Cognitive Behavioral Therapy:
How CBT Rewires Negative Thoughts

Cognitive Behavioral Therapy is a problem-oriented approach to managing difficult situations, breaking destructive habits, and shifting negative thoughts.

It started on a flight about five years ago. Sebastian was finally headed home from a marathon week of meetings with his newest client.

Rather than pulling out his laptop to squeeze in a few more hours of work as he’d regularly do, Sebastian leaned back in his seat for some much-needed sleep. He was so exhausted, he doesn’t even remember the beverage cart passing by him.

What started as a restful nap, or as restful as one can get in an airline seat, was suddenly interrupted by a rough patch of turbulence.

Sebastian was immediately awoken by what felt like an intense nosedive. He remembers reaching for his seatbelt as he heard the pilot over the intercom asking everyone, including the flight attendants, to take their seats.

The pilot wouldn’t take the seat belt sign-off for the rest of the flight as the severeness of the turbulence barely let up.

Sebastian felt an enormous sense of relief when the plane finally did touch the ground. What had really only been about 90 minutes since the start of the turbulence felt like endless hours to him. The back of his neck was sticky from sweat and he found himself clutching his hands tightly together in his lap trying to will them from shaking.

It was a scary moment, but Sebastian assumed it would pass. That is until about two weeks later when he was scheduled for his next flight.

Sebastian felt a panic begin to settle in as he arrived at the airport. He first noticed how dry his mouth felt, making it feel as though he couldn’t swallow. Then it was the shaking of his hands and finally a heavy pit sitting in his stomach.

He didn’t think he could get on the plane.

He considered emailing his boss to tell him he was sick and couldn’t get on the flight. That didn’t make sense though; at this point, his flight was scheduled to begin boarding in a handful of minutes.

It was too late to call in.

Reluctantly, he boarded the flight, telling himself it would be fine as soon as he sat down and could distract himself with work. But the panic never subsided. In fact, he never felt comfortable enough to pull out his computer. He sat sweating and shaking the entire flight.

Sebastian knew he had a serious problem. He was still early on in his career as an operations consultant. And traveling was a huge part of his job.

He had to find a way to overcome his newfound fear of flying.

After spending some time doing online research, it seemed like Cognitive Behavioral Therapy might be the answer he’d been looking for.


What Is CBT?

Cognitive Behavioral Therapy, or CBT, is simply a type of talk therapy done under the guidance of a therapist or mental health counselor.

It’s specifically developed to bring your attention to your own negative thinking with the goal of helping you see difficult situations more clearly and respond to them more effectively. It essentially rewires your habits and decision-making patterns.

In short, the theory behind this type of therapy goes a little something like this:

  1. Heightened stress or anxiety is partly the result of negative thinking and poor habits for dealing with those negative thoughts
  2. Stress and anxiety can be minimized, if not eliminated, by learning how to better cope with it more effectively.

According to Clinical Psychologist Dr. Anna Yam:

“CBT is based on the idea that our thoughts, emotions, and behavior are all interrelated. How we feel affects what we think, what we think affects what we do, and vice-versa. It works by helping clients clearly identify how their thoughts, emotions, and behaviors interact with one another and how to make small adjustments between each. These adjustments lead to better overall health and functioning because clients often feel better, think more clearly, and do more of the things that make for a meaningful life”.

The goal of cognitive therapy is to change your thinking and behavioral patterns to:

  • Recognize your own negative thinking and reframe those thoughts more constructively
  • Learn to calm both the mental manifestations and physical symptoms of anxiety
  • Face your fears head-on
  • Learn to interact with others, even in difficult situations
  • Gain more confidence in yourself and your skillset
  • Identify techniques for managing your emotions

You’ll work one-on-one with your behavioral therapist to develop a list of exercises to help you do these and meet any other goals you have.

You’ll do these exercises both in sessions with your therapist as well as on your own time.

You know the old saying, “you can’t control everything that happens around you, but you can control how you react to them”?

CBT teaches you just how to do exactly that.


Who Uses CBT?

Cognitive Behavioral Therapy is one of the most often turned to treatments used by doctors. And one of the biggest reasons for that is because it’s been found to be effective for nearly anyone- including children and adults.

It’s also been proven to improve a whole host of problems, including:

  • Anxiety disorders
  • Insomnia
  • Depression
  • Addiction
  • Eating disorders
  • Phobias
  • Smoking cessation
  • PTSD

However, it’s important to point out that you don’t have to be suffering from a mental health condition to benefit from this therapy practice.

In fact, it’s been shown to be helpful to anyone trying to better cope with challenging life situations like marital problems, difficult conversations, and public speaking.

CBT is used both as a standalone treatment and in combination with other therapies and medication.


How Is CBT Different?

Though it has similarities to the talk therapy you’re probably most familiar with, it’s actually quite different.

For starters, the focus is on what’s happening in your life now rather than your past. While your therapist may ask you some questions about your history or past behavior for context, most emphasis will be put on the now and what you’re trying to achieve at this point in your life.

Additionally, your therapist will continuously draw your attention to how you’re perceiving certain situations and how that type of thinking leads to negative emotions or outcomes.

For example, let’s say you’re rejected from a job that you really wanted. You feel like you just weren’t good enough and that you shouldn’t have even tried in the first place.

You’ll learn to stop that type of thinking and instead understand that the outcome (the fact that you didn’t get the job) has nothing to do with you being inadequate. Instead, you’ll learn to focus on it as a positive learning experience and how you can do better next time.

Unlike some other types of talk therapy where the agenda is loose and you’re able to freely talk throughout a session, these sessions are very structured. You and your behavioral therapist will work together to develop goals, create a plan for reaching those goals, and track your progress along the way.

CBT is also generally more short-term than other therapies, with most people only needing a few weeks or months to improve.

Last but not least, this type of therapy is different in the way you interact with your doctor. Here, you’ll be a part of your own treatment and an active participant in your improvement. Your doctor will often ask you questions about how you’re doing and feedback on exercises.


The Theory Behind CBT

The theory behind Cognitive Behavioral Therapy is pretty straightforward:

Your behaviors and emotions are directly influenced by how you perceive situations around you.

The way you think about these different situations comes from three areas:

Your Core Beliefs

These are your beliefs about yourself, others you interact with, and the world in general. Your core beliefs begin to develop at an early age and therefore can be highly influential and difficult to change.

Your Assumptions

Assumptions are your “rules” for life. They are guidelines that you believe you and others must always follow no matter how unrealistic or inflexible.

Your Learned Behavior Of Negative Thinking

Negative thinking is a habit that occurs often without you noticing. For example, “I suck” or “I’m never going to be able to do this”. Often these thoughts overestimate the importance of an event and underestimate your own ability to get through it.

Using CBT interventions, you gain a better understanding of these three elements and how they directly affect you. You’ll also learn new ways of coping with them and how to better manage your emotions and thoughts when things just don’t go the way you’d like them to.


How Does CBT Work?

CBT works in a format that’s probably very familiar to you.

You’ll meet one-on-one with a doctor; for most this happens in person but some may benefit through online sessions. The number of sessions needed to improve varies person-to-person. On average, you’ll go through anywhere from 5-20 sessions to reach your goal.

As we mentioned above, Cognitive Behavioral Therapy is focused on the here and now. While your first session may spend some time on your past, most time will be focused on your current goals and how you can meet them.

In your sessions, your doctor will help you break down whatever is standing in your way into 5 areas:

  • Situations
  • Thoughts
  • Emotions
  • Physical Feelings
  • Behaviors

You’ll understand how these five things influence one another and how you can better respond to each.

Sebastian began meeting with Marcie, a therapist he found online, every other week.

At the start of each session, she would kick things off by asking him: “How were the past couple of weeks?”. It was a signal to Sebastian to begin walking her through the exercises he had completed during the previous weeks, how he felt as he went through them, and how he was feeling about his progress.

As he spoke, Marcie would gently interject with additional questions about his feelings and how he managed discomfort when he experienced it. When he found a technique that was helping him, she would ask him how he might be able to apply it to future situations.

And when he was unsure his progress was where it should be, she would talk him through why he thought that and how he could make changes to what he was doing to see better progress.

The one thing that stood out to Sebastian week after week was how Marcie challenged his way of thinking, constantly asking him to explain his train of thought. She didn’t just want to know what he thought or how he felt; she wanted to help him understand why.

He could feel his shift in thinking as she did this, and that started to bring him comfort.

In addition to psychotherapies, you might be assigned self-help material to work through.


Benefits Of Doing CBT

The biggest benefit of CBT is your ability to change how you react to different situations around you.

You’re essentially rewiring your brain to react differently when things aren’t going your way.

And by doing so, it can eliminate many of the negative physical and emotional symptoms you experience in these moments and instead remain calm and focused.

Other benefits include:

  • Can be completed in a relatively short amount of time, especially when compared to other treatment options
  • Long-term results
  • Skills can be easily translated into everyday life and in different situations

As noted by Dr. Yam:

“One of the biggest benefits is its focus on what is wrong now, which helps the clinician and the client take a solution-focused approach. With CBT there is no expectation that the client will remain in therapy “forever,” which is a concern for a lot of individuals who are starting therapy. Providers who are trained in CBT and use it in their practice want to give you the tools to manage your own emotional health needs”.

However, it’s important to point out that this type of therapy isn’t perfect. There are some drawbacks.

For starters, it is hard work.

Other disadvantages may include:

  • Can be time-consuming
  • May experience additional anxiety and emotions throughout the process
  • Doesn’t address the underlying causes of your problem - instead just focuses on solving the problem itself

“One drawback of CBT is that it is a very active treatment. Clients are usually encouraged to do homework between sessions to practice and solidify skills and collect information about what is and isn’t working for them day-to-day. This approach might not appeal to everyone, including individuals who are seeking more psychoanalytic, reflective, and insight-building experiences in therapy,” Dr. Yam told us.

Working with your doctor will help ensure that you get the most out of your cognitive therapy.

It was about four weeks into his sessions with Marcie that Sebestian really began to see a difference in himself.

His manager briefly stopped by his desk to let him know he’d need to catch a flight to Houston in two weeks to meet with a client.

It’s not that Sebastian didn’t feel panic when he heard those words; in fact, the opposite was true. He felt the pit in his stomach start to immediately form and the start of sweat build on the back of his neck.

But rather than letting those feelings spiral as he had previously, he instead recognized the panic in himself and immediately began to address it.

He remembers taking a big breath of relief at that moment. He wasn’t “cured” by any means. But it did feel like a big deal that he had kept himself from totally losing it. It felt like a big step forward, especially when he thought back to his experiences just a few weeks earlier.


Goals And Objectives

Cognitive Behavioral Therapy isn’t about changing your circumstances or the situations around you. Instead, it’s focused on changing how you react to those circumstances.

So, the goal of CBT is to:

Empower you to take control of your perception patterns and change how you think and act in these moments.

For example, let’s say you have trouble falling asleep at night, even on the days when you struggled to stay awake throughout the day. Using CBT-i, cognitive therapy specifically aimed at eliminating insomnia, your doctor will put together a program that’s aimed at the specific goal of helping you fall asleep and stay asleep throughout the night.

Or maybe you find that first-time interactions with new acquaintances cause you an enormous amount of stress and are limiting your career growth opportunities. Your goal will be to develop a set of exercises to help you feel comfortable and confident in front of new people.

Whatever problem you’re hoping to solve, your doctor will set the objective of your personalized therapy program to specifically help with that problem. Though you may spend a little bit of time talking about past experiences to help you understand why this is a problem, the ultimate objective is to stay focused on this one problem and how to eliminate it moving forward.



Cognitive Behavioral Therapy is really an umbrella term for a whole host of techniques and exercises that can be drawn upon to address an array of issues.

The approach you and your doctor decide is in your best interest will depend on your personal needs, your goals, and what helps you make progress.

With that in mind, let’s take a brief look at some examples to get a better idea of what you might be up for.

Cognitive Restructuring

This is just a fancy way to say:

Change how you think.

Cognitive Restructuring a core practice in most CBT therapies and can include quite a few different exercises.

For instance, learning to recognize negative thought patterns. Before you can change how you think, you first need to recognize the moments when your thinking is unhelpful.

Your counselor may have you keep track of each and every moment you have a negative thought by writing it down. The goal here isn’t to stop these thoughts or even change them- not yet anyway. Instead, your sole focus is to recognize these thoughts for what they are and get a better understanding of when they come up and how often they occur.

Once you’ve done this step, your doctor will come up with a list of exercises to then change these thoughts.

For example, let’s say you find yourself constantly telling yourself “I don’t belong here” at work.

One way your therapist might help you challenge that thought is to make two lists: one that includes points that support your thought and another that includes points that dispute it. Then you’ll put the two lists together to create a balanced thought process.

For instance, you might recognize “I don’t have as much experience as some of my peers around me, but I’m growing in my career at a faster pace than expected”. This approach is seen as effective because you’re not forcing yourself to buy into a sunny view you don’t really believe in like “I totally belong here”.

But you are creating a more balanced thought approach.

Successive Approximation

In English?

Taking a goal that seems huge and impossible and chopping it up into smaller, more doable mini actions.

If your goal is to accomplish something new - whether it’s something you haven’t done before or are feeling too overwhelmed to do - this exercise specializes in helping you take action.

The second part of Successive Approximation is to find ways of rewarding yourself when you do take a step forward toward meeting a goal. The idea is to “shape” you to perform an action and reinforce the benefits of taking that action.

Let’s say the idea of public speaking makes you want to run out of the room and hide under your covers. But in order to keep the job you love, you’ve got to learn to stand up and speak.

If presenting truly terrifies you, it’s not going to be very helpful to just throw you in the deep end and have you start giving 20-minute presentations in front of a full room of people.

Instead, it’s more helpful to take one small step at a time.

Start by standing in the front of the room- even when you’re not speaking. Next, speak up in a meeting with about 5 or 6 people in the room. Then, try leading a training session in front of a slightly bigger group.

The idea here is to slowly build your way up to present in the way you want to.

Along the way, you reinforce the behavior through rewards.


CBT And Medication

In some cases, prescription medications are used in tandem or in addition to CBT. But this is totally dependent on the individual, the situation, and what they’re trying to overcome.

Cognitive Behavioral Therapy is person-centered; one person’s treatment path won’t look like another’s.

If a person’s anxiety is hindering them from functioning in everyday life or preventing them from making progress in their treatment, medication may be prescribed.

Dr. Yam does note that a combination of therapy and certain medications can be beneficial:

“Medication helps clients feel slightly more in control when they have elevated anxiety and depression, and CBT supplies the skills necessary to create and maintain lasting positive emotional and behavioral change”.

Propranolol, a beta-blocker medication, is an option that’s sometimes prescribed in conjunction with therapy. It’s a medication that prevents an adrenaline rush - increased heart rate, shakiness, and sweatiness - while you’re doing something that scares you. In turn, you’re better able to stay focused on the task at hand than your body’s fight-or-flight response.

Other potential prescriptions might include anxiety medications or benzodiazepines.

In other cases, medication may not be the right fit and won’t be recommended by a healthcare provider.

The choice of treatment is personal and you should always be sure to talk through all of your options with your doctor to discover what path is right for you.


Measuring Your Progress

At the end of the day, how are you supposed to know whether or CBT is working for you?

Since cognitive therapy is highly structured with a clear objective and planned steps, this is actually easier than in some other types of therapies.

In fact, Dr. Yam notes that the ability to track how you’re doing along the way is one of Cognitive Behavioral Therapy’s biggest benefits:

“Another benefit is the focus on measurable outcomes. It’s a good fit for clients who want to track their progress because CBT includes setting goals for treatment and using measures to assess progress towards these goals”.

So to start, an easy way to see if you’re making progress is to take a look and see if you’re any closer to your ultimate goal than when you started.

If you’re using CBT to sleep throughout the night, take a look at your sleep journal from the past couple of weeks and see if the number of mornings you feel rested is more often than before you started.

A rating process to track your progress may even be directly integrated into your sessions with your doctor. They may ask you to rate exercises you’ve just completed or discussed the progress you’ve made by completing the homework you’ve done over the previous week.

Last but not least, you can evaluate your progress by asking yourself a few questions for a quick temperature check:

  • How has my mood been? Overall, is it improving or worsening throughout the week?
  • Are the symptoms I was experiencing getting better?
  • Am I approaching problems more often and completing the exercises given to me?
  • Have I learned new skills that I can use whenever I need them?
  • Have other people noticed and mentioned a change in me?

Though Sebastian wrapped up his meetings with Marcie after seven sessions, he still continued to practice what he gained in the following years on his own.

It took him about a year to feel “normal” on his flights, but he did see himself making progress along the way. He’d observe how he was more comfortable on his last flight because there was no turbulence at all. Or if there was turbulence, he would note how quickly he was able to get his anxiety back under his control.

He was even surprised to find that much of what he learned in therapy was useful to him in other situations that raised his stress levels, like dealing with a particularly aggressive client or having to participate in a difficult conversation with a loved one.


How To Find A Behavioral Therapist

CBT is an effective method for helping many people solve many different kinds of problems. Ultimately, you should speak with a doctor to see if this option is the best solution for you.

Here are a few steps you can take to help you get started.

First, you’ll need to find someone to run your program. You can do this by reaching out to your primary care doctor or giving your insurance company a call for a reference.

If you don’t have insurance, you can do an online search. ABCT has an easy tool you can use. Additionally, there are a few sites and apps you can use for online programs.

It’s important to find someone you trust and who you feel you can work with. This is hard work and you’ll want someone you’re comfortable around.

If you have a specific problem you’re trying to solve, you may also consider finding a doctor who specializes in that area.


How To Prepare For Your First CBT Appointment

There are a couple of steps you can take to prepare for your first CBT appointment.

To start, think about what type of program best suits your needs and goals. For some, an in-person one-on-one session is best. For others, online options are a better fit.

Next, take some time to think about why you’re starting this type of treatment. Try writing down what the problem is, how it’s affected you, and how solving it can help improve your life.

Your doctor will help you flesh this out and make more sense out of this, but it still helps to have some sense of clarity before getting started.

Also, prepare yourself to answer the types of questions your therapist will be interested in hearing about. In your first session, you will spend a little more time talking about your current situation and your past medical and emotional history for context.

Your healthcare provider will also want to know if you ever have or currently are undergoing any other types of treatments, including medications. Be sure to have a list of any current medications you’re taking.

Dr. Yam recommends going in understanding that your therapy will entail work in between sessions.

“As a client, you have a say in how therapy unfolds which includes homework, and you’ll get the most out of therapy if you lean into the work,” says Dr. Yam.

Last but not least, it helps to come prepared with a list of questions for your therapist. This is an opportunity to answer all of the questions you have- how this will work, how many sessions you might need, what your program will look like, etc.

Think of this as your chance to really find out if your healthcare provider is, in fact, the right fit for you or not.

Remember: just because you’ve started with this doctor doesn’t mean you have to stick it out. If it’s not the right fit, it’s best to know that up front so you can move on to someone who is.


What If CBT Doesn’t Work?

CBT is seen as one of the most effective treatment options around. That said, it doesn’t mean it’s a perfect fit for everyone.

If you’ve taken a look at the work you’ve done both in and outside of your sessions and aren’t seeing the progress you need, you should speak with your doctor.

You may need to adjust the exercises you’re trying, the way you’re handling your homework outside of sessions, or even your counselor. Alternatively, your doctor may suggest a different solution or another treatment option.

To get the most out of your Cognitive Behavioral Therapy, keep the following things in mind:

CBT is most effective when you actively participate in the sessions.

Don’t leave everything up to your therapist- instead, work with them to create the best next steps for you. Be willing to work alongside them. Also, don’t be afraid to ask questions along the way such as when you should start noticing a difference in yourself.

Remember to be transparent at all times.

If you’re holding back or are reluctant to discuss how you’re feeling, you won’t be able to move on. Always be upfront and honest at every stage.

Stick with it.

This is hard and sometimes you may feel like quitting. But don’t stop before you’ve really given yourself the opportunity to improve. When the going gets tough, don’t stop.

If ultimately this type of therapy isn’t the right path forward for you, there are other options to explore with your healthcare team. These can include everything from mindfulness practices and relaxation techniques to exposure therapy.