Cognitive behavioral therapy (CBT) is a structured, present-focused, time-limited psychotherapy based on the idea that how people interpret events — not the events themselves — shapes emotions, body reactions, and behavior. Changing distorted thinking and unhelpful behavior changes mood. It combines cognitive therapy (Beck) with behavioral learning principles.

The cognitive model

Situation → automatic thought → emotion + physical reaction + behavior

Example: a friend does not reply to a message → "She doesn't like me anymore" → sadness, heaviness, withdrawal.

Levels of thinking

• Automatic thoughts — quick, spontaneous, situation-specific thoughts
• Intermediate beliefs — rules and assumptions ("If I'm not perfect, I'm a failure")
• Core beliefs — deep, global beliefs about self, others, and the world ("I am worthless," "I am unlovable")

Beck's cognitive triad of depression: negative views of the self, the world, and the future.

Features of CBT: collaborative ("collaborative empiricism"), goal-oriented, structured sessions with an agenda, homework, skills taught so the client becomes "their own therapist," usually 6–20 sessions. Strong evidence for depression, anxiety disorders, OCD, PTSD, insomnia, eating disorders, substance use, chronic pain, and as an add-on for psychosis.

Identify:

• Target problems and measurable goals
• Automatic thoughts and the emotions linked to them (rated 0–100%)
• Cognitive distortions (below)
• Avoidance and safety behaviors that maintain anxiety (e.g., carrying a water bottle, avoiding crowds)
• Activity level, pleasure and mastery in daily life (depression)
• Readiness for homework; literacy; cognitive capacity

Common cognitive distortions

Cognitive techniques

• Socratic questioning — guided questions that help the client examine their own thoughts ("What is the evidence? Is there another explanation? What would you tell a friend?"), rather than the therapist supplying answers
• Cognitive restructuring — replace distorted thoughts and core beliefs with balanced, realistic ones (not simply "positive thinking")
• Decatastrophizing — "What is the worst, best, and most likely outcome?"
• Behavioral experiments — test a prediction in real life (a client who believes "I'll be humiliated if I speak in a meeting" plans to speak briefly and records what actually happens)

Behavioral techniques

CBT for insomnia (CBT-I) — first-line treatment for chronic insomnia:

• Stimulus control: use the bed only for sleep and sex; go to bed only when sleepy; leave the bed if unable to sleep after about 20 minutes; fixed wake time; no naps
• Sleep restriction: limit time in bed to actual sleep time, then extend gradually. Use cautiously or avoid in bipolar disorder (sleep loss can trigger mania), seizure disorders, and in people with marked daytime sleepiness who drive or operate machinery
• Cognitive therapy for sleep worries; relaxation; sleep hygiene (caffeine, alcohol, screens)

CBT for chronic pain — goal is changing catastrophic thoughts and fear-avoidance and increasing function, not eliminating pain; paced activity, relaxation, coping statements.

Third-wave approaches: DBT, acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (relapse prevention in recurrent depression).

Medication and CBT. CBT is often combined with antidepressants (see Topic 9 for safety). Benzodiazepines taken just before exposure sessions can act as a safety behavior and reduce learning; they also cause sedation, dependence, and respiratory depression with opioids or alcohol, so they are not a substitute for exposure.

Listed in priority order.

1. Screen for safety — depression and panic treatment start only after suicide risk is assessed; exposure is postponed during acute crisis, psychosis, or intoxication
2. Start where the client is — in severe depression, begin with small, achievable activities (behavioral activation) before complex cognitive work
3. Use Socratic questions instead of arguing: "What makes you think that? What is the evidence against it? Is there another way to see it?"
4. Support exposure plans — teach relaxation first (for desensitization), follow the hierarchy step by step, encourage the client to stay in the situation until anxiety falls, and do not encourage avoidance
5. Prevent compulsions supportively in OCD — agree on delaying rituals; acknowledge anxiety; praise tolerance
6. Reinforce homework — review thought records and activity logs; praise effort, not only success
7. Social skills and assertiveness — role-play real situations; give specific, positive feedback
8. Evaluate — re-rate symptoms and beliefs; document change

• CBT is a skills-based, practical therapy; homework is essential
• Thoughts are not facts — they can be tested
• Anxiety during exposure is expected and temporary; avoidance keeps fear alive
• Keep practicing skills after therapy ends to prevent relapse (booster sessions help)
• CBT-I: fixed wake time, bed only for sleep, leave the bed if awake more than about 20 minutes

• CBT: present-focused, collaborative, structured, homework; goal is changing distorted thoughts and maladaptive behavior
• Thought record = main tool to identify and evaluate automatic thoughts
• Emotional reasoning = using a feeling as proof of fact
• Socratic questioning = helps the client evaluate their own thoughts
• Cognitive restructuring = replace distorted beliefs with realistic ones
• Behavioral activation first in depression — increase pleasure and mastery activities
• ERP for OCD: allow the obsessive anxiety but prevent the compulsion
• Interoceptive exposure for panic: provoke feared body sensations safely
• Systematic desensitization: relaxation + hierarchy, least feared first; flooding = most feared at once
• Behavioral experiment = test a negative prediction in reality
• CBT-I stimulus control: bed only for sleep and sex
• Social skills training uses modeling, role-play, and feedback