions, impulsivity, and social relationships. A strict emphasis on cognitive restructuring would likely fail with those clients.
- A hallmark of anxiety disorders is rumination. Many people that suffer from anxiety just can’t turn off their minds and stop thinking. While CBT techniques can be used to help with rumination (e.g., thought stopping), certain clients find that the constant focus on thoughts just makes them worry more. And that is the opposite of why they are going to therapy in the first place.
- Traditional CBT techniques rely on a belief in rational thinking. It posits that if you think realistically, you will have appropriate feelings for the situation. But what happens when you know that your thoughts are distorted but your feelings don’t change? Or you are giving yourself positive self-talk but you don’t believe in what you are saying. For some clients, there is a disconnect between thoughts and feelings that they can’t resolve, no matter how hard they try. In those cases, their frustration with the process becomes counterproductive.
- Finally, CBT techniques can make some clients feel bad about themselves. Initially, the client is asked to identify thoughts and behaviors that they are performing that are maladaptive. That focus on the negative can feel demeaning to certain people because their negative characteristics are being highlighted. For someone with a poor self-image, it can be too much. In the hands of an insensitive therapist, it has the potential to make the client feel even worse. That is why it is crucial that the CBT therapist first establish a positive rapport with the client and make treatment feel like a collaborative effort.
CBT techniques may not be a cure-all for every difficulty but they are effective for a diverse set of problems. It is especially helpful in treating the most common disorders, namely depression and anxiety. Here are more tips for cognitive behavioral therapy for therapists.
TheraPlatform has a variety of resources utilizing CBT techniques concepts, including worksheets and exercises. What’s more, their practice management software helps make billing, diagnosis, and documentation seem easy. Look at it as one-stop shopping for therapists. Do yourself a favor and start a 30-day free trial today.