Cognitive behavioral therapy (CBT): how sessions work and when they are enough

What is cognitive behavioral therapy?

Cognitive behavioral therapy (CBT, spelled "cognitive behavioral therapy" in American English) is a type of talking therapy in which a trained therapist helps you notice the unhelpful thoughts and behaviors that keep your difficulties going, and then change them step by step. Guidance from the UK's National Institute for Health and Care Excellence (NICE) describes it as a structured, goal-oriented treatment that focuses on your current problems and teaches you skills to deal with them. Cleveland Clinic adds that it usually runs for a limited number of sessions, and that the skills are meant to stay with you after therapy ends.

How are your thoughts, feelings and behavior linked?

The way you interpret what happens affects how you feel and what you do, and what you do feeds back into your thoughts. For example:

• The situation: you send a friend a message and they don't reply all day.
• The automatic thought: "Nobody cares about me."
• The feeling: sadness and a sense of rejection.
• The behavior: you withdraw and don't contact anyone, so there are fewer chances to connect, and the thought seems even more true.

In a session you are not asked to simply "think positive". Instead, you examine the thought: what is the evidence for it? Is there another explanation, such as your friend being busy? Unhelpful patterns that Cleveland Clinic mentions include "all or nothing" thinking, always expecting the worst, and assuming you know what other people think of you.

How does CBT work in a session, and what does homework mean?

Treatment usually starts with an assessment in which the therapist asks about your symptoms and your goals, and may then suggest a different type of therapy if it suits you better, as the UK's National Health Service (NHS) explains. Each session usually lasts about 60 minutes, weekly or at longer intervals depending on your needs, according to Cleveland Clinic. In it you talk about difficult situations and how they affected your thoughts, feelings and actions, then work out other ways of handling them with your therapist, such as:

• Noticing automatic thoughts and how they affect your mood.
• Reviewing the thought: is it accurate and helpful? Then putting together a more balanced one.
• Changing behavior gradually, such as returning step by step to activities or places you have been avoiding.
• Calming skills, such as slow breathing and noticing your feelings and bodily sensations without being swept along by them.

Homework: the part that makes the difference

Between sessions you are usually asked to practice what you have learned, and the NHS says this practice is important for CBT to work. You may record your progress on a worksheet or in a diary. Homework might mean writing down a situation that upset you and the thought that came with it, or taking a small step you have been avoiding. It is not an exam; it is how you carry the skill from the session into your life.

CBT can be given one-to-one, in a group, or as guided self-help. Cleveland Clinic points out that some discomfort when talking about difficult experiences is a normal part of change, and that you set the pace together with your therapist.

CBT for anxiety, depression and more: where is the evidence strongest?

CBT is one of the most studied psychological treatments. In a 2012 review published in the journal Cognitive Therapy and Research, which examined a sample of 106 meta-analyses, anxiety disorders were among the conditions with the strongest support. The main conditions it helps with are:

• Depression: in a 2023 meta-analysis published in the journal World Psychiatry, covering 409 trials and more than 52,000 patients, CBT had a moderate to large effect. It was as effective as medication in the short term and possibly better in the longer term, although that last finding rests on fewer studies.
• Panic attacks: you practice facing the bodily sensations you fear, such as a racing heart, and the 2012 review found this approach moderately effective.
• Obsessive-compulsive disorder (OCD): usually treated with exposure and response prevention, as the NHS explains, and the 2012 review found a large effect, similar to that of medication. See also OCD symptoms and treatment.
• Chronic insomnia: the American Academy of Sleep Medicine's 2021 guideline strongly recommends cognitive behavioral therapy for insomnia (CBT-I), and advises against relying on "sleep hygiene" tips alone.
• Other conditions: such as post-traumatic stress disorder (PTSD), eating disorders, and problems with alcohol and drugs, according to the NHS.

The picture is not perfect, though. The 2012 review warns that many studies were small or poorly designed, and the 2023 analysis did not show CBT to be clearly better than other psychological therapies for depression. It is a treatment with strong evidence, but it does not suit everyone to the same degree.

How many CBT sessions do I need, and how do I know I'm improving?

There is no single number that fits everyone, but these are the estimates given by official sources:

• The NHS says people usually have between 5 and 15 sessions, depending on the problem.
• For less severe depression, individual CBT usually consists of 8 sessions, and for more severe depression 16 sessions, with extra sessions sometimes needed when other problems are present, according to NICE guidelines from 2022.
• For relatively mild OCD, people usually need between 8 and 20 sessions, and more severe OCD may need a longer course (NHS).
• For chronic insomnia, treatment is usually delivered in about 4 to 8 sessions, according to the American Academy of Sleep Medicine.

How is progress measured?

Measuring starts with goals you agree on with your therapist: what exactly do you want to change in your life? You then follow your progress with simple tools. NICE advises considering regular outcome monitoring with validated questionnaires filled in during sessions, such as the PHQ-9 for depression. Other signs include what you record in your diary and getting back to activities you had been avoiding.

The US National Institute of Mental Health (NIMH) suggests asking from the start: how long will treatment last, and how will we measure progress? If a reasonable period goes by without improvement, talk openly with your therapist, because a different approach may be needed. Toward the end, your therapist will usually help you plan how to keep using your skills (NHS).

Therapy vs medication: when is CBT enough on its own, and when is medication added?

NIMH explains that psychotherapy can be used on its own, alongside medication or instead of it, and that the plan is chosen according to your needs and condition, with guidance from a professional. For example:

• Less severe depression: NICE's 2022 guidelines advise against routinely offering antidepressants as the first treatment unless that is the person's informed preference, and put psychological therapies ahead of them.
• More severe depression: NICE places the combination of individual CBT and an antidepressant at the top of its list of options, and the 2023 analysis found the combination worked better than medication alone.
• OCD: the NHS says a doctor may add a medicine from the SSRI group if talking therapy does not help or the OCD is fairly severe.
• Urgent or severe situations: Cleveland Clinic notes that severe depression, suicidal thoughts or psychosis may need care first, and that in bipolar disorder and schizophrenia CBT is often used alongside medication and other treatments.

Even when medication eases the symptoms, NIMH notes that psychotherapy can still help with self-defeating thinking patterns and fears. For more, read our guide to psychiatric medicines.

Other approaches your therapist may use: how do they differ?

NIMH notes that many psychological therapies are variations of established approaches such as CBT, and that a therapist may combine elements of several. They include:

• Exposure and response prevention (ERP): used for OCD, it has you face distressing thoughts gradually, from the easiest to the hardest, without carrying out the compulsive rituals.
• Behavioral activation: NICE describes it as focusing on the link between your daily activities and your mood, helping you cut down withdrawal and avoidance without targeting thoughts directly. It may suit you when depression has left you inactive and isolated.
• Dialectical behavior therapy (DBT): based on CBT, but it balances accepting yourself with working on change, and teaches skills for tolerating distress, managing emotions and dealing with other people. Cleveland Clinic says it is aimed at people who live with very intense emotions, as in borderline personality disorder and self-harm.

At Oxygen, both individual and group sessions are used, and the therapy programs include CBT, dialectical behavior therapy, motivational interviewing, a relapse prevention program and family therapy. There are also behavior modification sessions that focus on one specific behavior you want to change, such as frequent angry outbursts or a harmful habit, with small steps and follow-up from one session to the next.

How to prepare for your first therapy session

You don't need complicated preparation. Here are some practical steps, some of them recommended by NIMH:

1. Write down what is troubling you: your symptoms, when they started and how they affect your life.
2. Choose one or two goals: such as "getting back to work" or "falling asleep without hours of overthinking".
3. Prepare your questions: what approach will be used? How long will the sessions continue? How will my privacy be protected?
4. Mention your medicines and health problems: some symptoms can have a physical cause, which is why NIMH recommends a medical check-up when needed.
5. Be honest, including about any use of alcohol or drugs.
6. Give the relationship a chance: NIMH considers trust with your therapist essential, and Cleveland Clinic notes that trying more than one therapist is common.

It's fine to feel nervous at your first session; it is mainly a chance for the two of you to get to know each other.

When should you seek help, and how do you start at Oxygen?

Consider asking for a specialist assessment if:

• anxiety, sadness or poor sleep has lasted for weeks and is affecting your work, studies or relationships
• you avoid places, situations or people so much that your life has become narrower
• thoughts or rituals keep coming back and you can't stop them
• you have started relying on alcohol, drugs or pills to calm down or to sleep
• you have tried self-help and haven't improved

At Oxygen, the path starts with an appointment with a psychiatrist or a psychotherapy session to assess your situation, and then a plan is made with you to fit it: psychotherapy sessions on their own, or together with medication followed up by the doctor. Sessions are available for men and women aged 15 and over (under 18 with a guardian's consent), and the team includes female psychologists. If your condition needs closer care, there is inpatient psychiatric treatment for males only.