10 Principles of Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a type of psychotherapy that focuses on identifying negative thought patterns and beliefs in order to help patients adopt more realistic alternatives. Therapists use CBT to help patients manage anxiety, depression, substance use disorders, eating disorders, and other mental health problems. It is one of the most beneficial types of therapy, with a strong body of evidence confirming its effectiveness.

The beneficial impact of cognitive behavioral therapy is best observed through its principles. Which principles underlie CBT? The ten principles of cognitive behavioral therapy are listed below.

• CBT is based on an individual cognitive conceptualization of each patient and an ongoing formulation of patients’ problems
• CBT needs a strong therapeutic alliance
• CBT places a strong emphasis on participation and cooperation
• CBT is a problem- and goal-focused therapy
• CBT prioritizes present at first
• CBT emphasizes relapse prevention, aims to educate the patient to be their own therapist, and is educational
• CBT aims to be time-limited
• CBT sessions follow a set format
• CBT teaches patients how to recognize, assess, and deal with dysfunctional beliefs and thoughts
• CBT employs a variety of techniques

1. CBT is based on an individual cognitive conceptualization of each patient and an ongoing formulation of patients’ problems.

Cognitive behavioral therapy is an approach that utilizes a variety of techniques suitable for the unique needs and requirements of individual patients. Every patient is different, which is why their needs vary. The most significant principle of CBT is the strong focus on the conceptualization of a patient. In other words, therapists strive to formulate and understand patients’ problems first before they recommend more specific techniques.

The importance of this principle is that it provides a framework for a better understanding of the patient. A therapist is unable to address specific problems and needs of patients unless they understand them first. This helps patients make consistent progress in therapy.

The main benefit of this principle is that patients receive the most suitable mental health support for their problems.

It works by asking questions to get a glimpse into what problems a patient is struggling with. In a 2013 research article published in SAGE Journals, Miss Kristina Fenn and Dr. Majella Byrne of King’s College in London define that a patient’s cognitive conceptualization exists on three levels, namely core beliefs, intermediate attitudes, rules and assumptions, and automatic thoughts.

Core beliefs are fundamental understandings; generally developed early in life, influenced by childhood experiences, and are considered absolute truths. These principles are deeply ingrained beliefs concerning oneself, others, and the world. In most cases, a patient doesn’t articulate core beliefs consciously.

Attitudes are judgments about a specific outcome or situation. On the other hand, rules are behavior prescriptions for patients to adhere to under specific circumstances. And assumptions are predictions about the development of a situation based on a patient’s behavior.

Automatic thoughts show up unconsciously and are triggered in certain situations. Patients are predominantly more aware of the emotions they feel rather than the thought that induce them.

The understanding of the cognitive conceptualization of a patient begins during the first contact to interpret a patient’s mental distress or initial problem. The therapist takes notes and gathers information provided by patients to develop a comprehensive plan for their treatment.

2. CBT needs a strong therapeutic alliance.

Cognitive behavioral therapy stresses the importance of a strong therapeutic alliance established through a collaborative therapeutic relationship where the therapist and patient work cooperatively to recognize unhealthy thoughts and behaviors.

The importance of a strong therapeutic alliance is to allow patients to effectively identify and define problems by making them feel safe and understood. That way, it’s easier for patients to adapt to therapy, especially when recovering from addiction. Persons with addiction tend to feel like everyone is against them. Establishing a strong therapeutic alliance helps in that aspect and is essential in promoting a supportive environment that encourages patients to be fully dedicated to the process.

The greatest benefit of this principle is that a therapist gets to relate to the patient. By doing so, they can take a look at certain situations from their angle. As a result, the patient can modify therapy sessions to address the specific needs of each patient.

The principle works by showing empathy, competence, warmth, and care to patients with different mental health problems. CBT emphasizes the importance of building rapport, sincerity, understanding, and empathy, according to a 2013 research study by Miss Kristina Fenn and Dr. Majella Byrne of King’s College in London published in SAGE Journals. Feeling understood and valued is important for progress and successfully resolving mental health problems. Patients with mental health conditions and substance use disorders need an environment where they are not criticized and judged but rather valued and understood. With therapy, they can get that, which is the foundation for establishing a strong therapeutic alliance.

3. CBT places a strong emphasis on participation and cooperation.

Cognitive behavioral therapy is not a unidirectional process where the therapist delivers information for patients to listen to and go home. This type of therapy emphasizes the importance of teamwork and cooperation. Patients work together with therapists in identifying negative thought patterns and improving their mental health.

The importance of this principle is that it motivates a patient to engage in the process of their recovery. It shows and certifies the patient’s commitment to the process which leads to better treatment outcomes. The therapist only serves as a guide through self-discovery. The patient is the one that identifies destructive thoughts that lead to negative moods and risky behaviors.

The greatest benefit of this aspect of CBT is a higher likelihood of successful outcomes. According to a 2020 research article by Gøril Solberg Kleiven et al., published in Frontiers in Psychology, the patient’s role as an active participant in psychotherapy is crucial in the contribution of experiences during therapy sessions and is a critical factor in treatment success. Patients with a proactive approach put a lot of effort into their recovery. They feel stronger in resisting negative thought patterns and find it easier to replace them with realistic alternatives. This principle is also beneficial because it creates an environment where patients feel respected, not judged, and valued for their input.

The principle works through the active participation of the patient. This means a patient should actively work on tasks recommended by a therapist and engage in sessions. In addition to complying with homework and activities, punctual attendance and compliance with scheduled appointments are also considered critical components of patient participation.

They also need to do homework and be open to various techniques a therapist may employ.

4. CBT is a problem- and goal-focused therapy.

Cognitive behavioral therapy is an approach that focuses on the specific needs of the patients. It’s important to adopt a systematic approach curated for specific mental health problems. A patient can’t succeed in improving their mental health or recovering from addiction unless their problems are particularly addressed. To make CBT a successful treatment process, it focuses on the problem that patients want to address and should align with the goals that patients want to achieve through a therapeutic intervention designed to address their particular mental health issues.

The importance of this approach is that it improves treatment efficacy, boosts learning, and focuses treatment practices on targeted issues and possible solutions. Setting achievable goals helps the patient resolve the problem that troubles them. For example, they can focus on depression, anxiety, addiction, and stressors that induce disruptive thought patterns. By focusing on specific problems, therapists can help patients respond to them most effectively.

The benefits of this principle include equipping patients with the exact set of coping skills they need to overcome their problems and allowing them to focus on the recovery process.

The principle works in a way that the therapist evaluates a patient’s mental health and identifies specific problems to address. Miss Kristina Fenn and Dr. Majella Byrne of King’s College in London further explain that sessions start with a goal-setting activity where the therapist helps the patient in choosing items that will be explored in that particular session. Patients are also instructed to record all the intrusive thoughts that interfere with those goals. The therapist works closely with a patient to modify their response to those intrusive thoughts in order to make it easier to achieve those goals i.e., addiction recovery.

5. CBT prioritizes the present at first.

Cognitive behavioral therapy focuses on specific present situations or ongoing thoughts that cause distress to a person and finds ways to improve a person’s state of mind.

The importance of this principle is that it encourages a patient to live in the present, think about the present, and focus on the current problem or “task” at hand. Cognitive behavioral therapy only takes a look at the past when patients show a preference for it. The therapist may also address a patient’s past when they get stuck in dysfunctional thinking or in cases when learning more about childhood is necessary for addressing the current problem.

The most important benefit of prioritizing the present is that patients get to improve their state of mind effectively at present when a person’s suffering lies. For that reason, CBT aims to fix that problem and thereby relieve a patient’s pain or reduce the severity of symptoms they experience. This is also useful for persons with addiction. Their addiction is a current problem, and CBT focuses on resolving it rather than prioritizing the past.

CBT prioritizes the present at first because it is problem-oriented and is concerned with the here and now. It works by encouraging patients to talk about their beliefs, challenging them, and identifying problematic patterns. Changing these patterns helps resolve the current problem.

6. CBT emphasizes relapse prevention, aims to educate the patient to be their own therapist, and is educational.

Cognitive behavioral therapy aims to address the lack of understanding of the process and prevent relapse. According to a 2008 paper by Dr. Suzanne Graham and Dr. John Brookey published in the Permanente Journal, patients can’t take the necessary actions to make adequate decisions if they don’t understand health information. A patient who doesn’t understand how therapy works or how to fix distorted thinking will not make any progress. The therapist and patient work together to recognize and understand the causes of relapse and develop an approach to prevent them from happening.

An important aspect of CBT is to teach patients to be their own therapists. The importance of this principle of CBT lies in allowing patients to develop their sense of control. In their 2020 review published in the British Journal of Psychology Research, Dr. Murillo de Oliveira Dias and Marcia Cristina Oliveira de Simoni stress that through CBT, patients gain practical insight into how their negative thoughts led to dysfunctional behaviors and emotions. By teaching patients to be their own therapist, CBT empowers them to take active control of their own recovery and develop the skills and tools to manage their mental health in the long run, with or without the help of their therapist.

The greatest benefit of this principle is education and encouraging patients to practice what they learn. Therapists teach patients to adopt healthier and more realistic thought patterns and coping mechanisms. By focusing on educating patients, CBT allows them to work actively on their mental health. As a patient is more aware of their thought patterns and behaviors or their connection, they are more likely to reduce the risk of relapse. A 2018 study by Zuojie Zhang et al. of the Sichuan University in China, published in BMC Psychiatry confirmed that CBT sessions could reduce the risk of depression symptoms relapse. The same applies to other conditions and addiction.

This principle works through various exercises and homework that patients get to practice outside of sessions. Journaling is a good example of homework that patients do within CBT, but they may also need to rehearse skills they learned during a therapy session.

7. CBT aims to be time-limited.

Session duration is one of the most significant principles of cognitive behavioral therapy. Sessions are time-constrained in terms of the duration of each session and the number of sessions necessary for a patient with a specific problem.

The importance of time-limited sessions is that they exert pressure on the overall therapy process. Time-limited sessions create an expectancy effect. They allow therapists to take over a directive role in therapy. The UK Association for Cognitive Analytic Therapy explains that time-limited therapy sessions help maintain the focus and momentum of therapy. It also averts the vagueness of the process.

The benefits of time-limited sessions include greater adherence, preventing patients from leaving therapy prematurely, and improved structuring of the sessions. Patients benefit from this principle because they can evaluate their progress more effectively. They also tend to be more proactive and put a lot of effort into getting the most from their sessions.

The number of sessions depends on the specific mental health problem or severity of the addiction. The National Health Service UK reports that patients need 6 to 20 therapy sessions. According to a 2012 study by a group of doctors led by Dr. Jason A. Nieuwsma published in the International Journal of Psychiatry in Medicine, depression can be effectively treated through six to eight sessions of CBT. The duration of each session is 30 to 60 minutes, usually once a week. In most cases, patients start with longer sessions for a few weeks. As they make significant progress, the therapist reduces the duration of sessions to 30 minutes. This only refers to one-on-one sessions. Sometimes group therapies are also necessary, especially for patients suffering from addiction.

If a patient doesn’t make significant progress during the set number of sessions, the therapist may recommend they keep going to therapy.

8. CBT sessions follow a set format.

Cognitive behavioral therapy is a structured treatment that follows a set format that patients don’t find overwhelming or frustrating. Patients with addiction or other mental health problems tend to feel overwhelmed by the lack of structure in their life. The lack of structure results from dysfunctional thought patterns and behaviors.

The importance of a set format is that therapists get to create a calm and supportive environment. This kind of environment has a certain flow, patients know what to expect and feel safe. That’s why the main benefits of following a set format are greater confidence in the process, feelings of calmness and relaxation, and increased adherence. When patients know the format, it’s easier to stick to it.

A typical session of cognitive behavioral therapy consists of three segments. According to the National Health Service UK, the first segment is an introduction, which includes a mood check, a brief review of the week, and a presentation of the agenda for the session. The second part of the CBT therapy session includes reviewing homework, discussing issues on the agenda, setting new homework, and summarizing. The final part of the session is reserved for eliciting feedback. Therapists dedicate some time during the session to explain the progress a patient has made. Patients get to realize how far they’ve come, which can boost their motivation to overcome mental health problems or addiction.

9. CBT teaches patients how to recognize, assess, and deal with their dysfunctional beliefs and thoughts.

Therapists use cognitive behavioral therapy to help patients learn to recognize or identify disrupting thoughts or beliefs. Negative thinking tends to come naturally. In most cases these thoughts are irrational, but they have a tremendous power to disrupt a person’s thought process. When left unmanaged, these disruptive thoughts lead to dysfunctional beliefs and further aggravate mental health problems.

The importance of teaching patients to recognize these thoughts and beliefs lies in equipping them with skills to beat them. A patient is unable to overcome disruptive thoughts if they can’t recognize or assess their detrimental effect. This principle allows a therapist to empower patients so they can recognize and correct irrational thoughts by adopting a realistic approach to specific stimuli.

The main benefit of this principle of CBT treatment is that patients learn mechanisms or develop healthy practices necessary to tackle dysfunctional beliefs and thoughts. Healthier thoughts and beliefs influence behavioral patterns. For example, a person with addiction becomes more empowered to overcome negative thoughts and risky behaviors by adopting more positive beliefs and thought patterns.

Teaching patients to recognize dysfunctional thoughts and beliefs usually works through guided discovery.

The therapist creates a setting where they question a patient’s thoughts and evaluate their thinking. As a result, a patient gets more insight into the way they think and perceive the world around them. They can pinpoint disruptive thoughts or beliefs and work to fix them.

10. CBT employs a variety of techniques.

Cognitive behavioral therapy targets to change a person’s perception and action by employing both cognitive and behavioral techniques to address mental health problems. According to the book Brief Interventions and Brief Therapies for Substance Abuse by the Center for Substance Abuse Treatment, cognitive behavioral therapy implements cognitive therapy to change a patient’s thought patterns and behavioral therapy where behaviors caused by negative thought patterns are replaced by learning new and healthy behaviors.

The main importance of this principle of CBT is that therapists choose techniques to address the specific needs of patients. As previously mentioned, CBT is patient-centric. One technique doesn’t necessarily work for all patients because every patient is different. A therapist may opt for one or several CBT therapy techniques that help a patient the most.

The benefits of using multiple techniques include the opportunity to adopt better coping mechanisms, change unhealthy into healthy behavior patterns, increase confidence, and get a better insight into other people’s perspectives. CBT techniques encourage a person to change their perspective allowing them to realize that their thinking patterns were disruptive.

How this principle works depends on the specific technique with the goal to make the process interactive. According to Miss Kristina Fenn and Dr. Majella Byrne of King’s College in London, CBT can be done through behavioral techniques where the patient gets exercises or various activities that work to improve their thought processes. For example, they may need to write a journal, schedule pleasant activities, or do something else. This technique is especially effective to help patients rebuild normal routines, engage in pleasant activities, and improve their problem-solving ability by handling problems and tough issues. The therapist explains the purpose of the technique, describes how to perform it, and talks about its benefits. Additionally, the therapist acts as a guide that helps patients navigate through each technique, offers support, and explains how to adapt their thought patterns for healthier behaviors.

What is Cognitive behavioral therapy?

Where did the principles of CBT originate?

The principles of CBT originated at the University of Pennsylvania in the 1960s when Dr. Aaron Beck designed and conducted experiments to test several psychoanalytic concepts. His experiments yielded interesting results. They showed that depressed patients had negative thoughts that appeared spontaneously. The patients verbalized thoughts that lacked validity.

Beck noted these patients had cognitive distortions in their thinking. He started thinking that depression isn’t just a mood disorder but also a cognitive disorder. That’s why he changed the approach to treating patients with depression. Dr. Beck helped patients reevaluate their thoughts about themselves. When patients did so, they started becoming more resilient in handling everyday life functions. The therapy led to a long-lasting change.

With time, the use of this approach spread to the management of other mental health problems.

Besides Dr. Beck, a major contribution to the development of CBT came from American psychologist and psychotherapist Albert Ellis. He trained and practiced psychoanalysis but became dissatisfied with it. His dissatisfaction stemmed from the passivity and ineffectiveness of current therapy methods. That’s why he decided to explore and develop new approaches to psychotherapy. 

By 1956, Dr. Ellis presented a rational therapeutic approach. It involved therapists working actively with patients and helping them understand their irrational beliefs that contribute to emotional and psychological distress. This method is also known as REBT (rational emotive behavior therapy). In fact, REBT is considered to be a starting point for the development of CBT.

Doctors Ellis and Beck had a lot in common. Their greatest connection was huge dissatisfaction with current therapeutic approaches, and they believed patients need a more comprehensive form of therapy. 

Although doctors Ellis and Beck played the most important roles in the development and evolution of cognitive-behavioral therapy, the roots of this type of therapy were planted many years ago. In fact, precursors of some aspects of cognitive-behavioral therapy stem from ancient philosophical traditions, particularly Stoicism. Stoic philosophers believed that we could discard false beliefs that cause destructive emotions by using logic.

Modern roots of CBT stem from the early 20^th century. In the 1920s, American psychologists John B. Watson and Rosalie Rayner popularized the theory of behaviorism and established it as a psychological school. The behaviorist theory focuses on external and outward behaviors rather than the internal psychological and emotional state of a person. Watson believed physical responses speak a lot about internal actions. 

Around 1924, behavior-centered therapies came into practice. In the 1950s, South African psychiatrist Joseph Wolpe pioneered behavioral therapy and set the foundations for the development of exposure therapy in treating people with anxiety. The works of Watson and Wolpe influenced other psychologists and psychiatrists to develop new behavioral therapies. For instance, psychologists Arnold Lazarus and Hans Eysenck developed behavioral therapy that revolved around the classical condition. Basically, the classical condition refers to a practice where a neutral stimulus such as a tone becomes associated with a specific stimulus such as food to create a behavior.

The development of Behavioral therapy was one of the foundations for Cognitive-behavioral therapy.

When it comes to cognitive therapy, the second foundation for the development of CBT, Austrian psychotherapist Alfred Adler played an important role. He was known for basic mistakes and ideas. In his teachings, basic mistakes are factors that arise early in childhood and affect a person’s life in adulthood. These mistakes need to be corrected in order to improve mental health and resolve conflicts and other problems.

Adler’s work influenced Albert Ellis’ and later Aaron Beck came into the picture.

What are the basic Cognitive-Behavioral therapy techniques?

The basic CBT techniques are listed below.

• Cognitive restructuring or reframing: a therapeutic process that helps a person discover, modify, replace, or challenge negative or irrational thoughts. This technique encourages a person to take a hard look at their negative thought patterns. For example, sometimes people over-generalize, assume the worst-case scenario would happen, or focus too much on insignificant details that affect their behaviors. In an article about Cognitive Restructuring published In The Wiley Handbook of Cognitive Behavioral Therapy in 2013, Dr. David A. Clark further defines cognitive restructuring as an organized collaborative process where individuals are guided to recognize, identify, explain, and change dysfunctional thoughts, judgments, and beliefs that are deemed responsible for their mental distress. Once a person is aware of these negative patterns, they can reframe them into more positive and adaptive alternatives.
• Exposure therapy: helps people overcome anxieties and fears by exposing them to a stimulus that causes fear. Exposure therapy is performed in a safe environment and the exposure is performed gradually. Exposure therapy incorporates therapist support to patients to slowly overcome and improve permissiveness to triggers that cause fear and mental distress. A 2022 systematic review published in BMC Psychiatry by Tengyue Huang et al. of The First Affiliated Hospital of Chongqing Medical University in China found that exposure therapy is beneficial for PTSD comorbidities and showed significant improvement in patients’ depressive symptoms both in children and adults.
• Guided discovery: a technique therapists use to help patients reflect on how they process information. James Overholser, Ph.D. of Case Western Reserve University defined the stages or structures that may be incorporated in guided discovery in his 2012 article published in the Journal of Contemporary Psychotherapy. Guided discovery involves supporting patients in developing realistic and adept perspectives on normal problems, identifying problems with concrete practical objectives, assisting patients in developing coping mechanisms, guiding patients through the entire process, and implementing the plan while assessing its efficacy. This technique encourages patients to get a closer look at something from different perspectives. That way, they get to choose a more positive path.
• Activity scheduling and behavior activation: a technique based on the premise that a person can alleviate depression or improve mood by engaging in pleasant activities regularly. It helps establish positive habits and provides an opportunity for a person to practice what they have learned. For instance, if there’s an activity that a person avoids or delays due to anxiety and other negative emotions, scheduling it can be helpful. Activity scheduling is a lucrative element in treating depression due its simplicity and straightforward approach which makes it promising for patients to follow through as stated by Genevieve Riebe et al. of the University of Washington in their paper published in the International Journal of Geriatric Psychiatry in 2012. This technique also includes scheduling (purposely finding time) for something fun and enjoyable.
• Journaling: a great technique for people to observe and release thought patterns they have on a daily basis. Journaling is an opportunity for a person to get in touch with their feelings. A therapist may choose journaling as a CBT technique and instruct a patient to write down all negative thoughts they have between sessions. After listing negative thoughts, a patient then needs to write positive alternatives to them. Journaling may also include keeping track of new thoughts and behaviors. Doing so helps a person track their progress more effectively.
• Successive approximation: also known as shaping, revolves around taking complicated or overwhelming tasks and breaking them up into smaller and achievable steps. Therapists choose this technique for patients with difficulties completing a task. The successive approximation works by encouraging people to master a smaller task or a task that is similar to the overwhelming one. Each successfully completed task is rewarded, and a person gains more confidence to tackle more complicated tasks in life.
• Role-playing: allows a person to identify their feelings about a specific situation while also learning how others are feeling at the same time. Role-playing makes it easier for a person to verbalize their feelings and improve interactions with others. It helps people work through difficult situations in life.
• Stress reduction techniques: the main purpose of these techniques is to lower stress levels and thereby allow a person to increase the sense of control. Stress reduction is helpful for dealing with social anxieties, phobias, and even addiction. The therapist may employ various techniques to reduce stress, including imagery, muscle relaxation, and deep breathing exercises. 

What are the benefits of Cognitive-Behavioral Therapy?

The benefits of cognitive behavioral therapy are listed below:

• Development of more rational thought processes: the main benefit of cognitive-behavioral therapy is that it helps a person gain more control over their thoughts. Cognitive distortions are common, and they may appear automatically. In many cases, a person doesn’t even realize their thinking process is distorted. To them, these thoughts may seem realistic. When left unresolved, cognitive distortions include our thought processes entirely and also affect the way we feel or behave. Cognitive-behavioral therapy is helpful for developing more rational thought processes to resolve and prevent cognitive distortions.
• Promotes relaxation: behavioral aspect of cognitive-behavioral therapy helps people learn to control their response to stressors and other negative stimuli. Doing so allows a person to respond to the situation in a calmer manner.
• Improves self-esteem: many mental health conditions and addiction are strongly associated with low confidence and self-esteem. Lack of self-esteem further contributes to negative thoughts and behaviors, thus creating a vicious cycle. One of the most important benefits of CBT is that it can break this cycle and give a major boost to a patient’s self-esteem. Through the skills they learn during therapy, patients develop stronger confidence in their abilities and decisions.
• Gives hope: cognitive-behavioral therapy is all about showing people with mental health disorders and addiction there’s hope and a chance to feel better. Sometimes people with these problems believe there is no way out. They feel hopeless, which further aggravates their symptoms and leads to risky behaviors. Thanks to CBT, patients realize their thoughts are sometimes inaccurate and irrational. They learn to adopt a healthier mindset, which leads to better mental health and improved behaviors.