Cognitive-behavioral therapy (CBT) is a term that can mean many different things because it comes from two divergent schools of psychological thought.  Cognitive therapy primarily focuses on thoughts while behavioral therapy focuses on actions.  In short, cognitive therapy aims to teach people how to recognize and approach negative, unhelpful thoughts, known as “automatic thoughts,” and give them skills to deal with the thoughts when they arise.  Behavioral therapy emphasizes actions rather than thought patterns and believes people need to act differently to achieve the results they want.  Further, behavioral therapy for anxiety disorders places a lot of emphasis on exposure and response prevention (ERP), which I will describe briefly below.  

Most CBT therapists working today blend the cognitive and behavioral approaches; however, therapists land at different points along a spectrum with some people focusing mostly on behaviors at one end or thoughts on the other end.  The important thing to remember, though, is that all of these approaches work – it is merely a matter of style or preference for each individual CBT therapist.  Thus, understanding these distinctions between cognitive and behavioral therapy can be helpful when trying to decide whom you'd like would to work with.  (For more information on CBT, please see the References section of this site.)

Cognitive Therapy

As mentioned above, cognitive therapy emphasizes learning how to recognize destructive, unhelpful thought patterns and building skills to overcome those negative thoughts.  In essence, people tend to have distorted thoughts that drive how they feel and what they do.  In cognitive therapy, people are asked to become aware of those maladaptive thoughts first.  Once they can recognize them, people then learn how to restructure their thoughts so that the negative automatic thought no longer has power over them and they can make decisions based on their true wishes, not the erroneous information coming from their brains, and act accordingly.  With cognitive restructuring, people learn how to become skeptical of their initial negative beliefs, assumptions and expectations and develop the capacity to determine if the thoughts are true and worthy of their attention.  Cognitive therapy is based on the groundbreaking work of Aaron Beck and Albert Ellis.

Behavioral Therapy

Like cognitive therapy, there are many different ways a therapist can use behavioral techniques.  Most behavioral therapists emphasize a exposure and response prevention (ERP), alternate behaviors (e.g., such as squeezing a ball when you have the urge to pull a hair) or systems of rewarding sought-after behaviors.  Exposures occur in a graded or gradual way (i.e., getting progressively more difficult) and are designed to facilitate the process of “getting used to” a situation and no longer being so bothered by it.  Other names used to describe this process of becoming less stressed when repeatedly encountering the same situation are desensitization or habituation.  Response prevention is simply not allowing the person to engage in a behavioral act (e.g., washing, counting) designed to decrease the feelings of anxiety. 

Together, these two components comprise Exposure and Response Prevention (ERP).  The idea behind ERP is that when people become anxious, they perform some act to try to relieve their anxiety. The problem is that the relief is temporary and the person learns to associate these acts or behaviors with relief.  Why is this a problem?  Because, eventually, the behaviors take up so much time that people become less functional – they end up spending increasing amounts of time engaging in the behaviors and/or avoiding situations that cause anxiety to rise, rather than spending time on things they want or need to do.  Thus, ERP asks people to face the situations that increase anxiety and to ignore the strong pull to act in some way that would decrease the anxiety temporarily.

How I Use CBT

As I will discuss later, my goal as a therapist is to help my patients get to the root causes of their problems so they can identify, process and find relief from their suffering.  Within this framework, then, the cognitive aspects of CBT are very appealing.  And, while I do use behavioral techniques and ERP in my work, I sometimes become concerned that extreme exposures without appropriate anxiety regulation can be detrimental to my patients. 

Let me explain: exposure and response prevention (ERP), a behavioral component of CBT, teaches people to face their anxiety head-on by placing themselves in upsetting situations and encourages them to become emotionally dysregulated in the process.  People are asked to become anxious and then sit with that anxiety until the anxiety passes on its own.  The technique works and many people have transformed their lives by undergoing this process.  But, to me, putting yourself in a significant amount of distress can be overwhelming emotionally and physically, and might not be for everyone.  Make no mistake, behavioral techniques work and are effective; I simply choose another way of working.

The difference with me is that I use exposures as a way to: 1) desensitize people to distressing situations and 2) teach people how to manage their anxiety and increase their self-care skills.  Exposures are basically a training ground for me – a way to have someone experience anxiety so they can use mindfulness and put their anxiety regulation and cognitive skills into practice.  Equally important, exposures should be used to make sure people do not avoid certain situations or places because of their fears.  In the end, I want to teach people skills they can use for a lifetime and apply to any situation.