Fact Sheet: Cognitive behavioral therapy

If you hear the term “psychotherapy”, you might first think of Sigmund Freud and psychoanalysis, and picture yourself lying on a couch, talking about your childhood. But there are many different kinds of psychotherapy that use very different approaches and methods. And they are not only used for mental illnesses, but also to help someone cope with a chronic disease, for example. Cognitive behavioral therapy (CBT) is one of the best studied forms of psychotherapy.

This therapy was developed by American psychotherapists in the 1960s. Since then, the methods of cognitive behavioral therapy have constantly evolved. To get a quick overview of the main features of CBT, click here.

In addition to the CBT overview, this fact sheet answers the following questions on cognitive behavioral therapy: How does it work and how is it different from other forms of psychotherapy? When is it considered? What happens during a session with a psychotherapist? How long does treatment take? And last but not least: Is it paid for by statutory health insurance?

What is cognitive behavioral therapy?

CBT combines two therapeutic approaches: cognitive therapy and behavioral therapy. Which methods of treatment will be applied depends on the illness or problem to be treated. Depending on what seems to make sense in an individual case, elements and methods from both approaches are used in therapy. The basic assumption of therapy is always the same, however: What we think, how we feel and how we behave are all connected – and all of these factors together have a decisive influence on our well-being.

Cognitive therapy

The term cognitive, is derived from the Latin cognoscere, meaning “to recognize”. The point of cognitive therapy is to get a clear idea about your own thoughts, attitudes and expectations. Inappropriate and distressing beliefs can be revealed and then changed. The idea behind this is that it is frequently not only the things and situations themselves which cause problems, but rather the meaning that we give them.

A typical example for such a distressing thought pattern is generalization. In some situations, many people tend to jump to conclusions and to assume the worst, for example: “My husband has left me – I must be a bad partner, I will never find anyone ever again!” In psychology, this generalized way of thinking is called “over-generalizing”. A general “truth” is deduced from a single incident and applied to similar situations. The fact that many relationships fall apart and that the reasons are rarely found in just one of the partners is thereby overlooked.

Another distressing error in reasoning is “catastrophizing”: If something disturbing happens, people immediately draw exaggerated conclusions about the scope of the supposed disaster ahead. Cognitive therapy helps to think more clearly and to control your own thoughts better.

Exaggerated patterns of thought and beliefs such as over-generalizing or catastrophizing sometimes develop into “self-fulfilling prophecies” and make life difficult for the people affected. With the help of cognitive therapy, however, it is possible to learn to replace these thought patterns with more realistic and less harmful thoughts.

Behavioral therapy

Behavioral therapy is rooted in American “behaviorism”. This theory assumes that human behavior is learned and can therefore be unlearned or learned anew. Behavioral therapy consists of finding out whether there are certain behaviors that make life difficult for you or cause your problems to be more severe. In a second step, you will work on changing these behaviors.

People who have developed depressive thoughts frequently tend to withdraw and no longer pursue their hobbies, for example. As a result, they feel even more unhappy and isolated. Behavioral therapy aims to recognize these feelings and then to find ways for someone to become more active again.

In anxiety disorders, behavioral therapy often includes learning methods to help you calm down. For example, you can learn to reduce anxiety by consciously breathing in and out deeply so that the body and breathing can relax. When doing this you concentrate on your breathing instead of what is bringing on your anxiety. This kind of technique can help you to calm down instead of getting all worked up with anxiety.

CBT is characterized by a close and trustful cooperation between the psychotherapist and the client. Together they work out treatment goals and speak regularly about the progress achieved and any possible difficulties that may have cropped up. The therapy is shaped together. Sometimes it takes a while to find the right therapist.

What is the difference between CBT and other psychotherapies?

Cognitive behavioral therapy (CBT) is a problem-oriented strategy. It focuses on current problems and on finding solutions for them. Unlike psychoanalysis, for example, it does not deal primarily with the past. Also, the main goal of CBT is not to discover what causes the problems, but rather to tackle them here and now. Enabling self-help is important: you should be able to cope with your life again without therapeutic help as soon as possible. This does not mean that the influence of past events is completely ignored in cognitive behavioral therapy. However, it deals primarily with recognizing and changing current distressing patterns of thought and behavior.

Analytic psychotherapy, which has its origin in classic Freudian psychoanalysis, uses different methods. Here the therapist tries to help the client discover and understand problems and their deeper causes.

When is CBT an option?

Initially, CBT was used mainly for treating depression. However, it soon became apparent that its basic assumptions can also help with other problems, disorders and illnesses. So different methods of CBT were developed that specifically aim to help in certain diseases or illnesses, for example eating disorders, anxiety or panic disorders, obsessive-compulsive or addictive disorders as well as sleep disorders. CBT can also help people with certain chronic diseases, for example tinnitus and rheumatism, to better cope with their symptoms.

The methods used in CBT demand a great deal of commitment and self-initiative. For the therapy to be successful people have to cooperate actively and to also work on their problems between sessions. This can be a great challenge, particularly if someone is very ill, for example with severe depression or anxiety disorder. This is why sometimes medication is used at first to try to quickly relieve the first symptoms and thus make it possible to start psychotherapy.

The decision for a certain kind of psychotherapy also depends on the goal. If you feel the need for deep insight into the causes of your problems, CBT is probably not the right choice. CBT is particularly useful if you are mainly interested in tackling concrete problems and are only secondarily concerned with the “why”.

How does CBT work and how long does it take?

In the first session, you will briefly explain your current problems. You will tell the psychotherapist what it is you hope to achieve with the therapy and discuss the treatment goals and the therapy plan with the psychotherapist. The personal goals can change over the course of therapy and will then be adapted accordingly.

Compared to other types of psychotherapy like psychoanalysis, for example, CBT is a brief treatment. It cannot be said across the board how long a successful therapy will take. Some people already feel considerably better after a few sessions, while others need treatment for several months. This depends on the kind and severity of the problems, among other things. An individual session lasts about an hour. The sessions usually take place once a week. Cognitive behavioral therapies are offered both on an out-patient and an in-patient basis, and also sometimes as group therapy.

The therapy often includes recording your own thoughts in a journal over a certain period of time. You will then scrutinize the results together with the psychotherapist: Do I assess things appropriately and realistically? What happens if I behave differently than I normally do in a certain situation?

One method of behavioral therapy that is frequently used with anxiety and obsessive-compulsive disorders is the so-called “exposure therapy”. In this treatment the client is gradually confronted with the triggers for the anxiety, so that the client learns how to cope with the anxiety and agitation that then occurs. If, for instance, someone has developed a compulsion to constantly wash his or her hands because of a fear of germs, the therapist could, after thorough therapeutic preparation, ask the person to touch something that he or she perceives as dirty. After that the client would try not to wash his or her hands immediately.

CBT also uses methods like relaxation exercises, stress management training and strategies to solve problems. Because problems and life situations are different from person to person, as are the wishes and aims associated with the therapy, psychotherapy is always tailored to individual needs.

Could CBT also have adverse effects?

Cognitive behavioral therapy can help with various diseases, problems or disorders. It is not suitable for treating all diseases or disorders, however. Nor can adverse effects resulting from therapy be ruled out. Being directly confronted with your problems or anxieties might be very stressful at first. It is crucial that you are able to speak openly with your psychotherapist about any difficulties that might come up during therapy.

Hardly any research has been done on adverse effects of psychotherapy. So we do not know how frequently they might actually occur.

Are the costs covered by statutory health insurance?

In Germany, statutory health insurance pays for cognitive behavioral therapy to treat mental illnesses such as depression, anxiety or obsessive-compulsive disorders. CBT can also be paid for if a chronic disease such as tinnitus leads to considerable psychological strain. It can sometimes take weeks or months, however, before you can get an appointment with a psychotherapist or before the health insurance approves treatment. When looking for a therapist, it is good to know that in Germany most psychotherapists who are trained in CBT call themselves behavioral therapists (in German: Verhaltenstherapeuten).

In Germany, a psychotherapeutic practice can bill the state health insurance directly for up to five trial sessions. This way you can get to know the psychotherapist, find out what problems there are and whether therapy makes sense. If the trial sessions show that it is difficult to establish a trusting therapeutic relationship, it is possible to choose another psychotherapist. After five sessions at the latest, the psychotherapist must present a medical report about the required treatment to the health insurance. Once the health insurance agrees to assume the costs, the actual therapy can begin.

What can I do if I find it hard to look for help with emotional problems?

Some people find it difficult to seek help from a psychotherapist for their problems. There can be a number of reasons for this: Some people are afraid of being labeled mentally ill, or they feel insecure because they do not know what happens in psychotherapy. Others doubt whether psychotherapy can actually help them. However, after starting or finishing therapy, people often say that they should have sought help earlier. It is not easy to challenge and change your own thoughts and ways of behaving – it can actually be very stressful and demanding. But very often the effort is worth it: successfully overcoming a depression or an obsessive-compulsive or anxiety disorder greatly improves quality of life.

If you find it difficult to go to a psychotherapist, you might

• First take a walk and have a look at the building where the practice is – it is often helpful to get an impression of the surroundings;
• Telephone the practice without saying your name and find out how a therapy is done;
• Look for a practice in an area that is further away from where you live;
• Bring a family member or a friend to the first session; or
• Talk with other people who have already made use of therapy, in a self-help group for example.

You can find out more about research on CBT with various illnesses here.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)