How Therapists Really Use CBT

One of the most common complaints of new social work graduates is that their program did not teach them how to do therapy. Over 530,000 social workers were in the behavioral health workforce in 2022.⁶ Ironically, social work grad programs focus on generalist curricula, teaching you how to practice in a broad range of settings. Psychotherapy is just one of the jobs that a social worker can do.



Some schools offer introductory courses in therapy to help you apply their tools wherever you land after graduation. One common offering: cognitive behavioral therapy, abbreviated CBT for short. In this blog, we’ll dive deeper into CBT, what it is and isn’t, and how to go beyond the basics of using it as a therapist.



What is CBT?



Cognitive Behavioral Therapy is an approach that emphasizes the relationship between thoughts, feelings, and behaviors. Before the development of this model, the psychoanalytic view of depression was that people are depressed because they have an innate need to suffer.¹ In the 1960s, Dr. Aaron Beck found that many of his patients’ reported experiences did not fit this perspective.¹ He found that instead, spontaneous, negative, critical thoughts impacted patients' mood and behavior.¹ He termed these “automatic thoughts,” and began to develop the cognitive behavioral model of depression.



In the years since then, CBT has been adapted for a broad range of applications. Today, clinicians use it to treat depression, anxiety, PTSD, OCD, and some physical ailments as well, like sleep disturbance or chronic pain. While the specialized formats of CBT may differ, they all start by focusing on the same basic tenets.



What are the core concepts of CBT?



CBT centers on cognition, the processes that make up thought, through three main concepts:



1. Automatic thoughts – our immediate, unpremeditated assessment of events.
2. Cognitive distortions – logical errors in how we interpret situations.
3. Underlying dysfunctional beliefs – the unhelpful ways we view the world.²



Therapists often start by providing education on these concepts to their clients to create a common vocabulary. Then they would work together to start identifying and describing what the concepts mean to the client in their own experience.



Let’s put these concepts in action. A teen client who struggles with social anxiety might have the automatic thought, “I’m such a loser” when noticing they have no one to sit with at lunch. In therapy, they learn to identify cognitive distortions in their thinking. The client recognizes they are minimizing their feelings by downplaying their positive qualities. They start to notice themself brushing off compliments from friends, which strengthens the unhelpful belief that they are unlikeable, or that they have no friends. Learning these key concepts help the client and therapist to map out the problem and change behavior patterns that worsen depression.⁷



Criticisms of CBT



CBT has become a hot topic in the psychotherapy community. CBT has a “top down” approach, meaning that it starts with cognition to manage mental health issues. "Bottom up” therapies like EMDR and somatic work, which focus on emotion regulation and body sensation first, have grown in popularity of late. Critics say CBT is heady, impersonal, and less effective than these alternative modalities.



Other clinicians take issue with CBT’s focus on the present with regard to thoughts, emotions, and behaviors, rather than the root causes.5 With our field's increased awareness of the impact of childhood trauma, it does follow that ignoring this context in favor of a present focus can hinder treatment.



A third common complaint is that the approach of CBT relies too much on personal responsibility of the client. For instance, many CBT therapists require their clients to complete homework or self-monitoring of symptoms between sessions.⁵ On a deeper level, CBT focuses on issues like low self-esteem, self-blame, or self-judgment, which are symptoms of an underlying problem rather than the issue itself.⁵ Both instances lack awareness of the client's psychosocial stressors or executive function issues.



These critiques are valid. Let’s revisit that teen client with social anxiety. Adolescents can struggle with having the vocabulary to describe what they are feeling. This is developmentally appropriate -- they just haven’t learned that skill yet! But without that self-knowledge, starting CBT can be tricky. As the clinician, if I am too focused on emphasizing the present, I might miss screening for historical context. Understanding the client’s trauma history sheds a new light on their unhelpful core belief that they are “unlikeable.” With this context, over-emphasizing personal responsibility might come off as blaming the client for their poor self-esteem.



How I Use CBT



I was trained in CBT in my last semester of my Master’s program by an old-school professor whose mentor was literally B.F. Skinner (yes, really). I showed up weekly with a sharpened pencil, ready to take step-by-step notes that I would then commit to perfect memory and execute in the future. To my complete shock, that is not how the future played out. What stuck with me the most was not how to perform cognitive behavioral interventions, but how to think critically using this new lens.



In the intervening years, I have told clients, “I know this approach isn’t cool and sexy like ___” more times than I can count. While I know Dr. Beck and company have caught some flak, I still find myself using it as a guide in my work. I use CBT, but I’m not so rigid in my practice that I’m closed to feedback from my clients. I like CBT, but no approach is one-size-fits-all.



To bridge this gap, I’ve started using a few offshoots of the main CBT approach, including:



1. Anti-oppressive CBT – an approach which acknowledges that our lives do not happen in a vacuum and strives to reduce the power imbalance and structural inequity contributing to mental health conditions.⁴



2. Trauma-focused CBT – a modified version that uses the cognitive behavioral model to understand the impact of trauma in treating and preventing post-traumatic stress.³



3. Mindfulness-Based Cognitive Therapy – combining the principles of CBT with the skills learned from mindfulness meditation to increase self-knowledge and engage with thoughts differently.⁸



Final Thoughts



CBT may not be new, cool, or sexy, but it is a classic for a reason. In addition to the offshoots mentioned above, many of the newer modalities gaining in popularity today are based on cognitive behavioral principles. You heard it here first folks: the art of therapy is often derivative.