CBT is one of the most popular forms of talking therapy available.
It’s the most commonly offered therapy by the NHS in the UK, and it’s offered by many other practitioners in private and public health services around the world. It’s safe to say that if you have some experience of therapy, it’s likely that you’ve encountered CBT.
But what is CBT, what does a CBT session look like, and most importantly, does it work for everyone (including LGBTQ+ people)?
On this page, find out more about how CBT works, the history of CBT, and what makes it LGBTQ-affirmative.
What is CBT?
CBT is a form of talking therapy, which sometimes involves practical exercises, diaries, and worksheets.
It’s all about understanding and untangling how the way you feel influences your thoughts, and the way you behave.
The general idea is that unhelpful ways of thinking and behaving can lead to, or worsen, distress.
The goal of CBT is often to change these difficult thinking patterns and ways of behaving, and to learn more positive coping skills.
CBT can be used to treat depression, anxiety, OCD, and many other mental health problems.
What does CBT stand for?
CBT stands for Cognitive Behavioural Therapy.
It’s therapy that combines two approaches:
- Cognitive therapy, which looks at changing the way you think, and
- Behavioural therapy, which looks at changing behaviours.
What happens in CBT therapy?
In a CBT session, your therapist might use a range of techniques to tackle thoughts, feelings, and behaviours.
There’s a wide range of styles of CBT, so this will depend on the exact therapist you’re working with, but some popular techniques include:
- Cognitive restructuring: Learning how to spot, and challenge, unhelpful thought patterns.
- Logs and records: Keeping a diary to log your moods, thoughts, or actions.
- Exposure therapy: Careful, managed experimentation with behaviours or situations that you’d usually avoid or find difficult.
- Mindfulness: Calming and grounding techniques to support you to feel more present.
The history of CBT in three waves
CBT as we know it today is largely rooted in the work of Dr. Aaron Beck, an American psychiatrist who developed the core ideas in the 1960s and 1970s.
But the true origins of CBT are actually even further in the past, beginning in the early 20th century.
We can broadly split the history of CBT into three “waves”.
First wave CBT: Behavioural therapy
Behavioural therapy started to emerge around the 1920s. This came from therapists who brought ideas from behavioural science – for example, Ivan Pavlov’s famous research on conditioning – into the therapy room.
The focus of behavioural therapy was on changing behaviour by using rewards and consequences.
Behavioural therapy was thought to be a practical, short-term way to tackle the symptoms of anxiety and depression. It offered a quicker alternative to psychoanalysis, the more in-depth style of talking therapy being developed by Freud and others.
This early iteration of behavioural therapy was offered to veterans returning from war in the 1940s, to help them find ways of coping with their distress.
Second wave CBT: Cognitive therapy
CBT as we know it today began to really take shape in the 1960s and 1970s, with the work of the American psychiatrist Dr. Aaron Beck.
Beck started out as a neurologist, who became interested in psychoanalysis, and particularly in how our negative thoughts shape our feelings and experiences.
In Beck’s research on depressed people, he found that negative automatic thoughts (this could be something like, “there’s no point in life”) would commonly arise and make people feel worse.
He started trying to work with these thoughts, and challenge them directly, through cognitive therapy – and he found that his patients felt better faster.
Combined with Beck’s work on cognition, the second wave of CBT was also shaped by Rational Emotive Therapy (RET), the brainchild of American psychotherapist Albert Ellis. This later became Rational Emotive Behavioural Therapy (REBT).
This kind of therapy was all about encouraging patients to sort out which of their thoughts were “rational”, and which were “irrational” or self-defeating.
The combination of these approaches gave rise to CBT as we know it today: a way of tackling difficult, unhelpful thoughts and feelings.
Third wave CBT: Mindfulness and more
The “third wave” of CBT refers to CBT from roughly the 1980s to now – and it’s still developing!
It covers many different offshoots of CBT that are offered by therapists working today, such as Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavioural Therapy (DBT), and Acceptance and Commitment Therapy (ACT).
Broadly, the third wave of CBT recognises that our thoughts and feelings are also shaped by our context and experiences.
Along with challenging thoughts and changing behaviours, third wave CBT practitioners might also explore mindfulness, acceptance, and core values.
How does CBT work?
CBT works by taking a closer look at the thoughts, feelings, and behaviours that are behind your distress, and supporting you to understand and change them.
For example, let’s say you’re struggling with online dating after coming out. You want to meet someone, but dating is making you feel low and hopeless, and you notice thoughts popping up like, “No other queer people will ever want to date me”. As a result, you stop opening the app and avoid dates altogether.
A CBT therapist could help you understand:
- Your thoughts: The self-critical voice in your head that is jumping to the worst-case scenario.
- Your feelings: Low self-worth and loneliness.
- Your actions: Avoiding dating completely.
Once you recognise those negative thoughts and feelings, you’ve built some more self-awareness. This helps you notice the pattern when it’s happening in real-time.
You might take it further by using cognitive restructuring techniques to challenge or adapt your ways of thinking.
You might even gradually experiment with pushing yourself out of your comfort zone with dating – all with the support of your therapist.
This is just one example of how CBT might work. The exact approach will depend on your own situation and preferences, and the therapist you’re working with.
How does CBT work for anxiety?
CBT helps to break cycles of anxious thinking by slowing down to interrupt and interrogate your worries.
It usually focuses on addressing the thoughts that are making you anxious right now, staying with the present moment rather than going into the past.
There’s a large amount of empirical evidence that suggests that CBT is usually helpful for anxious clients. In the UK, CBT is recommended as a first-line treatment for anxiety.
But as with all kinds of therapy, this doesn’t mean it’s right for everyone. Some people with anxiety find that they need support to regulate their emotions before they can do the cognitive work of CBT, for example.
Others with more severe anxiety or obsessive thinking might find that CBT can make rumination worse.
How does CBT work for depression?
For depressed people, CBT can be a helpful way of identifying the thoughts and behaviours that are contributing to a spiralling low mood.
The practical, short-term nature of CBT, and use of techniques like activity scheduling, can also be motivating for people who feel depressed.
Evidence points to CBT’s effectiveness for working with depression – but again, this doesn’t mean that everyone will get along well with it.
For example, some might want to go deeper into exploring past experiences and the roots of their depression, rather than focusing on the present, as CBT encourages.
Does CBT work for everyone?
No therapy modality is perfect for everyone. Like every other kind of therapy, CBT might not work for you – and that’s okay.
CBT may not be recommended for people who:
- Have memory problems or difficulty paying attention, perhaps because of cognitive impairments or complex trauma.
- Would like to take a deeper dive into the roots of their issues, rather than exploring coping strategies in the present.
LGBTQ-Affirmative CBT: Is CBT right for queer and trans people?
Like other types of therapy, CBT works best for LGBTQ+ people when it’s adapted to be affirmative. This isn’t just good practice – there’s a growing body of research behind it.
LGBTQ-affirmative CBT recognises the impact of minority stress on LGBTQ+ people.
“Minority stress” is the name for the chronic stress that’s created by living as a “minority” in society – and so facing homophobia and/or transphobia.
There’s a real psychological cost that comes with fearing rejection or discrimination because of who you are. There’s also a cost to having to conceal your true self, to avoid those risks.
LGBTQ-affirmative CBT recognises the toll that living in an unequal society takes on you.
This means that while they might use cognitive restructuring techniques to challenge unhelpful thoughts, LGBTQ-affirmative CBT therapists should also recognise how those thoughts have been shaped by your environment.
You might carry internalised homophobia or queer shame, for example, that have shaped negative thoughts about yourself.
LGBTQ-affirmative CBT could support you to:
- Recognise and loosen negative beliefs that you’ve internalised as a result of external homophobia, transphobia, and cisnormativity.
- Tell the difference between a real risk in your environment, and a harsh belief you’ve absorbed about yourself – because the two need different responses, and only one of them should be challenged.
- Cope with experiences of homophobia and transphobia, and build self-acceptance.
- Identify your personal values, and act according to them.
- Take steps to challenge attitudes in the community or society around you.
Find out more about LGBTQ-affirmative therapy.
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