Cognitive behavioral therapy (CBT) is an
effective treatment for depression.
At the heart of CBT is an assumption that a
person's mood is directly related to his or her
patterns of thought. Negative, dysfunctional
thinking affects a person's mood, sense of self,
behavior, and even physical state.
The goal of cognitive behavioral therapy is to
help a person learn to recognize negative
patterns of thought, evaluate their validity,
and replace them with healthier ways of
At the same time, therapists who practice
CBT aim to help their patients change
patterns of behavior that come from
Negative thoughts and behavior predispose
an individual to depression and make it
nearly impossible to escape its downward
When patterns of thought and behavior are
changed, according to CBT practitioners and
researchers, so is mood.
The focus and method of cognitive behavioral therapy sets it
apart from other, more traditional therapies:
CBT is based on two specific tasks: cognitive restructuring,
in which the therapist and patient work together to change
thinking patterns, and behavioral activation -- in which
patients learn to overcome obstacles to participating in
enjoyable activities. CBT focuses on the immediate
present: what and how a person thinks more than why a
person thinks that way.
CBT focuses on specific problems. In individual or group
sessions, problem behaviors and problem thinking are
identified, prioritized, and specifically addressed.
CBT is goal oriented. Patients working with their therapists
are asked to define goals for each session as well as
longer-term goals. Longer-term goals may take several
weeks or months to achieve. Some goals may even be
targeted for completion after the sessions come to an end.
The approach of CBT is educational. The therapist uses
structured learning experiences that teach patients to
monitor and write down their negative thoughts and
mental images. The goal is to recognize how those ideas
affect their mood, behavior, and physical condition.
Therapists also teach important coping skills, such as
problem solving and scheduling pleasurable experiences.
CBT patients are expected to take an active role in their
learning, in the session and between sessions. They are
given homework assignments at each session -- some of
them graded in the beginning -- and the assignment tasks
are reviewed at the start of the next session.
CBT employs multiple strategies, including Socratic
questioning, role playing, imagery, guided discovery, and
CBT is time limited. Typically, treatment with CBT lasts 14
to 16 weeks.
Anyone with mild or moderate depression can potentially benefit
from cognitive behavioral therapy, even without taking
medication. A number of studies have shown CBT to be at least as
effective asantidepressants in treating mild and
moderatedepression. Studies also show that a combination
ofantidepressants and CBT can be effective in treating major
CBT can be an effective treatment for mild and moderate
depression in adolescents as well. It's also been shown to be
effective at reducing relapses in patients who experience
frequent relapses after having gone through other treatments.
Nearly two out of every three patients who are treated
successfully for depression are treated with medications alone.
Other patients, though, have lingering symptoms even when
medication is partially working. CBT can be effectively used to
treat many of these patients.
Although a wide range of people respond
well to cognitive behavioral therapy, experts
point out that the type of person likely to
get the most benefit is someone who:
Sees him or herself as able to control the
events that happen around them
Has the capacity for introspection
Cognitive restructuring refers to the process in CBT of identifying
and changing inaccurate negative thoughts that contribute to the
development of depression. This is done collaboratively between
the patient and therapist, often in the form of a dialogue. For
instance, a college student may have failed a math quiz and
responded by saying, "That just proves I'm stupid."
The therapist might ask if that's really what the test means. In
order to help the student recognize the inaccuracy of the
response, the therapist could ask what the student's overall grade
is in math. If the student answers, "It's a B," the therapist can
then point out that his answer shows he's not stupid because he
couldn't be stupid and get a B. Then together they can explore
ways to reframe what the performance on the quiz actually says.
The "I'm stupid" response is an example of an automatic thought.
Patients with depression may have automatic thoughts in
response to certain situations. They're automatic in that they're
spontaneous, negative, and don't come out of deliberate thinking
or logic. These are often underpinned by a negative or
dysfunctional assumption that is guiding the way patients view
themselves, the situation, or the world around them.
Other examples of automatic thinking include:
Always thinking the worst is going to happen. For instance,
a person may convince himself he is about to lose his job
because the boss didn't talk to him that morning or he
heard an unsubstantiated rumor that his department was
going to cut back.
Always putting the blame on oneself even when there is no
involvement in something bad that happened. For
example, if someone did not return your call, you might
blame it on the fact that you are somehow a very
Exaggerating the negative aspects of something rather
than the positive. Think of someone who exercises a stock
option from a bonus a week before the stock rises another
10%. Instead of enjoying the bonus money he just got, he
tells himself he never gets the breaks or that he's too
afraid to take risks that he should take. If he weren't, he
would have known to wait.
The idea in CBT is to learn to recognize those
negative thoughts and find a healthier way to
view the situation. The ultimate goal is to
discover the underlying assumptions out of which
those thoughts arise and evaluate them. Once
the inaccuracy of the assumption becomes
evident, the patient can replace that
perspective with a more accurate one.
Between sessions, the patient may be asked to
monitor and write down the negative thoughts in
a journal and to evaluate the situation that
called them up. The real goal is for the patient
to learn how to do this on his or her own.
Behavioral activation is another goal of CBT
that aims to help patients engage more often
in enjoyable activities and develop or
enhance problem-solving skills.
Inertia is a major problem for people with
depression. One major symptom of
depression is loss of interest in things that
were once found enjoyable. A person with
depression stops doing things because he or
she thinks it's not worth the effort. But this
only deepens the depression.
In CBT, the therapist helps the patient schedule
enjoyable experiences, often with other people who
can reinforce the enjoyment. Part of the process is
looking at obstacles to taking part in that experience
and deciding how to get past those obstacles by
breaking the process down into smaller steps.
Patients are encouraged to keep a record of the
experience, noting how he or she felt and what the
specific circumstances were. If it didn't go as
planned, the patient is encouraged to explore why
and what might be done to change it. By taking
action that moves toward a positive solution and
goal, the patient moves farther from the paralyzing
inaction that locks him or her inside the depression.
Mental health professionals who practice CBT receive special
training and follow a manual in their own practice. Although
actual sessions may vary, they typically follow this outline:
The session begins with a check on the patient's mood and
Together, the patient and therapist set an agenda for the
Once the agenda is set, they revisit the previous session so they
can bridge to the new one.
The therapist and patient review the homework assignment and
discuss problems and successes.
Next they turn to the issues on the agenda, which may or may
not all get addressed.
New homework is set.
The session ends with the therapist summarizing the session and
getting feedback from the patient.
A typical session lasts 50 minutes to an hour.
Some other types of therapy are open ended in
that there is no clear end date established. With
CBT, the goal is to terminate therapy at a certain
point, usually after 14 to 16 weeks.
It takes about eight weeks for the patient to
become competent at the skills that are being
taught in therapy and to reasonably understand
the model. While this is going on, the patient
usually experiences a significant reduction of
symptoms. Between eight and 12 weeks patients
often experience a remission of symptoms.
During the remaining time, they continue to
practice the skills learned and to address issues
related to ending the sessions.
More severe cases of depression may take
longer to resolve. For most patients, though,
14 to 16 weeks with occasional sessions
during the first year to reinforce the new
skills is adequate. "Booster" sessions are
sometimes recommended to help reduce the
risk for relapse and provide "refreshers" for
making use of core CBT skills.
Have you ever felt anxious, sad, isolated,
stressed, or hopeless? Consider using
Cognitive Behavioral Therapy (CBT) to
address these feelings. This is one type of
therapy among many, but it has become
widely used in recent years. CBT focuses
on acquiring a set of skills so you can be
more aware of how your thoughts and
emotions are interconnected. CBT can also
improve your feelings by changing negative
or dysfunctional thoughts and behaviors.
Seeking professional help will enhance
your ability use CBT effectively.
There are Five Methods:
Identifying Negative Thoughts
Challenging Negative Thoughts
Problem-Solving Your Primary
Using Relaxation Techniques
Finding Professional Help
You may believe that a bad situation leads to
negative feelings. The CBT approach challenges this
by stating that it is the thoughts we have that lead us
to have those emotions. A situation gives rise to a
thought which in turn leads to a feeling or action.
Here is an example of how a positive outcome is
linked to thought: You went to the gym and
exercised. You thought that you accomplished your
fitness goal for the day. You felt satisfied and happy.
Now here is an example of a negative outcome: You
went to the gym and exercised. You thought that you
didn't push yourself hard enough to meet your goal.
You felt disappointed or not good enough.
You have brief thoughts throughout the day that are triggered
by a situation. You may not notice or pay attention to
these thoughts, but with CBT it is important to have
awareness of these quick thoughts. Pay specific attention
to negative (or maladaptive) thoughts that you have when
reflecting on a situation.
Maladaptive automatic thoughts are distorted reflections
on an event, but you may accept them as true. These
maladaptive thoughts may then trigger feelings of sadness,
anxiety, frustration, or hopelessness.
Here is an example of a maladaptive automatic thought--
"I'm a failure, and I'll never amount to anything." This
thought is after you get a lower grade than you wanted on
a class exam. You then feel hopeless and depressed.
Now here is a positive thought process--"This is just one
exam, and I can continue to work hard at this to bring my
grades up." You are more likely to be hopeful with this
Underneath your automatic thoughts, you may have
core beliefs that are distorted reflections of reality.
These core beliefs are what drive these maladaptive
thoughts. Thinking about how your core beliefs may
be skewed towards negative thinking will help you to
understand why maladaptive thoughts occur.
Your core beliefs are related to your self-esteem or
self-confidence. You may believe that you are
unlovable or not-good-enough which leads to a
pattern of obsessive behavior or continued feelings of
anxiety or depression.
While CBT acknowledges how core beliefs impact
your present problems and thoughts, the techniques
of CBT do not focus primarily on the past history of
one's core beliefs but instead on how to address the
present problems at hand.
There are many different ways that you may distort your thoughts which
lead to negative emotions or behaviors. Notice the ways that you think or
talk about a problem, and how you may be doing one or more of the
Catastrophizing by predicting only negative outcomes in the future
Having all-or-nothing thinking
Discounting the positive
Labeling something or someone without knowing more about it or them
Rationalizing based on emotions rather than facts
Minimizing or magnifying the situation
Having "tunnel vision" by seeing only the negatives
Mind reading in which you believe you know what someone is thinking
Overgeneralizing by making an overall negative conclusion beyond the
Personalizing the situation as something specifically wrong with you
By putting your thoughts in writing, you will be able to see your
thoughts and emotions a little differently. The thought record
should include a section about the situation, the automatic
thought, and the emotion, and a separate section that reflects on
the pros-and-cons, and another possible way to think about the
situation. Your thought record should help to answer all these
What actually happened? Include where, what, when, and how.
What thought went through your mind? Create rating scale of
how much you believed it was true such as from 1-10 or 1-100.
What emotion did you feel? Rate the intensity using a scale.
What has happened to make you believe this thought is true?
What has happened to disprove this thought?
What is another way to look at this situation?
How would you rate your mood after reviewing all these
questions? Use a scale.
Just like when making an argument, your thinking
may have pros and cons, or different ways of
seeing the same thing. Think about the
alternative ways of seeing a situation, or how to
imagine a different approach or reaction to the
Open your mind up to other possible outcomes or
ways of thinking.
Identify alternative ways of thinking about a
situation that are possible or believable to you.
Consider asking someone you trust to identify
different ways of thinking about the situation.
Does that other person understand the problem
or situation in a different or more positive way?
Listen closely to those alternatives.
Think about something that you enjoy or enjoyed in the
past, or something that you may want to accomplish
but have not done yet. Consider activities that are
possible or achievable possibly in the short term.
Reimagine activities as small, doable goals.
Consider scheduling one pleasant activity a day. It
can be a different one each day, the same, or
combination of a few. Make these activities small,
but something that you can look forward to doing.
If you used to play music in a band and want to be a
musician again, think about activities to start with,
such as playing music once a week at home. Set aside
time when you can play with few distractions.
Create an action plan. Consider writing down your goal,
and then writing out your small steps. Think about
the steps you need to take in the next week, month,
or year, and create a timeline of how each step
follows the next one.
Look for alternative options or behaviors to
accomplish a goal if there are barriers.
For example, a successful businessman has a physical
disability that makes it difficult to continue working.
He may have a goal to be working again. Consider an
alternative goal of being productive, and then the
plan will have more options than barriers. He may be
able to teach others about business, talk with
students about how to be an entrepreneur, or be
productive by providing advice or guidance to his
Use a daily calendar to monitor your emotions
throughout the day. Consider making a "schedule
for your emotions" by writing down what you are
feeling every 3-4 hours. Look at any patterns
that you see over time.
Do you always feel bad at the beginning of the
day and then by 12 noon you're feeling good?
Think about any triggers between those times.
Or vice versa, do you feel good in the morning
before work, but by 2pm each day you're feeling
miserable? Identify if there were specific things
or events that occurred.
Once you have learned to identify triggers that
lead to negative thoughts and behaviors, you will
be more self-aware about how to activate the
brain. The moment you have a negative thought,
use that moment to evaluate the truth behind
that thought, and what may be a different way
to approach it.
Come up with positive and self-affirming
statements that you can remember. Use these
positive statements to guide you when your
anxiety or depression is triggered.
Use positive affirmations about yourself, your
life, and the world around you. Identify positive
things, even if they are small, that can help to
train your brain to think positively.
If there is a problem that you are trying to
solve, use CBT techniques to help you focus
your thoughts in a clear way. When you have
a lot of different emotions and thoughts in
your head at once, you may need to focus on
only one problem at a time.
Avoid attempting to solve multiple problems
at once. Start small and focus on the one
problem that is your primary concern.
Focus on taking an active rather than a
passive role when solving problems.
Brainstorm all the possible options, whether
they are bad, good, or neutral. Write down
these various options. Even ideas that seem
impossible at first may help to jumpstart you
in the right direction.
Think about solutions or advice you might
give to someone else who is facing this same
Consider talking with a close friend or
someone you trust for additional options.
Think about each option available to you, Stick
with the most logical options first, then create
pros and cons for each. Consider the pros and
cons of the options that may seem very
challenging last. 
This list will help you to see other options in a
more balanced way. Make sure to look at both
the positives and negatives, and not just one or
Consider whether you need advice from an
expert or a professional for certain pros and
cons, such as a financial advisor, lawyer, or
Examine how the pros and cons stack up
relative to one another. Consider creating a
rank order for your options.
Talk with someone you trust about whether
these rankings seem realistic. Ask them if
they have any concerns about the plan you
think is best.
Find out the steps you need to take to enact
the plan you have chosen. Your pros and cons
list for the option you have chosen may help
you to understand the steps you need to take
and the ones to avoid.
Create a timeline of small steps that you
need to do. With organization and planning
you are more likely to carry out and achieve
Avoid being easily deterred if your plan does not
go the way you wanted. Go back to the planning
phases of problem solving and figure out what
missteps may have been made or not addressed.
If the plan led to a positive outcome, enjoy that
moment. Even if the problem is not fully
"solved," be thankful that you are headed in the
If the plan still needs some tweaking and
negative thoughts still arise, keep going and stay
motivated. Most negative thoughts, feelings, and
situations don't go away overnight, but that
doesn't mean they are impossible to work on.
Breathing exercise can help you to cope with stressors,
triggers, and automatic negative thoughts. While
relaxation techniques may not "get rid of the problem," it
is important to learn how to focus your mind and energy
constructively to avoid anxious or obsessive thoughts.
Consider this abdominal breathing technique:
Place one hand on your chest and the other on your
Exhale with your mouth, and take a slow deep breath in
with your nose.
Inhale as deeply as you can and hold for 7 seconds.
Slowly exhale through your mouth for 8 seconds.
As you release the air with relaxation, contract gently your
abdomen to remove the remaining air from your lungs.
Repeat this cycle for a total of 5 deep breaths. Try to have
rate of one breath every 10 seconds. This helps both your
heart rate and your mind.
This is another relaxation technique that starts
with deep breathing, but focuses your mind on
how to release muscle tensions the body. This
can help relieve anxiety. It can be done with the
guidance of a mental health or holistic health
Focus on deep breaths, and notice your
Focus on tensing and releasing muscles in the
body for five seconds each.
Focus your mind on your body parts, starting
with the feet. The progression is feet, legs,
pelvis, stomach, back, arms, neck, and face.
These techniques can help you redirect your negative
thoughts or stressors to something peaceful and safe.
They can help you when triggers for maladaptive
thoughts occur. You can also do these at night before
bed. Your peaceful place can be somewhere you have
been before, or possibly dreamed about. Visualize
Close your eyes, and imagine a peaceful or happy
Notice the colors, shapes, movement, light and
textures of this place
Listen to sounds around you that emerge
Notice smells in this place
Focus on any sensations of touch such as the floor or
earth beneath you, the temperature, or anything you
There are many professionals who are trained in
specialized forms of CBT such as Trauma-focused
Cognitive Behavioral Therapy, Problem-Solving
Therapy, and Acceptance and Commitment
Therapy. Contact a counseling center or
private practice therapist in your local
community and find out about their experience
with CBT. When looking for a mental health
professional, consider these:
Licensed professional counselors
Licensed clinical social workers
Licensed Marriage and Family Therapists
Certified addiction counselors
Most health insurance plans have behavioral
health as part of your (or your family's)
medical coverage. Consult your insurance
company about local providers. Find out if
the mental health professionals covered
under your insurance are specialized in CBT.
Consider consulting with your primary care
doctor for possible referrals for a trained
mental health specialist.
If you need a medication consultation,
request a referral for a psychiatrist or mental
health nurse practitioner.
There may be low or no-cost options through your
school if you are a student. Also, many
employers have employee assistance programs to
help employees who are going through difficult
Find out if there may be options to go to a
counseling center through your school. Ask if
there are counselors who specialize in CBT.
Identify if your employer has an employee
assistance program. Contact the number
available. The information discussed through the
employee assistance program is confidential. It
may be free of charge for the first few
There are crisis hotlines available if you are in
immediate crisis. There are also hotlines to
find places for treatment and local resources
in your area.