What is Cognitive Behavioral Therapy?

I travel all over the world teaching Cognitive Behavioral Therapy (CBT) to clinicians. CBT is a great catch all because clients have generally heard the term CBT before and might actually look up therapists locally that practice it, most professionals in healthcare are aware of therapy in general and usually will recommend CBT as a treatment for a variety of issues, which is great but what is CBT? Well, it's kind of complicated.

The confusion is worsened because CBT isn't one thing and a lot of people think it is. I try to preempt any confusion with my clients, on my book a session page, I specifically note that there is no single cognitive behavioral therapy, it's a family of recognized psychological treatments with empirical support. Psychological meaning related to mental and emotional states, empirical meaning the therapies have been verified through randomized controlled trials to be effective for treating specific issues. This is where the really exciting part about CBT starts: you could have twenty different CBT therapists and each would not just have a different style but could also use different techniques. Generally these techniques are broken into three different generations of CBT. Before I describe the generations of CBT, please note that new does not necessarily mean better—past generations of CBT get good outcomes, they are after all evidence-based. However, just like the latest innovations in technology (think iPhones or computers) advancements occur, new information is collected, old ideas are falsified, and a new generation gets released. Check out my video 'What is CBT and how to do it!' for practical examples or read on below to learn more about the generations of therapy.

To date (the summer of 2018) there are three generations of therapies. Remember that each generation is relevant, contributing advancements to the field. Yet, time marches on and with it, so does the science that informs the work therapists do.

The first generation is past-oriented: focusing on suffering as a disease, the psychology of the abnormal. If you're depressed or anxious, that needs to be corrected by changing something in you to remove the experience of anxiety or depression. This also supports a hierarchy, the therapist is the expert, a sort of technician of the therapy. Importantly, this past-oriented theory focuses on historical reasons why someone thinks and acts the way they do today. Therapists who are trained in a first generation approach tend be meticulous at taking a persons history and understanding the nuance of how one has come to be working with a therapist. First generation therapies tend to be longer in duration and the experience of working with someone who helps you unpack how you understand yourself based on what you've been through can be an incredibly validating experience.

The second generation is present-oriented: focusing on why people do what they do right now. Conceptually, the second generation wanted to know what maintains a persons thinking and behaving, looking for environmental causes. This second generation looks to the problems someone is experiencing here-now and solutions to correct their thinking (cognitions) and doing (behaviors). From this perspective, therapists are driven by a theory that encourages them to be experts on the objective world, seeking information from the clients experience to change what they think and do.

The third generation is present and future oriented: focusing on building resources and competency in a person to grow their life in the presence of pain. The relationship between therapist and client from this perspective is about the client being an expert on their experience and the therapist being a companion on their journey. The therapist points out ideas, draw parallels between experiences, and suggests new skills along the way. This generation is uniquely not theory-driven but instead uses behavior analysis tools to create an individualized profile on how each persons behavior works . This is all at once liberating and exhausting. It requires a level of presence and technical mastery on the therapists part that can seem intimidating at first—remember I told you I travel all over the world giving workshops on the subject? Feedback I get at every workshop I give is therapists telling me how much the third generation makes sense but also how difficult it seems at first to master the entire approach. This is why my co-author Jessica Borushok and myself wrote a book on a third generation approach of CBT called ACT (Acceptance and Commitment Therapy) and we called the book, The ACT Approach because we wanted to make it clear that no matter who the reader is or what orientation/training they come from they can use the third generation perspective and incorporate it into their practice.

The evolution of the third generation of therapies has also enabled new and exciting innovations in cognitive behavioral therapies/evidence-based practice: specifically compassion, mindfulness, the integration of yoga, and many other developments that may have previously been left out of empirically supported treatments.