How is cognitive behavioral therapy different from traditional psychodynamic or other types of therapy?

Cognitive behavioral therapy (CBT) is very different from most other types of therapies. Whereas traditional psychodynamic therapy focuses a lot of attention on one’s childhood experiences and family experiences, CBT focuses almost entirely on the here and now in order to quickly solve current problems. This doesn’t mean that CBT therapists don’t believe that people are shaped by their family experiences. We do. But we believe that the best way to change thoughts, feelings, and behaviors is by working in the present not by discussing the past.

There are other differences. CBT therapy always involves therapeutic tasks done between sessions, or homework. There are many types of tasks that a CBT patient might do. Common tasks involve writing down thoughts and feelings in order to become more aware of negative distorted thoughts that produce painful feelings. Other types of tasks might involve behavioral tasks such as confronting one’s social anxiety by practicing having conversations with strangers.


How long does cognitive behavioral therapy take?

CBT is a much more efficient type of treatment than traditional therapy. Whereas traditional therapy often takes years, good results can be achieved using CBT in a matter of months. For some problems, such as simple phobias such as spider phobias, treatment is even briefer, usually just two or three sessions. Of course, the duration of therapy partly depends on several factors. These factors include how severe the problem is, how long the patient has had the problem, and how hard the patient is willing to work in therapy. Typically at the end of the first of the evaluation session, the CBT therapists can give a better, more accurate estimate of how long therapy will take.

I have very bad panic attacks. Can cognitive behavioral therapy help me?

Not only can cognitive behavioral therapy help with very bad panic attacks, but it may be the only treatment that really works. Often people of panic attacks are given powerful drugs. Although these drugs sometimes lower frequency of panic attacks, they rarely eliminate them. And when the patient stops using the drugs, there is usually a relapse into panic.

A specific type of CBT has been developed to treat panic and agoraphobia. Several studies have shown that this approach results in the elimination of panic in over 80% of the patients treated. The problem is that very few therapists are actually trained in this approach, which is called interoceptive exposure, and was developed by Dr. David Barlow.

Can cognitive behavioral therapy help me even though it doesn’t focus on my childhood?

CBT will help you more because it doesn’t focus on your childhood. Many therapies that focus on childhood experiences create a sensation in patients of being victims. “I had a bad childhood therefore I must be miserable.” CBT does not believe this. What maintains painful feelings in the present is negative thoughts that also occur in the present. These negative thoughts can be identified and changed, leading to better moods and more functional behavior. Long discussions of childhood experiences are a distraction from change oriented therapy.

What happens during a typical CBT session?

The first thing that happens during most CBT sessions is going over the following week’s homework. The therapist and the client will together look at the homework, using that homework to learn the basic skills of CBT such as identifying negative thoughts and correcting them. During this session the therapist and the client may role-play fighting the negative thoughts, or may do behavioral experiments. Sometimes the patient and the therapist may go outside the office and practice doing certain things such as talking to strangers, or riding an elevator, or other things designed to practice overcoming fears.

Why don’t you work with insurance companies?

First of all, I do provide my clients with what is called a super bill form, which allows them to submit their therapy bills for reimbursement from their insurance company.

I don’t work with managed care companies for several reasons. The first and most important reason is that managed-care companies usually dictate the type of therapy and the length of therapy that their patients may receive. I believe that these decisions are best made collaboratively by the therapist and the client, not by some clerk in an insurance company.

Another reason is confidentiality. Many managed-care companies require therapists to file detailed reports of the therapy. These go into a computer database, and we all know that these databases can be breached or compromised. By working outside of managed-care it guarantees that your therapy records stay in paper form, outside of any computer database.


Should I take medication for my anxiety disorder?

Although general physicians often prescribe either antidepressant medication or anti-anxiety medication when patients have anxiety problems, it’s usually not a good idea to take medication for anxiety disorders. If you are going to take medication, it’s better to take antidepressant medication than antianxiety medication. The reason for this is that most anti-anxiety medications such as Xanax, Valium, etc. are habit forming and addictive. Long-term use of these medications produces a dependence which is very hard to withdraw from, and usually results in a resurgence of anxiety upon withdrawal. Antidepressants are not habit forming, and can lower the intensity of anxiety.

The main reason not to take medication for anxiety disorders is that they are very treatable using CBT alone. In fact, there is some evidence that patients who take medication for anxiety disorders respond less well to CBT. CBT treatments for panic attacks result in success in over 80% of the patients. CBT treatment for simple phobias such as fear of spiders or fear of heights has virtually 100% success rate.

And the best reason to use CBT rather than medication is the long-term results. What you learn with CBT stays with you for a lifetime. But when patients withdraw from medications they almost always relapse back into anxiety. So for a long-term solution CBT beats medication every time.

Should I take medication for my depression?

This is a more complicated question. Medication for depression certainly helps some people. The problem is that it’s often difficult to predict who will respond to antidepressants and who will not. Other problems include side effects, which can be considerable. The most common side effects of many antidepressants are sexual side effects, lowering libido and/or making orgasm more difficult. Other side effects include sedation, nervousness, weight gain, headaches, and nausea.

The evidence of the effectiveness of antidepressants for depression is very mixed. It appears that for mild to moderate depression antidepressants are not very effective. For severe depression there is more evidence that antidepressants work, although the evidence is still not strong.

A good model to consider is to begin with CBT for mild to moderate depression, and to consider adding medication if there is not a good response to CBT therapy. For severe depression it may be reasonable to consider combined treatment of both CBT and medication, although this should always be discussed with your therapist.


What approach do you use when you work with couples?

CBT approaches to couples therapy first involve doing a good assessment of what types of problems the couple is having. Do they have too many negative interaction such as fights or disagreements? Or do they lack positive interactions such as affection, kissing, talking, and making love? What are the issues that create conflict or distance?

Once this assessment is done then a behavioral treatment plan can be developed. Sometimes this involves teaching couples communication skills so that they can resolve problems while staying connected. Other times this might involve a component of sex therapy in order to improve their intimate connections. Sometimes there are parenting issues, and a behavioral approach to parenting can often resolve problems such as tantruming, failure to do homework, etc.


My relationship is fine, but our sex life isn’t. Can CBT help?

CBT certainly can help improve your sex life. The CBT approach to sex therapy involves learning how to communicate effectively about sexual needs and desires. Couples are usually pretty good at communicating about other things in their marriage, but often avoid talking about sex. CBT teaches people how to talk about sex, so that they can get what they want from their partner. There are often behavioral exercises that couples will perform between sessions. These exercises help them learn more about each other’s sexual turn-ons and turn-offs.
What is CBT?

How effective is CBT?

One large study looked at 16 meta-analyses of the effectiveness of CBT for wide range of disorders. (A meta-analysis is a study which looks at a series of other studies and summarizes their results.) This super meta-analysis study found that CBT was highly effective for depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depression and anxiety. CBT was found to be moderately effective for marital problems, anger, childhood somatic disorders, and chronic pain. So based on the results of studies of thousands of patients we see that CBT is moderately to highly effective for a wide variety of disorders. (There were 9995 clients in 332 studies in this meta-meta-analysis.)

How should you select a CBT therapist?

The key issue in selecting a CBT therapist is to make sure they actually practice CBT. Many therapists claim to practice or use CBT but actually practice traditional psychotherapy. The first question you want to ask a potential CBT therapist is where and how they receive their training and CBT? Did they learn CBT in their graduate school training? Or did they learn CBT in a series of weekend workshops?

Also ask how long they have been using CBT. Ask them if they primarily use CBT or mix CBT with other approaches. Most good CBT therapists primarily practice CBT, and do not tend to mix it very much with other approaches.

Also ask them if they are familiar with the panic disorder treatment used by David Barlow? Do they use “interoceptive exposure” in their practice? This is a particular approach used for panic disorder that any well-trained CBT therapist should be very familiar with and utilize. If they don’t know what this is or don’t utilize it, then they are probably not really practicing CBT.

Another good question to ask is, “Do you give homework between every session?” If the answer is no, then you’re probably dealing with someone who doesn’t really do CBT. Most CBT therapists give some homework between every session, usually consisting of tracking thoughts and feelings by writing them down.

Typically most of the therapists who actually practice high-quality CBT will be clinical psychologists. There are a few psychiatrists, and a few Masters level therapists who have received good training and CBT, but they are rare. If you want high quality CBT you probably want to work with a clinical psychologist.