Cognitive behavioral therapy (CBT) is considered the first-line treatment for a large number of psychological conditions. Yet despite its widespread use and proven efficacy, CBT is still highly misunderstood.

When many people think of CBT, they automatically think of "thought challenging." However, this view is overly simplistic and fails to capture the true essence of the therapy.

CBT assumes that between a situation and a distressing emotion is someone's interpretation. However, it also looks at other determinants, such as predisposing factors, precipitants, intrinsic and extrinsic reinforcers, and early childhood experiences that shape our core beliefs and the meaning we make of things that happen to us. CBT is not simply about challenging someone's thoughts but about helping individuals explore alternative and potentially more adaptive perspectives when in distress.

The term "thought challenging" can be problematic, as it suggests that CBT assumes the problem is only with the person's perspectives. If we approached therapy like this, we would likely risk damaging the therapeutic relationship, and patients would understandably feel gaslighted and invalidated.

Instead, CBT uses Socratic Questioning to help individuals develop more adaptive perspectives and build skills to cope with psychological distress. Therapists never assume that patients' thoughts are invalid or incorrect; instead, they assist their patients by using guided discovery to determine whether they could be taking other, more balanced perspectives. Furthermore, therapists help patients to recognize their internal resourcefulness and problem-solving ability.

One common question I hear in discussions about CBT is: "But what if a patient's thoughts are true? What then?" This question highlights some misconceptions about CBT and the assumption that it is solely about changing someone's thinking. In reality, there are several ways that CBT can approach thoughts that are reflective of reality:

1. Help the patient problem-solve the things within their control while giving them the tools to deal with uncomfortable emotions. For example, a patient may be distressed about an upcoming job interview. A CBT therapist may help the client identify specific steps they can take to prepare for the interview, such as researching the company and practising common interview questions. The therapist may also provide tools to help them manage their stress, such as emotional regulation strategies.
2. Investigate any potential invalid conclusions the patient may have made about their reality that could contribute to or exacerbate their distress. Imagine, for example, a patient who has recently fought with a friend. While their thoughts may be reflective of reality—such as "I shouldn't have said X; that was terrible of me"—their invalid conclusions—such as "This makes me a terrible person. I am not worthy of this friendship. I am a failure"—could still be investigated for validity. A therapist may work with the client to examine the evidence for and against this belief and help them develop a more balanced perspective about themselves.
3. Lastly, CBT can help individuals move towards a place of acceptance over what is uncontrollable in their lives. It is important to note that the above approaches may not always be applicable. Sometimes, a patient's distress may be appropriate, given the circumstance. In these instances, CBT can still be helpful by providing tools to help patients manage their distress and build resilience. For example, a patient grieving the loss of a loved one may benefit from learning coping strategies such as self-care, mindfulness, and acceptance-based strategies to cope with their grief. People often need a safe space to be heard, validated, provided empathy, and unconditional positive regard, and CBT can provide all those things.

In conclusion, cognitive behavioral therapy (CBT) is a powerful tool for helping individuals cope with psychological distress. However, it is essential to understand that CBT is not just about thought challenging. It is a collaborative and exploratory therapy that aims to help individuals develop more adaptive perspectives and build skills to cope with difficult emotions.

In essence, CBT is patient-centred and seeks to assist the individual in building the skills necessary to become their own therapist. CBT practitioners can better understand and guide their patients toward more adaptive coping by recognizing the many determinants of psychological distress, including early childhood experiences, predisposing factors, precipitants, intrinsic and extrinsic reinforcers, and current stressors.

And even when a patient's thoughts may reflect reality, CBT offers several approaches, such as problem-solving and acceptance, to help individuals move towards a healthier and happier life.