Cognitive Behavioral Therapy

Aka: Cognitive Behavioral Therapy

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II. Background

  1. Cognitive Behavioral Therapy (CBT) is a time-limited, patient goal-oriented psychotherapy
  2. Replaces problematic thinking and behaviors with more adaptive patterns
  3. Challenges maladaptive beliefs, plans pleasurable activities, and extends exposure to unpleasant situations
  4. Monitors progress via symptom measures
  5. Results in improved reactions to internal and external stimuli

III. Indications: Mental Health

  1. Conditions for which CBT is as effective or more effective than medications
    1. Anxiety Disorder
    2. Major Depression (also reduces Suicidality)
    3. Posttraumatic Stress Disorder (PTSD)
    4. Insomnia
  2. Other First-Line Indications
    1. Tic Disorders
    2. Borderline Personality Disorder
    3. Obsessive Compulsive Disorder
    4. Somatic symptoms
  3. Other mental health conditions for which CBT is an effective adjunct
    1. Attention-Deficit Hyperactivity Disorder (ADHD)
    2. Other Personality Disorders
    3. Autism
    4. Bulimia Nervosa
    5. Binge Eating Disorder

IV. Indications: Physical Health

  1. Primary Indications
    1. Tinnitus
    2. Fatigue
  2. Adjunctive Indications
    1. Chronic Pain Management
    2. Irritable Bowel Syndrome
    3. Vasomotor Symptoms of Menopause
    4. Obesity Management

V. Technique: General

  1. Time limited schedule
    1. One session per week (60-90 minutes each)
    2. Total course: 8 to 12 weeks
    3. Performed in person or via TeleHealth with a licensed CBT therapist
      1. Synchronous TeleHealth (via telephone, video conference) is as effective as in-person encounters
        1. Olthuis (2016) Cochrane Database Syst Rev (3): CD011565 [PubMed]
      2. In contrast, stand-alone CBT smartphone apps have minimal effects on mental health symptoms
        1. May be considered as a first-step intervention for patients lacking access to care
        2. Chen (2025) Arch Psychiatr Nurs 57:151916 [PubMed]
        3. Milne-Ives (2022) PLOS Digit Health 1(8): e0000079 [PubMed]
  2. Monitoring of progress
    1. Patient tracks cognitions, behaviors and emotions to understand their impact on dysfunction and distress
    2. Collect symptom measures frequently between visits
      1. Informs tasks and interventions that modify responses to be more helpful and realistic
  3. Goal-oriented treatment
    1. Starts with psychoeducation in which patient gains insight into their diagnoses
    2. Patient directs goals and actively participates in their treatment
      1. https://manhattancbt.com/cbt-uses-goal-setting/
    3. Focus on changing maladaptive thoughts or behaviors
    4. Patient has weekly homework assignments
  4. Therapy Strategies
    1. Identify and challenge maladaptive thoughts and behaviors

VI. Management: Cognitive Interventions

  1. Goals
    1. Address cognitive distortions and core beliefs
  2. Psychoeducation (directed toward specific symptoms and conditions)
    1. https://www.therapistaid.com/therapy-guide/cbt-psychoeducation
    2. Negative symptoms are maintained by thoughts, behaviors and emotions
    3. Recognize and evaluate thoughts and their impact on distress
  3. Thought tracking
    1. https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/self-help-cbt-techniques/thought-record/
    2. Recognize unhelpful thinking patterns
    3. Log situations that trigger strong feelings (and the associated thoughts, emotions)
  4. Cognitive restructuring
    1. https://cogbtherapy.com/cognitive-restructuring-in-cbt
    2. Reframe unhelpful thoughts and cognitive distortions into more constructive, balanced thoughts
    3. Evaluate the accuracy and usefulness of thoughts
  5. Acceptance (and Mindfulness)
    1. Accept the thoughts and emotions in the moment, instead of trying to avoid or change them
    2. Increase cognitive and behavioral flexibility
    3. Decrease time spent ruminating on distressing thoughts
    4. Consider specific MindfulnessExercises that promote acceptance
      1. Focused breathing
        1. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/wellbeing/breathing-exercises
      2. Body scan meditation
        1. https://www.afnatal.org/guides/5-minute-body-scan-script
      3. Cognitive Defusion Techniques
        1. https://cogbtherapy.com/cbt-blog/cognitive-defusion-techniques-and-exercises

VII. Management: Behavioral Interventions

  1. Goals
    1. Decrease dysfunction
    2. Encourage positive behaviors
  2. Behavior Tracking
    1. Monitor behavior (via journal, smartphone, wearables)
    2. Recognize and log the specific actions that influence symptoms
      1. Focus on specific distressing symptoms (e.g. pain, anxiety)
  3. Behavioral activation
    1. https://www.abct.org/fact-sheets/behavioral-activation/
    2. Plan and participate in activities with personally meaningful positive reinforcement
    3. Consider Exercise as an initial broadly applicable activity
      1. Gear Physical Activity to patient capabilities and interests
    4. Increase specific behaviors with positive effects (identify jointly with therapist)
    5. Commit-to and complete planned activities even when motivation is lacking
    6. Reflect and log how these behavior changes influence thoughts and emotions
  4. Behavioral exposure (to unpleasant thoughts and situations)
    1. https://www.psychologytools.com/articles/delivering-more-effective-exposure-therapy-in-cbt
    2. Confront feared triggers and situations (decreases avoidance, anxiety and arousal)
    3. Engage uncomfortable situations repeatedly (to reduce anxiety intensity over time)
    4. Plan an exposure hierarchy with therapist
      1. Gradually progress from situations that are moderately uncomfortable to higher anxiety ones
  5. Relaxation Techniques
    1. https://www.ncbi.nlm.nih.gov/books/NBK513238/
    2. See Acceptance and MindfulnessExercises above
    3. Progressive Muscle Relaxation (Progressive Relaxation)
    4. Tame It Mindfulness Tool
    5. Applications
      1. Insight Timer
        1. https://insighttimer.com/
      2. Calm App
        1. https://www.calm.com/
  6. Problem Solving and Skills Training
    1. Teach practical strategies and skills (e.g. effective communication, problem solving)
    2. Practice via simulated scenarios

VIII. Management: Emotion Interventions

  1. Goals
    1. improve emotional dysregulation and functioning)
  2. Emotional awareness
    1. Recognize and label emotions
  3. Emotion tracking
    1. Log emotional responses to thoughts, behaviors and situations
  4. Emotion regulation through ongoing skill building
    1. Manage difficult feelings

IX. References

  1. Coffey (2015) Am Fam Physician 92(9):807-12 [PubMed]
  2. Williamson (2026) Am Fam Physician 114(3): 272-80 [PubMed]

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