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An Overview of Cognitive-Behavioral Therapy
Ilana Berry
Seattle University




Cognitive Behavioral Therapy has become increasing popular since it was
developed in the 1960s. Its flexibility, broad range of interventions, and straightforward
approach has made CBT heavily researched, and evidence showing its effectiveness has
made CBT a widely used form of psychotherapy. In a Psychotherapy Networker survey
of 2,000 psychologists, 69% said they practiced CBT (Hays, 2009). More recently, those
who practice Multicultural therapy have encouraged cognitive behavioral therapists to
incorporate more diverse approaches into the treatment (Hays, 2009). CBT has the
potential to be a great treatment to use with multicultural communities, due to its
emphasis on behaviors rather than emotions and its easy to understand ideas. However,
there is still a lot of room for CBT to grow to become a truly culturally aware treatment
method. This overview examines the basics of CBT, and seeks to explore how CBT could
effectively become a more culturally competent treatment method.



Cognitive-Behavioral Therapy (CBT) began its development in the 1960s, by the
combined forces of Albert Ellis and Aaron Beck. Stemming from Beck’s cognitive
therapy and the ideas of conditioning developed by Ivan Pavlov and B.F. Skinner, CBT
has become not only a highly used treatment method, but one of the most empirically
supported treatment methods as well (Sudak, 2006). CBT was originally conceived to be
a treatment for depression, but has since proved its effectiveness in the treatment of many
other mental health issues such as obsessive-compulsive disorder, anxiety disorders, posttraumatic stress disorder, and eating disorders, among others (Sudak, 2006). CBT is a
technique driven therapy, with active client participation and strong collaboration
between counselor and client.
The main goal of counselors practicing CBT is to help clients understand that the
meanings or emotions they attach to the events in their lives is rooted entirely in their
perception, and with determination can be modified into something positive and
affirming (Seligman & Reichenberg, 2010; Sudak, 2006). Any treatment modality where
the idea of cognitive restructuring is at the heart of the treatment can be considered
cognitive-behavioral (Sudak, 2006). CBT emphasizes thoughts first and how they relate
to accompanying behaviors. While it does consider emotions and background, they play
much less of a role in treatment. (Seligman & Reichenberg, 2010)
CBT is considered a time limited approach, with the average treatment length
anywhere from 8 to 20 sessions (Dobson & Dobson, 2009). This brief style of treatment
can be very alluring to those who are motivated to see results quickly, although CBT is



not considered a “quick fix.” It still requires time and energy to achieve results and
should not be used as a Band-Aid for whatever is ailing the client.
This theory stood out to me for several reasons. I appreciate the emphasis on
thoughts and behaviors. I find it a very compelling idea that a person’s unproductive
behavior can stem from their unproductive thoughts. Behaviors are easy to see and
therefore a natural place to start in therapy. CBT values a strong therapeutic alliance and
views people as unique individuals. Finally, CBT is widely used in schools and agencies,
so it makes sense for those going into school counseling to have a strong foundation in it.
Cognitive-Behavioral Therapy
Health and Dysfunction
Dysfunction: CBT is focused on events that cause harmful thoughts, which in
turn lead to harmful behaviors. Thus, dysfunction is viewed as indulging in said
inappropriate or unhealthy thoughts and behaviors. This cycle becomes a pattern that is
likely linked to an underlying problem (Seligman & Reichenberg, 2010).
This view of dysfunction might seem harsh at first; labeling people’s thoughts or
actions as unhealthy or distorted might not sit well with a client. I do feel like this is a
realistic idea of why someone might be unhappy; however, counselors should take care to
phrase this in a way that does not place blame on the client. Our thoughts are our own; it
is entirely too easy to let something unhealthy, i.e. “I am unattractive,” and turn it into a
behavior that is negative—crash dieting or spending copious amounts of money on new
clothes. It is simple and broad, and in a society that is very action driven, I think it is
very reasonable treatment method.



Health: In the eyes of CBT, a healthy and happy person is one who is not trapped
in a cycle of unhealthy thoughts and actions. A happy person is confident within
themself and effectively manages distorted cognitions. They are able to work to change
any behaviors that may detract from their sense of self or cause them shame, instead of
giving in to those thoughts and making them into absolute truths (Seligman &
Reichenberg, 2010).
I appreciate this idea of health because it’s idealistic without being unrealistic. A
person is going to have negative thoughts sometimes; we’re all human and none of us are
perfect. However, some people deal with these thoughts in healthy ways and don’t spend
too much time dwelling on them or turning to unhealthy behaviors.
Multicultural Considerations: While CBT was not originally developed with
multiculturalism in mind, it is not difficult to find ways to apply the concepts of health
and dysfunction to any group of people. The idea of negative thoughts can be applicable
to many people of different cultures, and learning to modify them is a straightforward
solution (Hays, 1995). Nevertheless, there are some limitations. The biggest thing to
consider is how different cultures may perceive the cognitive distortions. A thought or
action that we as white European Americans might view as unhealthy might not be in the
eyes of someone from the Middle East or Asia (Hays, 1995). It is incredibly important
for the cognitive behavioral therapist to know their client and understand what
differences might exist between them, especially when it comes to whatever presenting
problem brought them together. A counselor should never marginalize or trivialize the
client’s problem, nor should the counselor dictate what is wrong or right. A mutual
respect between counselor and client needs to be present so they can come to an



agreement about what they’d like the end goal of health to look like and how treatment
will proceed.
Process of Change
According to the cognitive-behavioral model, people have the ability to modify
their responses to the events that happen to them (Dobson & Dobson, 2009). Therefore,
change can only occur if someone realizes that their thoughts might not be productive,
and is willing to put in time and effort to modify them. “We can become more functional
and more adaptive by understanding our emotional and behavioral reactions, as well as
using cognitive strategies systematically” (Dobson & Dobson, 2009, pg. 4). CBT seeks
to teach people how to do that.
CBT works with the assumption that people have three levels of cognition:
automatic thoughts, intermediate beliefs, and core beliefs/schemas (Newman, 2013).
Automatic thoughts are thoughts that are constantly running through our minds,
unconscious and rapid. Intermediate beliefs go deeper, and refer to general assumptions
about our selves, others, and the world. At the deepest level, our core beliefs are what we
consider the fundamental truths of our lives (Newman, 2013). CBT seeks to first educate
clients, and then help them identify ways to reverse negative thoughts, beliefs, and
Dobson & Dobson (2009) state that “The cognitive-behavioral model does not
endorse the idea that people simply have an emotional response to an event or situation,
but rather, the way that we construe or think about the event is pivotal to the way we
feel” (pg. 4). It’s difficult to change how we feel about a situation if there is no reaction
accompanied with the emotion. A person who is afraid of spiders sees one, thinks of it as



something to be afraid of, and feels fear. Modifying the thought, e.g., spiders are NOT
something to be afraid of, will eventually change the emotion behind it and ultimately,
any physical reaction of fear.
As mentioned previously, the primary goal of CBT is to help people recognize
maladaptive cognitions, and teach them how to assess and modify them (Seligman &
Reichenberg, 2010). Often, goals are cognitive or behavioral in nature, but these goals
usually benefit each other. For example, teaching someone how to modify negative
thoughts about themselves before a job interview (cognitive), coupled with modeling of
how to present self confidence and knowledge during the interview (behavioral)
(Seligman & Reichenberg, 2010). Dobson & Dobson (2009) articulate that goal setting is
a very integral part of treatment, and while it may seem easy, it can be difficult for some
clients. Many may start out with vague or unattainable goals that might be outside the
boundaries of CBT. Counselors can make this process easier for clients by
communicating openly and ensuring that the client has a clear idea of the plan for
treatment (Dobson & Dobson, 2009).
A universal goal that CBT seeks to meet is teaching clients skills that will help
them to improve their lives. This might include helping a client maintain a fitness
program, relieve them of specific phobias, or help someone reduce a habit they find
undesirable (Seligman & Reichenberg, 2010).
It is incredibly important when setting goals to create an agenda for therapy and
make sure client and counselor agree on it. The agenda doesn’t have to be rigid, but it
should attempt to define the course of treatment and limit errant sessions or passive



silences. An agenda also helps the client to understand that the treatment will be going in
a beneficial direction for them (Newman, 2013).
Therapeutic Alliance
“Competent CBT clinicians are very mindful of the importance of being warm,
genuine, and supportive, not only because these are important qualities and components
in their own right, but also because they also enhance the more technical aspects of CBT”
(Newman, 2013, pg. 33). The therapeutic alliance is extremely important in CBT, and at
its core it is warm, collaborative, and respectful. It is essential to form a positive
connection with a client in order to be in the best position to understand their problem
and help them through it. If the therapeutic relationship isn’t strong, a client may not be
as willing to work hard, not respect what the counselor says, and ultimately leave
treatment early. Another important part of the therapeutic alliance in CBT is the
empowerment of the client. Counselors want to encourage clients to take credit for their
own successes, not attribute it to the counselor (Seligman & Reichenberg, 2010). It is
important to distinguish that while the therapist is considered to have expertise, the client
is the expert on his or her own life and problems (Dobson & Dobson, 2009).
The therapeutic alliance is something that is very important to me as a counselor.
I want to practice in a humanistic way, so it is important that whatever theory I work with
allows me to focus on my relationship with the client as a person. Some might say that
CBT does not allow for this, or that the brief nature of the treatment makes it more
difficult. However, I disagree. It is the therapist themselves who has a major role in
determining what the alliance will look like, and CBT acknowledges the importance of a
strong alliance and that treatment is more effective because of that.



Role of Counselor and Client
Counselors can take on many roles, from teacher to devil’s advocate to
encourager (Seligman & Reichenberg, 2010). As in any treatment method, it is essential
for the counselor to display warmth and empathy. The counselor is an educator, someone
the client has come to for an expert opinion. Homework assignments are often given to
the client as part of the treatment process.
The client is expected to take responsibility for their treatment and their actions.
They are the ultimate expert on their lives and problems, but they are also expected to
learn and take the homework assignments given to them seriously. The client is expected
to participate fully in treatment, and is expected to give feedback to the counselor (Sudak,
2006). It is within the client’s control to dictate the amount of outside homework that
may be given to them—if they are uncomfortable with an assignment or feel like it won’t
work for them, the counselor must respect this (Sudak, 2006).
Techniques and Approaches
CBT places a lot of emphasis on using techniques during therapy, which can
range from very basic to very complex. The interventions can be primarily cognitive or
primarily behavioral in nature, and the goal of these interventions is to help clients
become more comfortable at coping with whatever problems that they are dealing with
(Newman, 2013). Having so many interventions allows the counselor to tailor the
sessions to each person, which fits well with CBT’s view of all clients as unique beings.
Due to the number of techniques to choose from, I’ve selected some of the more
significant ones to describe in detail.



One of the most important tools used in CBT is the automatic thought record.
The basic idea of the automatic thought record is that the client keeps a diary or a log of
any automatic or dysfunctional thoughts they have and any accompanying emotions or
behaviors. (Dobson & Dobson, 2009). According to Sudak, (2006), the automatic
thought record helps put the dysfunctional thoughts into context, and helps the client
identify ways in which they could have responded differently. Ultimately, using the
thoughts in the record, the counselor helps the client to challenge his or her negative
thoughts and hopefully come to reevaluate them in a positive manner (Sudak, 2006).
This is tied to the concept of cognitive restructuring, which involves teaching the client to
identify any negative thoughts, and teaching them questions they can use to modify the
thought and move past it (Newman, 2009).
Role playing is a technique that is often used in CBT, which is something that is
used in other treatment modalities such as Gestalt and Adlerian Therapy as well. In CBT,
negative thoughts are verbalized so the client can become more aware of those thoughts
and become more adept at responding to them in positive ways (Dobson & Dobson,
2009; Newman, 2013). Humor is also widely used, although the therapist has to be
careful when doing so. The goal of humor is to help the client see that it is their thoughts
that are funny, not themselves. This can go awry though, if the client ever feels like they
are a punch line to a joke (Dobson & Dobson, 2009).
Multicultural Considerations
Strengths: There are several reasons that make cognitive behavioral therapy
ideal for multicultural populations. CBT values people as unique individuals, and



emphasizes modifying treatment to match each individual’s needs and values (Hays,
2009). This ideal allows a therapist practicing CBT to match interventions to specific
clients, and evaluate if a client might be uncomfortable with an intervention because of
their cultural background. A therapist who is culturally competent will take the time to
learn about their client’s religious, cultural, and spiritual beliefs and ensure that treatment
is modified in ways that is respectful of those beliefs (Newman, 2013). CBT is mostly
focused on conscious processes and behaviors, which is an idea that can be
communicated easily to someone who speaks English as second language (Hays, 1995;
2009). Furthermore, the prominence of client self-assessment, which demonstrates
respect for the client’s viewpoint, illustrates to the client that the therapist truly cares
about their opinion. CBT also does not have to be a overly intrusive method, and is well
suited for some cultures that may not be as comfortable with the idea of revealing their
innermost thoughts to a stranger (Seligman & Reichenberg, 2010). Open trials of CBT
occurring in Japan have indicated that CBT has been quite effective in treating depression
and anxiety there. Japanese society is extremely conservative, so conventional
therapeutic methods haven’t been heavily studied or successful (Ono, et al., 2011). The
fact that CBT was shown to be successful despite that conservatism is very promising.
Ono et al., 2011 says “we should continuously seek ways to adjust clinical techniques and
interventions in the light of diversity” (pg. 127) to ensure that CBT can evolve and
continue to be helpful.
Limitations: CBT places high value on empowerment of the client, but some
cultures do not place that kind of importance on empowerment like the EuropeanAmerican culture. For example, Hays (1995) discusses the importance of assertiveness.



Being assertive is something of a Euro-centric value, but other cultures do not place the
same emphasis on it. It is important in CBT to recognize this and pay attention to what
the client really wants to work on, not what you as the therapist think they need to work
on. CBT can come across as placing blame on the client for issues that might be the
result of social issues (Hays, 2009). A huge limitation is that because CBT does not
delve deeply into a person’s background, it might miss important cultural factors that
have negatively affected the client (Hays, 2009). It is very important that the therapist
takes the time to get to know a client and their background. Furthermore, a culturally
competent therapist should never assume they know what the problem is, and as Newman
(2013) articulates, “culturally competent CBT clinicians are aware of their own faulty
assumptions” (pg. 208).
Social Justice
Strengths: Many of the ideas concurrent with CBT fit well with social justice
considerations. The concept of schemas, a core concept or belief, can be affected and
manipulated by social, cultural, gender, and familial systems. CBT is an effective way to
get to the root of the schema and modify the thinking (Gitterman & Heller, 2011). CBT
understands the importance of social systems and recognizes the role they can play in
influencing thoughts and behaviors. CBT could also be a uniquely suited method for
addressing social justice concerns because of the importance it places on empowerment
(Hays, 1995; 2009). By modifying a person’s thinking, CBT can build up their selfconfidence and teach them ways to stand up for themselves in the face of oppression.
Limitations: Similar to its limitations for multicultural approaches, CBT is often
too focused on the symptoms of the client (the thoughts or behaviors) to focus on whether



or not there is an underlying social problem that is exacerbating the symptoms (Hays,
2009). CBT can be very brief and may not take the time to adequately explore any
environmental or oppressive forces that might be negatively affecting the client. And
because CBT is focused on the thoughts and actions of the client, it can neglect to
consider that the behaviors of the client might be dictated by society (Pilgrim, 2011).
CBT should continue to evolve to combat these limitations, and therapists should try to
practice holistically.
General Critique
Strengths: Overall, CBT has many strengths that make it an excellent form of
psychotherapy. It is a straightforward and flexible treatment method that is backed by a
substantial amount of empirical research. The wide range of interventions used make it
easily adaptable for different clients and problems, and in general the interventions are
respectful and emphasize collaboration between counselor and client (Seligman &
Reichenberg, 2010). Empathy and positive regard are considered important ingredients
to a successful therapeutic alliance, and counselors encourage and empower clients to
take responsibility for their own problems and thus their own recovery (Seligman &
Reichenberg, 2010). CBT has been shown to be very effective with a wide range of
mental health issues; research has supported its use in treating mild to moderate
depression, anxiety disorders, eating disorders, and substance use disorders (Seligman &
Reichenberg, 2010). Combined with pharmacotherapy, CBT has even been showing
effectiveness in treating bipolar disorder and schizophrenia (Sudak, 2006).
CBT can be molded depending on the situation, and can be easily combined with
different treatment methods if a client would benefit from it. Gestalt Therapy, Person-



Centered Counseling, and Adlerian Therapy have all been successfully combined with
CBT in effective ways (Seligman & Reichenberg, 2010).
Limitations: Despite the considerable strengths of CBT, there are some
significant limitations. As previously discussed, therapists who practice CBT often target
specific behaviors or thoughts, without looking at a bigger picture. Symptoms may be
ameliorated, but the deeper issue at hand may not get addressed (Seligman &
Reichenberg, 2010). If not done sensitively, CBT can come across as placing blame on
the individual, and the idea that their thoughts are dysfunctional may validate their
thought that something is wrong with them or they are broken. CBT is a time-limited
treatment, so it may not be well suited for more serious mental health issues. Pilgrim
(2011) asserts that CBT take too narrow of a focus on mental health problems, and that
the idea of cognitive distortions does not allow for the possibility that problems might be
a response to social forces. Pilgrim (2011) also discusses that the lack of any
psychoanalytic or humanistic ideas within the CBT framework makes CBT a “onedimensional” treatment (pg. 127). It is also a possibility that “clinicians may become so
caught up in the power of CBT that they fail to help clients take adequate responsibility
for their treatment and progress (Seligman & Reichenberg, 2010, pg. 331). This might
lead to the client feeling manipulated rather than empowered, thus diminishing any
growth that could have happened (Seligman & Reichenberg, 2010).
Another limitation to be aware of is the brief nature of CBT. This doesn’t have to
be a limitation, but sometimes clients will be under the impression that because CBT can
have such a short treatment length, it must be easy and therefore, a better treatment for
them. This isn’t always the truth—CBT is brief, but it is not a “quick fix.” Clients still



have to work hard and put in the effort to solve the problems they sought treatment for
(Dobson & Dobson, 2009). On the other side, the brief nature of CBT can be offputting—many still don’t think it takes enough time to truly dig deep enough into why
the client is experiencing negative thoughts (Dobson & Dobson, 2009; Pilgrim, 2006).
I began this quarter excited to find a theory that would match my therapeutic
ideals and illustrate a way in which I wanted to practice counseling. What I found was
many theories that were interesting and several that I felt could be worthwhile to actually
practice. Cognitive-Behavioral Therapy was one that at first I was a little unsure about. I
liked many aspects of the theory, and I’ve always valued the role of thoughts and
behaviors in mental health issues; however, I was also sensitive to calling people’s
thoughts or actions distorted or dysfunctional. In addition to of all of the aspects I liked, I
think that my uncertainty about CBT contributed to my desire to learn more about it.
Ultimately, I chose CBT for this paper because as a school counselor I’ll likely have to
use it. CBT isn’t perfect, and even after writing this paper I don’t believe it’s a perfect
therapy. In spite of that, writing this paper highlighted the many ways that CBT can be
positive and effective, and I feel that I now have a much wider knowledge of CBT.
Through writing this paper I have developed a sense of how to reconcile my personal
hesitations with the theory into how I would practice it, and making that kind of
connection has deepened my interest in CBT and my desire to learn even more about it.
Writing this paper has been a very good experience for me, not only because I
was able to develop a more concrete opinion about a theory, but because it helped me
start thinking about what kind of counselor I want to be in the context of a therapy I will



likely have to use. I definitely have a more positive view of CBT, and it’s helpful to see
the limitations laid out so clearly as well. I believe that most of the limitations can be
dealt with by competent and aware therapists, so being personally aware of any potential
negative aspects will help me to find ways to resolve them in the future and use CBT in
the most effective way.



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