If you’ve ever dealt with common challenges like anxiety, depression, insomnia or chronic pain, perhaps you’ve heard about a treatment known as CBT. It can be an alternative to taking sleeping pills, antianxiety medications or antidepressants. Or it can complement medications. But what does CBT stand for, and how does it work?
To answer your questions about cognitive behavioral therapy or CBT, we consulted with clinical health psychologist Dr. Ava Schumacher. She’s an expert in mind-body connections.
Schumacher cares for patients at the UCHealth Integrative Medicine Center in Denver’s Central Park neighborhood.
As a health psychologist, Schumacher helps patients use the power of their minds to cope with health challenges and boost well-being. She works with people who are struggling with a variety of difficulties, including medical challenges, chronic pain management, stress, anxiety, and sleep problems, also known as insomnia.
“It’s essential to care for all aspects of ourselves — including mind, body and spirit,” Schumacher said. “I often integrate mindfulness and cognitive behavioral therapy or CBT into my work with patients.”
What does CBT stand for, and what is cognitive behavioral therapy?
CBT stands for cognitive behavioral therapy, and CBT is a specific kind of talk therapy that patients can engage in with a trained mental or behavioral health professional. Once people learn how to use CBT, they can apply the strategies to many aspects of their lives, and the benefits can be long-lasting.
“The whole point of CBT is to gain a deeper understanding of the interconnectedness between our thoughts, behaviors and emotions and to understand how they affect each other and how we can make changes,” Schumacher said.
“A key goal of CBT is to change unhelpful thinking patterns into more helpful ones,” she said.
Helpful thinking patterns can, in turn, impact emotional experiences and empower people to change their actions and behaviors.
For example, if a person is feeling anxious or depressed, they are more likely to have anxious or depressed thoughts (of course). These worries or sad thoughts can then make a person feel worse. When people spiral into negative thought patterns, it can affect their emotions and behaviors, as well as their physical health.
“It can be hard to change this cycle on our own,” Schumacher said. “If we’re already viewing things through a negative perspective, those thoughts tend to build on themselves. That’s where CBT comes in. We focus on how our thoughts are affecting our emotional experiences and behaviors and how we can make changes to our thoughts.”
Along with CBT, Schumacher also uses other techniques, including mindfulness. Learn what mindfulness is and how it works.
Is CBT especially helpful for specific mental health issues?
Yes, Schumacher said.
“CBT works well for a wide range of concerns, including anxiety, depression, stress management, sleep problems, chronic pain and improving self-confidence,” she said.
People can apply the tenets of CBT to a variety of circumstances.
“All of us have thoughts, emotions and behaviors,” Schumacher said. “Understanding how our thoughts relate to our emotions and behaviors can help us interrupt unhelpful patterns.”
CBT can be used as a standalone intervention, or alongside other treatments, such as medications, depending on each person’s unique history, circumstances, and the severity of their symptoms.
How long does CBT take? Can I learn how to do it in a few therapy sessions?
Yes, patients can learn how to use CBT techniques during short-term therapy.
“If you’re dealing with certain types of problems like a health challenge, managing chronic pain, insomnia, or experiencing life stress at home, work, or in your relationships, CBT can be a really great short-term intervention,” Schumacher said.
“We usually try to help people in about five to 15 sessions in our clinic. Our goal is to teach people the skills to help themselves develop more helpful habits and ways of thinking. My goal is that eventually you won’t need to come see me anymore because you will have learned how to implement new skills on your own.”
Tell me more about CBT and automatic thoughts.
“We all have automatic thoughts. These are the thoughts that just bubble up in our minds without trying to consciously think a certain thing. And thoughts are not facts, but many of us tend to respond to our own thoughts as if they are facts, assuming they’re true,” Schumacher said.
When providers work with patients using CBT, they help them first identify the automatic thoughts that pop into their brains, then begin to evaluate them.
“We can learn to change our thoughts and mental habits over time,” Schumacher said. “We change our thoughts or change our minds. We do that all the time.”
Here’s an example of how this concept of changing a thought works with anxiety. (Learn more about anxiety and how all adults may soon be screened for it.)
If a person with anxiety is supposed to connect with a friend but doesn’t hear from the person, the anxious person might automatically jump to a negative conclusion, like assuming that they did something wrong and that the friendship is falling apart.
Our reactions to others vary depending on our interpretations of our situations.
A go-with-the-flow person might not take a friend’s failure to get in touch personally.
They might think: “Oh, they’re probably swamped with work and family. Maybe I’ll reach out tomorrow.”
“In that case, they’re probably not too distressed,” Schumacher said. “The other person’s behavior might be disappointing, but you’re still engaging with them and inviting connection.”
A person with anxiety or depression, on the other hand, might start spiraling into negative or destructive thoughts and feelings like these: “Why didn’t they call? Maybe I did something to make them upset.” Or, “People always forget about me. No one wants to talk to me. It’s pointless to try to make friends.”
This is where cognitive behavioral therapy comes in. A person can learn to identify and change troublesome thoughts and beliefs.
“Often, our anxious and depressing thoughts are self-critical and self-blaming,” Schumacher said. “Sometimes you feel like you can’t get these thoughts out of your head, but CBT can help you learn to address these kinds of thoughts in a different, more helpful way.”
Psychologists can help people become more aware of these negative thoughts with the aim of channeling more balanced or positive thoughts and actions.
“Our automatic thoughts and beliefs have a really big impact on our emotions and behaviors. These cycles can become habits,” Schumacher said.
Is CBT or cognitive behavioral therapy just a way to ‘think happy thoughts’?
Absolutely not, Schumacher said.
“We don’t just say, ‘think happy thoughts.’ We need to focus on and deal with what’s really going on. It’s not useful to deny reality,” she said.
But there usually are multiple ways to think about any given situation, and we want to make sure we’re seeing things as accurately and in as helpful of a way as possible.
Schumacher helps patients avoid jumping to negative conclusions or worst-case scenarios. She guides them to recognize unhelpful thought patterns. Many people experience these patterns without realizing it.
For some people who are extremely anxious or depressed, it can take a lot of work to reframe negative thinking. But learning how to think differently can help many people tap into powerful, long-lasting change.
“CBT is a longer-lasting intervention. You learn about your stressors and you learn skills that can help you deal with stressful thoughts, and these skills can be applied to a variety of circumstances in life.”
To change negative thinking, I hear it’s helpful to learn about cognitive distortions. What are cognitive distortions and how are they related to CBT?
People with anxiety, chronic pain or insomnia can deal with a lot of negative thinking.
Cognitive distortions are patterns of thinking, mental filters or biases which lead us to have inaccurate and oftentimes overly negative thoughts.
“The mind is often more likely to focus on negative aspects of a situation,” Schumacher said. CBT can help people recognize these thinking traps and reframe their perspective.
There are many types of cognitive distortions. Here are just a few examples of common thinking traps:
- Black-and-white or all-or-nothing thinking — Seeing a situation in only two categories, rather than shades of grey. (If I don’t ace this test, I’m a failure.)
- Catastrophizing — Assuming that a situation will turn into a giant problem or a catastrophe, jumping to often disastrous conclusions. (I can’t believe it’s 3 a.m., and I still haven’t fallen asleep. I will never get a good night’s sleep again.)
- Emotional reasoning — Believing something is indeed true based on strong feelings. (I know I do a lot of things well, but I still feel like a failure.)
- Mind-reading — Believing we somehow know what others are thinking (I just know he doesn’t like me).
“It’s common to make black-and-white assumptions,” Schumacher said. “That’s just one type of distortion. Catastrophizing is also really common. Most of us are familiar with jumping to worst-case scenarios. If something happens, we often react by assuming the worst, usually without considering other, oftentimes more likely, outcomes. Of course, that’s going to make us feel even more anxious when that happens.”
With CBT, people learn how to recognize these inaccurate, unhelpful cognitive distortions and come up with alternative, more balanced, helpful ways of thinking.
“The first step is to identify the automatic thought. What is going through our minds? Then evaluate the thoughts and look at the evidence,” Schumacher said. “What is really going on?”
So, with the example of the friend who didn’t call, take a look at the facts and evaluate what is true or false.
“Maybe they didn’t call this time. But they just sent me a card for my birthday and told me how busy they are at work. Maybe they just forgot to call this time,” Schumacher said.
“We ask questions and consider evidence,” she said. “It’s all about finding balanced, realistic thoughts.”
Schumacher often encourages patients to avoid cognitive distortions by asking what they might tell a friend if they were in a similar situation or considering what their friends might tell them.
“Take a step back. Friends often give us a more balanced and realistic perspective than we give to ourselves,” Schumacher said.
Even when faced with incredibly challenging situations, we usually can offer emotional support and hope to our friends. CBT helps us learn how to have more helpful perspectives and maintain hope when facing our own difficulties.
For example, when faced with a devastating diagnosis or a tragic life event, a person can think of it in two distinct ways. The less helpful (but natural) response might be: “This is absolutely terrible, the worst thing that has ever happened to me, and I can’t deal with it.”
A more helpful approach might be: “This is a tragedy in my life, and though it will be difficult, I will find a way to get through somehow.”
Do relaxation techniques work well with CBT?
“Yes. Relaxation training is a common component of CBT, and it can be very helpful in reducing the effects of stress on the body and calming the mind so we can change the way we handle challenges,” Schumacher said.
One of the most common relaxation techniques is deep breathing. There are many ways to do breathing exercises. You can use an app or build relaxation into your daily routine. It can also be helpful to take a few moments to practice deep breathing when you notice that you are falling into spirals of negative thinking to help calm body and mind.
If you want to try using deep breathing, try taking breaks three times a day and use this simple method:
- Let your breath naturally flow deeply into your body, expanding the belly, without forcing it
- Inhale for about a count of five
- Pause briefly after the inhale
- Exhale for about another count of five, slowly and gently releasing the breath
- Pause again briefly after the exhale, before taking the next breath
In addition to interrupting negative thoughts, deep breathing exercises are a great way to reduce stress. Slow, deep breaths tell your body to calm down and reduce anxiety. Relaxing your body also helps the brain calm down.
What are some other techniques that can help with relaxation?
Deep breathing, guided imagery, and progressive muscle relaxation are all great techniques that can invoke the body’s relaxation response. Many other positive self-care activities can help promote well-being and reduce anxiety, including the following:
- Take a walk or engage in another form of exercise.
- Take a bath.
- Read a book.
- Spend time with your pet.
- Call a friend.
- Consider avoiding screen time and social media as they may not be restorative.
Does avoidance work to reduce stress? And how does CBT help people face daunting tasks rather than avoiding them?
Avoidance can seem to help reduce stress in the moment, but in the long term, it usually makes it worse.
“The longer we try to avoid something, the scarier it can become,” Schumacher said.
CBT helps people sort out their thoughts and consider why they might be procrastinating or avoiding difficult tasks. Then they can challenge their beliefs about the situation and make plans to act.
CBT can also help people who are dealing with challenges like social anxiety. During the pandemic, for example, many people who were already worried about being in crowded places became paralyzed with fear. But the more they avoided crowds, the greater their fears became.
“The more we face our fears in safe, supportive, planned ways, the more comfortable we can become,” Schumacher said.
Gradual exposure to distressing situations is also known as “exposure therapy,” and a therapist can help you figure out how to overcome anxiety-provoking situations step-by-step.
Learning how to recognize avoidance in everyday life is the first step to moving past it. That’s why you’ll often hear advice about breaking a big, daunting task into smaller, more manageable steps. Or simply dig in and get started, and a task that felt overwhelming will seem easier.
CBT helps people understand that thinking patterns are directly related to emotional and behavioral patterns, Schumacher said.
How can CBT help with insomnia or sleeping problems?
There’s a specific type of CBT for insomnia and it’s known as cognitive behavioral therapy for insomnia or CBT-I.
“CBT-I is the first line treatment for insomnia, and it can be very effective. It generally produces better, longer-lasting results for insomnia than sleeping pills,” Schumacher said.
CBT for insomnia focuses on changing both thoughts and behaviors.
With sleep problems, Schumacher often helps her patients start first with behavior changes. To sleep well, it’s vital to create a good environment for sleep and develop healthy sleep habits. This is also known as “sleep hygiene.” People typically sleep better in a cool, quiet, dark room. Exposure to screens right before sleep can make it harder to fall asleep or stay asleep, so it’s wise to avoid watching TV or binging on shows on your laptop or tablet in bed. It’s also smart to keep your phone far from your bed and to avoid working in bed.
“Your bed should be reserved for sleep and intimacy,” Schumacher said.
It also helps to avoid intense exercise, big meals or alcohol consumption in the hours before going to sleep. And it’s helpful to go to bed and wake up at approximately the same time every day – even on weekends. (Read this story for many more tips from a sleep medicine specialist on how to sleep better. And, if you wonder if you might have a common sleep ailment called sleep apnea, you can learn more about sleep studies and various treatments for sleep apnea.)
“Sleeping better often starts with changing behavior during the day and evening. So many things affect our sleep patterns,” Schumacher said.
Once a person has adopted behavior changes like avoiding alcohol and screens before bed, CBT-I can kick in with changes in thoughts.
“With CBT-I, people can learn how to calm their minds and bodies to promote better sleep,” Schumacher said.
If a person’s mind is racing at bedtime, it can help to meditate, use relaxation techniques or practice identifying and challenging stressful thoughts that might be interfering with sleep.Some people do well with white noise.
For those who struggle to go to sleep or those who find themselves wide awake in the middle of the night, anger and agitation can be a natural reaction.
“People don’t like having insomnia and thoughts about not sleeping can cause even more stress and anxiety,” Schumacher said. “Struggling to fall asleep or waking up at 2 a.m. can be a big problem. But the thoughts about waking in the middle of the night can be just as bad. You might think, ‘If I only get 4-1/2 hours of sleep, I won’t be able to function at all tomorrow.’”
These kinds of thoughts can cause stress in the mind and body — which makes it even more difficult to fall asleep — and can serve to perpetuate the problem.
Schumacher helps people reframe cognitive distortions such as black-and-white thinking or catastrophizing.
“We look at the thoughts, and we challenge the thoughts,” she said.
For instance, just because you can’t go to sleep one night or are wide awake at 2 a.m. doesn’t mean you’ll never be able to sleep again or won’t function the next day. You might fall back to sleep. Or, you might function reasonably well without a great night’s sleep. While that’s not ideal, you have probably managed to do so before.
CBT can help people challenge and modify their thoughts and beliefs about sleep and the impact of insomnia on their lives and minimize some of the anxiety and frustration that is all too common in insomnia. And that can help people get into a better state for sleep.
Sleep experts advise people who are having trouble sleeping not to toss and turn endlessly in bed. Rather, if they haven’t fallen asleep after about 15 minutes (without watching the clock!), they should get out of bed and do something calming or boring, such as practicing relaxation or listening to calm music to until they feel drowsy again. Then they can return to bed and try to sleep again.
It is important to limit the amount of time spent awake in bed to minimize the body and mind’s association of wakefulness with being in bed. The goal is to strengthen the bed as a cue for sleep.
Some people use alcohol, marijuana or cannabidiols (CBDs) to help them sleep. How do these substances compare to CBT-I when helping people sleep?
Research shows that CBT can be far more effective as a long-term solution to insomnia than sleeping pills. And CBT may help people get higher-quality sleep and longer-lasting results compared to those who rely on CBDs or other marijuana derivatives to help them sleep.
“Marijuana and CDBs can certainly help some people fall asleep. So, they can be helpful in the short term,” Schumacher said.
“But they also can affect the quality of sleep. Over the long run, using marijuana for chronic insomnia can lead to poor quality of sleep. That can also be true for sleeping pills,” she said.
CBT-I can generate better results over the long run.
“CBT-I gets to the root of the problem. Let’s set the stage for good sleep. Let’s tackle the thoughts and beliefs that are getting in the way of good sleep,” Schumacher said.
How can CBT work for pain management?
Like insomnia and anxiety, CBT can work well for people coping with chronic pain. And, as with sleep problems, CBT can yield more lasting results.
Pain is both a sensory experience and a mental/emotional experience. While psychologists can’t erase the physical experience of pain, they can help people reframe how their minds handle the pain to improve coping, daily functioning, and overall quality of life.
“The way you think about pain can help you cope with it,” Schumacher said.
“Sometimes patients worry that seeing a psychologist for their pain means that their doctors or the psychologist doesn’t believe the pain is real, or that they’re making it up. The pain is absolutely real,” Schumacher said. “And our nervous system and the process of pain perception is very complex. The way we think about pain and the behaviors we use to cope with pain can have a strong impact on the overall experience and impact of pain in our lives.”
Schumacher said that CBT can be a highly effective component of treatment for chronic pain. CBT is often used alongside other interventions ranging from medications to physical therapy to surgery, depending on the patient’s health condition and type of chronic pain.
“In some instances, CBT can work better for chronic pain than medications like opioids,” she said. There are certainly many people who also benefit from opioids or other pain medications, Schumacher said. But it’s common for people who use pain medications to develop a tolerance over time that reduces the effectiveness of pain pills. “In the long run, opioid use can be linked to worse pain over time,” Schumacher said.
(Read about a patient with chronic pain who used alternative methods to cope with his pain.)
How committed do patients need to be for CBT to be effective?
“CBT is a very active treatment. It’s not like a doctor prescribes a pill, and you take it,” Schumacher said.
“CBT should be a very collaborative process. You set goals during your therapy sessions, then you need to put CBT into practice in your day-to-day life,” Schumacher said.
Can you learn CBT techniques on your own?
It’s much easier to learn how to use CBT when you’re working with a pro.
“CBT is best delivered through a trained, licensed mental health professional. An expert can help you see things in a new light and ask the right questions. They are like a mirror to you so that you can get fresh perspective,” Schumacher said.
“A therapist can determine whether CBT or another type of talk therapy will be most helpful, or whether a person could also benefit from a referral to another type of provider for medications or some other kind of expertise,” Schumacher said.
She encourages anyone experiencing behavioral health challenges to seek help.
“Therapists can help individuals resolve problems related to roadblocks in their lives. For a person dealing with insomnia, anxiety or depression, putting more helpful thoughts and behaviors into practice can really make a difference,” Schumacher said.
And it’s vital to work with a behavioral health expert whom you can trust.
“One of the predictors of positive outcomes in therapy is having a good, supportive relationship with your therapist. If you don’t gel with someone, it’s totally OK to move on. Having a good match is a critical ingredient for therapy to be effective,” Schumacher said.
It can be difficult to find psychologists or therapists who are accepting new patients now. (UCHealth patients can access behavioral health experts through many primary care clinics.)
If you’re waiting to get in with an expert, or you want to sample some skills that you can learn through CBT, Schumacher recommends starting with relaxation techniques or reading more about CBT. There are many different CBT-focused books and resources that are tailored to specific concerns people may have.
Schumacher recommends “The Little CBT Workbook” for those interested in a general approach to CBT.
For people experiencing chronic pain, she likes the book, “Managing Pain Before it Manages You.”