Cognitive Therapy: How Does It Work?

Cognitive therapy was founded by Aaron Beck to provide a structured treatment for depression. Cognitive therapy focuses on cognitions- the automatic thoughts that we all have, and how these thoughts can be helpful or harmful for us. Making people recognize their own dysfunctional thoughts and help them to modify these thoughts to live a healthy life is the goal. 

Cognitive Therapy is a well-organized, powerful, usually short-term approach that has proven its effectiveness. Aaron Beck and his colleagues developed a structured, short term, present-oriented, problem solving, approach for treating Depression. The book, Cognitive Therapy of Depression had a powerful impact on the field of Psychotherapy.

Judith Beck, daughter of Aaron Beck has summarized cognitive therapy, “In a nutshell, the cognitive model proposes that dysfunctional thinking maintains psychological disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they start experiencing improvement in their emotional state and behavior.” 

The purpose of Cognitive Therapy is to teach people to identify, evaluate and modify their own dysfunctional thoughts and beliefs.

Cognitive theory suggests that every mental health condition is characterised by relatively predictable types of underlying cognitive distortions. For example, feelings of depression typically stem from thoughts pertaining to loss.

According to cognitive theory, psychologically healthy people are aware of their cognitions. They can test their own hypothesis, and if they have any dysfunctional assumptions, can replace them with healthier, more accurate and more helpful beliefs that lead to more positive emotions and behaviour.    

 Principles of Cognitive Therapy.

Cognitive therapy is based on the finding that changes in thinking lead to changes in feelings and behavior and treatment requires a collaborative therapeutic alliance.

It is short term, problem focused and an active structured approach to treatment.Task assignments, follow up, and client feedback are important in ensuring the success of the treatment process.

Levels of Cognitions.

Cognitions can be categorized according to four levels

  • Automatic thoughts- An automatic thought is the response to trigger or event in a form of mental activity or images.
  • Intermediate beliefs -It is a belief system in which a person has certain rules or attitudes which a person adapts for the rest of their life or in many situations.
  • Core beliefs - Core beliefs act as a filter through which the person sees himself/others/ world.
  • Schemas- It is a mental framework which helps the person to organize and interpret information.

In Cognitive Therapy, treatment typically begins with automatic thoughts and then proceeds to identification, evaluation, and modification of intermediate and core beliefs and finally to revision of schemas.

Example- After many disappointing relationships, Raj had developed a rewarding relationship with Riya. After two years of relationship, Riya suggests marriage and Raj agrees to it. Raj has following thoughts:

Automatic Thoughts: I can’t be the sort of husband Riya wants and our marriage will end.

Intermediate beliefs: A good husband always sacrifices his own needs for his family. Marriage is tough and has fewer successes.

Core Belief:  I am not able to love another person and can’t contribute in a relationship. I am incapable. 

Schema: I am a loser and cannot get success in life. This makes me feel that I will end this marriage.

Due to this maladaptive schema, Raj will find information which confirms his beliefs and will enter marriage with a negative attitude, along with ineffective behaviours that will contribute to the failure of his marriage and maintenance of his beliefs. 


Treatment using Cognitive Therapy usually is time limited, for example 6 to 14 sessions long for relatively straightforward problems. Sessions are carefully planned and structured to maximize effectiveness. Originally developed for the treatment of depression, cognitive therapy has been found to be effective for mood disorders, anxiety disorders, PTSD etc. 



In the first session the therapist establishes rapport and trust with the patients, normalizes the difficulties patients have and develops hope. After that the therapist gives an introduction about disorder, the cognitive model and the process involved in the therapy.

Points involved in the process of the first session

·         The therapist develops a goal list.

·         The therapist starts with the problem which is most important to the patient.

·         For accomplishing the above goals the therapist first sets the agenda and then explains to the client the rationale for setting the above goals.

·         Then the therapist  does a mood check.( By using a questionnaire for eg Beck Depression Inventory )

·         The therapist obtains a weekly update. 

·         Then the therapist discusses the patient’s diagnosis and engages in psychoeducation.

·         It is very important for the therapist to give the client some initial information about their condition, as the client then can start attributing some of their problems to their disorder instead to their own self. 


The Middle Part of Session 1

1.      The therapist firstly identifies the problems and specifies them.

2.      Then the therapist set the goals by taking larger agenda into specific goals.

3.      Educate the patient about the cognitive model.

4.      Behavioural activation.( The therapist encourages the client to break the vicious cycle of not doing anything,  for example the therapist may recommend client to engage in an activity which makes the client happy)

5.      Discuss the problem in depth. 


End of Session 1

1.       Provide or elicit a summary.

 In the summary part there are kinds of summarization which are important throughout the sessions.

·         The first is to summarizes the content

·         The therapist often asks the patients to make a second kind of summary after the therapist has evaluated an automatic thought or belief.

·         The third is a brief summary when a section of a session has been completed, so that therapist and the client both have a clear understanding of what they have just achieved.

2.       Homework assignment.

·         Homework is an important part of treatment and it includes recording thoughts, changing patterns of behavior, activity scheduling, and conducting behavioral experiments to test distorted beliefs.

·         Typical ongoing homework assignments are discussed below

a)  Behavioral activation

b)  Monitoring automatic thoughts

c)  Evaluating and responding to automatic thoughts

d)  Problem solving

e)  Behavioral skills

f)   Behavioral experiments

g)  Bibliotherapy

h)  Preparing for the next therapy session

3.      Elicit feedback.

Feedback is an important and final element of every therapy session. Eliciting feedback strengthens rapport, it gives a message to the client that the therapist cares about the client. It allows the client to express views on scope for improvement. Additionally to verbal feedback the therapist may decide to give the client a written therapy feedback form. 



The most important thing in CBT is that every step in therapy is transparent and clearly reasoned.

The process of CBT involves client choices in agenda setting and using socratic questioning makes the therapy very logical and easy to understand. 

 CBT thus is effective, collaborative, active and is based on an educational model. CBT aims to direct the behaviours and help the client to unlearn maladaptive behaviours and learn adaptive behaviours. 

 CBT is  largely effective because it is time-limited and employs a specific agenda for each session. This later gives guidance to the client so that he/she after termination are able to regulate their emotions and behaviours effectively. Furthermore, the concept of homework makes clients more active and help the patient in applying the specific skills and concepts learned from the session to his/her real-life problems. That is the very reason CBT has rapidly increased in popularity from the last 40 years.

Posted 2 years ago