If you’re new to therapy, it’s understandable not to know what to expect from CBT. The portrayal of therapy on TV and in films is often far from reality. We see people lying on a sofa or curled up in a big chair with a giant pillow, in a daze. They talk through their dreams or an obscure childhood memory. Then the therapist looks at their watch and says, “Time’s up! Same time next week?” This is not what you will get from Cognitive Behavioural Therapy!
CBT is a pro-active form of therapy. Of course there is room for discussion and exploration, but the focus is predominantly on active change and resolution. This is done over a limited number of sessions, rather than being open-ended or life-long. The focus throughout therapy is on achieving clearly defined goals. This is supported by homework to help you practice using the exercises learnt in session. The goal of CBT is for you to gain the tools you need to make sustainable changes without long-term dependency on a therapist.
In CBT, we recognise that aspects of our past influence our patterns of thinking and behaving related to the difficulties we are currently experiencing. These experiences are acknowledged in understanding these patterns but the focus is on making change in the present and into the future rather than unpicking the past.
This guide walks you through some of the main components, to help you gain a sense of what to expect from CBT.
What is CBT?
Cognitive Behavioural Therapy (CBT) is a highly evidence-based form of therapy. This means that there is robust research from clinical trials that shows it to be an effective treatment. The focus is on understanding and changing the way we think and behave in order to improve how we feel emotionally. CBT is recommended by the National Institute for Health and Care Excellence (NICE) for most common mental health problems. This includes, but is not limited to, depression, generalised anxiety, social anxiety, post-traumatic stress disorder, eating disorders and obsessive-compulsive disorder.
The Cognitive-Behavioural model highlights multiple links between the way we think, the way we feel physically, the way we feel emotionally and the way we behave. Making a change in one area, has an impact on the others.
What to Expect from CBT: Initial Assessment
Depending how you access therapy, you may go through a screening call or triage appointment. This is an initial stage to determine whether CBT is a suitable treatment for you. If so, or if you go straight to a CBT therapist, the first appointment is an initial consultation. This is essentially an assessment of your difficulties and needs. This informs your treatment plan. Your therapist will provide space for you to talk through how you’ve been feeling, your understanding of what may have triggered your current difficulties, and how this is impacting you day to day. They will support you to identify therapy goals so that you can both be clear on what it is that you want to gain from treatment. Then you work towards these goals together over a number of sessions.
Ahead of your assessment, your therapist should also outline confidentiality so you are clear on when your information may need to be shared with others.
What to Expect from CBT: The Process
In the first sessions of CBT, the focus is on building an understanding of the problem and how it’s maintained. This helps provide a clear rationale and strategy for making change. Sessions then move into more active treatment focused on exercises and interventions to support change.
There is sometimes an expectation that simply attending therapy is enough. Some may think it is the therapist’s role to make everything better. However, this is not the case. CBT is an active and collaborative process between therapist and client. It is understood that the therapist holds the expertise in mental health, and the client holds the expertise in themselves. By working together as a team, the expertise is shared.
The therapist doesn’t give quick solutions or advice but instead, uses questions to help the you think about things differently. The aim is for you to be guided to come to new ways of thinking and understanding. Homework tasks are then agreed to help test out or reinforce ways of thinking and behaving. The majority of real learning and progress takes place outside of the sessions because this is where real life happens. It’s between sessions where there are the most opportunities for you to apply your learning and practice new skills.
What to Expect from CBT: Session Structure
In CBT, to support focus and progress, an agenda is set at the start of the session. This makes sure we stay on track with your goals. Homework is absolutely key to progress and will be reviewed as a standard agenda item within every session. In fact, it is such an important part of the process that it is quite common for therapy sessions to be used for homework if the agreed task has not been completed. This is to ensure you have understood the exercises and feel confident using them independently. You are then more likely to be able to use them once therapy has ended and continue making progress.
The homework review generally feeds into the next task or exercise that the therapist introduces. Not completing the home practice therefore slows things down. This may result in the need for additional sessions. If not completing the homework is an ongoing problem, your therapist may advise stopping therapy until you are able to fully commit to the process.
What to Expect from CBT: Goal Setting
The first homework task in CBT is usually around goal-setting. Your goals guide the treatment plan and ensure that focus is maintained on working towards achieving them. Often, people will express wanting to feel ‘normal’ or ‘gain coping strategies’ or ‘not feel depressed.’ These are great starting points but it’s quite difficult to measure progress with such broad goals. The first treatment session often focuses on understanding these goals and breaking them into smaller steps. Goals are then reviewed throughout treatment as a way to check progress and maintain focus.
What to Expect from CBT: Number and Frequency of Sessions
As part of the assessment process, a number of sessions is usually established and agreed before commencing treatment. This varies depending on the nature of the problem but is usually between 8 and 25 sessions. Sessions are usually 50-60 minutes in length. They are usually weekly to start. As you build confidence and start working towards ending, your therapist may suggest reducing the frequency to fortnightly. The additional time between sessions gives you longer to test out new skills and strategies between sessions. The idea is for you to start getting used to managing independently, without a therapist.
For some mental health problems, your therapist may suggest more frequent sessions. With certain eating disorders, for example, it is recommended that appointments occur twice a week initially. The recommendation for social anxiety and post-traumatic stress disorder is for 90-minute sessions for specific parts of the treatment. The number of recommended sessions, duration and frequency should all be discussed at the start of therapy.
What to Expect from CBT: The Challenges
As with all things that require effort, CBT can come with challenges. Knowing what these are ahead of treatment can help you prepare for them. For example, if part of your current difficulty is feeling stressed and overwhelmed, making time for homework may feel like a real challenge. You may find that changes in your personal routine, work schedule or finances make it hard to commit to regular appointments. In this case, by sharing this with your therapist, you can work together to find solutions to help you manage this.
What to Expect from CBT: Two-Way Feedback
A CBT therapist will usually end each session inviting feedback from you. This is an opportunity for you to share your honest views. It’s great to share what has been helpful, but it’s important to also share anything you might be struggling with, don’t understand or are finding unhelpful. Although the end of the session is often a natural time for feedback, it is not necessary to wait until then. It is important you feel comfortable to share your views and ask questions throughout the session as needed.
What to Expect from CBT: Ending Therapy
The end of therapy should be planned. Therapists will often refer to your stage of therapy and the final session as you get closer to it. Unless there are exceptional circumstances, the final session shouldn’t come as a surprise. You should feel well prepared to end. The final session is usually a summary session. In the session, the focus is on reviewing everything you have learnt. This then informs a plan for you to follow after therapy. Having a written plan for you to refer to helps you maintain and build on your progress. This is often referred to as a therapy blueprint.
Some therapy services allow you to return to them if you find you need further support. Private therapists will often offer the option to book a follow-up appointment. Sometimes sessions are limited. For example, some services or insurance providers may only offer 6-12 sessions. If the number of sessions available is less than what is clinically recommended for the problem you are struggling with, this is considered within the treatment plan. Your therapist will usually be transparent about this to help you manage expectations. It may be that you choose a priority goal to focus on, or supplement sessions with self-help materials, or as signposted to other services after treatment. In this case, you may not feel fully ready to end therapy. However, you should still feel prepared for it to end, and have some guidance on next steps you can take.
It is important to know that in CBT, the process doesn’t end when the therapy ends. The idea is that you continue practicing the skills you have learnt to keep maintaining positive change and progress.
Are You Ready to Start CBT?
If you feel ready to get started with CBT, all you need to do for now is get in touch.
Updated October 2024.
