Cognitive Behavioral Therapy (CBT)
Understanding Patterns and Creating More Choices
I love Cognitive Behavioral Therapy because I have watched it change so many lives for the better.
CBT is one of the most extensively studied forms of psychotherapy. It is practical, collaborative, and remarkably versatile. It can be used as a robust standalone approach and can also integrate well with other modalities when a more layered approach is useful.
At its heart, CBT provides a framework for understanding the relationships among our thoughts, perceptions, emotions, behaviors, and physiological responses. These parts of our experience continually influence one another, often in ways that happen automatically.
This gives us multiple ways to understand what is happening and multiple places to begin making changes.
One of the things I appreciate most about CBT is that it gives you a useful system for understanding and caring for yourself. You learn to recognize your own patterns, understand what keeps them going, and develop more effective ways of responding.
And because these are skills you learn rather than something that happens only in the therapy room, you can become increasingly able to use them independently.
Understanding Your Sled Tracks
The obstacle to feeling better isn’t a lack of effort or caring – most people are already trying very hard to solve the problems that bring them to therapy.
But understanding something and being able to do it are not the same thing.
Some ways of interpreting and responding to situations become so automatic that we don’t recognize them at first. Someone asks you to take on something when you’re already stretched too thin, and before you’ve really considered whether you can or want to do it, you’re figuring out how to make it work.
These responses can feel less like choices than simply what the situation calls for. In therapy, we start slowing them down enough to see what’s happening. As the patterns become easier to recognize, we can look more closely at what you’re responding to, what your automatic response may be leaving out, and whether it still fits your current circumstances and values.
That gives us a much better starting point for figuring out what a more useful response could look like — one that takes into account information your automatic response has been overlooking.
I often describe these patterns as sled tracks.
The first time you ride a sled across fresh snow, it doesn’t move easily and leaves only a light impression. The more times you travel the same route, the deeper and smoother the track becomes. Eventually, the sled naturally falls into the path that’s already there.
Our thoughts, expectations, emotional responses, and behaviors can work in much the same way. With repetition, some patterns become so automatic that we may barely notice them happening.
CBT helps us recognize the tracks we’re already following and intentionally create new ones.
At first, a new way of thinking or responding can take more conscious effort. With practice and repetition, the new track becomes deeper and easier to follow. Over time, more accurate and helpful perspectives and responses can become increasingly natural and automatic — our new default sled tracks.
An Interconnected System
A central principle of CBT is that thoughts, emotions, behaviors, and physiological responses are interconnected. What happens in one part of the system can influence the others. The way we interpret a situation can influence how we feel and what we do. What we do can reinforce an expectation or give us new information that changes it. Our physiological state can also affect how we experience and respond to what is happening. This gives us more than one way into a problem.
Sometimes we work with automatic thoughts: thoughts and interpretations that arise spontaneously, without deliberate effort. CBT helps you become better at noticing these thoughts and evaluating them rather than automatically accepting them as facts.
Sometimes a thought is inaccurate or outdated. Sometimes it’s incomplete. Sometimes we’re making a prediction without enough information. And sometimes something genuinely difficult is happening and our assessment of it is reasonable.
The goal is to understand what you’re responding to as accurately as possible and have more choice about what you do next.
Change Doesn’t Only Happen Through Thinking
Despite the name, CBT isn’t only about thoughts. Behavior is an equally important part of the work. What we do (and what we avoid doing) can affect our emotions, reinforce our expectations, and influence what we learn from experience.
Depending on what brings you to therapy, this might mean practicing a different response, approaching something you’ve been avoiding, solving a practical problem, testing an assumption, or trying something new and paying attention to what actually happens.
This is one reason CBT can be especially useful when you already understand a problem intellectually but understanding it hasn’t been enough to change it. Sometimes we need the experience of doing something differently before it can begin to feel different.
Regulation Matters, Too
I also integrate nervous system regulation into my work with CBT. When stress takes us outside our window of tolerance, it can become harder to think flexibly, take in information, and use skills that may be readily available when we’re more regulated. This is one reason knowing what to do and being able to do it in a difficult moment can feel like two very different things.
Paying attention to what is happening in your body as well as your thoughts and behaviors gives us another source of information and another place to intervene. We can identify regulation strategies that work for you and help make the cognitive and behavioral parts of the work more accessible when you need them.
What CBT Looks Like in Therapy
Good CBT is collaborative and individualized. We aren’t looking for a generic list of “thinking errors” to correct or assuming that every difficult feeling is caused by an irrational thought. We start with what is actually happening in your life. Together, we look for patterns in how you understand, feel about, and respond to situations and consider where change might be useful.
Sometimes that means examining an automatic thought or assumption more closely. Sometimes it means changing a behavior, working on regulation, solving a problem, learning a new skill, or practicing a different response.
Understanding a pattern is important, but new responses need practice before they begin to feel familiar. Using what you’re learning in your everyday life gives you opportunities to see what works, make adjustments, and become increasingly confident using the skills on your own.
Skills You Can Keep Using
One of the reasons CBT has remained the heart of my practice is that besides giving us a way to work on the problem that brought you to therapy, it also gives you a framework you can continue using as new situations arise.
Over time, you can become better at recognizing automatic thoughts and sled tracks. You can notice when you’re outside your window of tolerance and use the regulation strategies that work for you. And with practice, newer ways of experiencing and responding can become more familiar and automatic.
The aim is to understand yourself and your patterns more clearly, have effective ways to work with them, and have more useful options available when you need them. These are skills you can keep using long after our work together has ended.
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Your questions, answered
What is Cognitive Behavioral Therapy (CBT)?
Cognitive Behavioral Therapy, or CBT, is an approach that helps us understand the relationships among your thoughts, interpretations, emotions, behaviors, and physical responses.
These parts of our experience influence one another. What you think about a situation can affect how you feel and respond. What you do can reinforce an expectation or give you new information that changes it. Stress and physiological activation can also affect how you interpret and respond to what is happening.
That interconnectedness gives us more than one place to begin. We can work with thinking patterns, behavior, avoidance, problem-solving, skills, and physiological regulation depending on what would be most useful.
What kinds of problems can CBT help with?
CBT has been studied extensively and is used to treat a wide range of concerns, including anxiety disorders, depression, panic, OCD, PTSD, and other mental health conditions.
In my practice, I also draw from CBT when working with concerns such as chronic worry, perfectionism, self-criticism, stress, burnout, emotional boundaries, and patterns that repeatedly create difficulty in everyday life.
The particular strategies we use depend on what you’re experiencing and what seems to be maintaining it.
What does CBT actually look like in a therapy session?
CBT is collaborative and active. We might slow down a recent situation and look at what you noticed, thought, felt, and did. We might identify an automatic assumption, look more closely at the information supporting it, or notice something important that your first interpretation left out.
Other times, the most useful work may be behavioral: solving a practical problem, approaching something you’ve been avoiding, practicing a different response, learning a skill, or trying something and seeing what actually happens.
What we focus on will depend on what you’re working on and where change seems most useful.
Does CBT mean positive thinking?
No. CBT is about looking at your thinking more accurately, rather than replacing difficult thoughts with positive ones.
Sometimes a thought is distorted or based on an assumption that doesn’t hold up. Sometimes it’s incomplete. Sometimes you’re predicting an outcome you can’t actually know. And sometimes something genuinely difficult is happening and your assessment of it is reasonable.
The goal is to understand the situation as accurately as possible and have more choice about how you respond.
What if I know what I’m worried about probably isn’t true, but I’m still worried?
Knowing something intellectually and experiencing it differently aren’t always the same thing.
You may already know that a feared outcome is unlikely, that one mistake doesn’t make you incompetent, or that another person’s disappointment doesn’t automatically mean you’ve done something wrong. That knowledge may still have surprisingly little effect when the familiar response shows up.
CBT can help us understand what keeps that response going. Behavioral changes, new experiences, repeated practice, or learning to respond differently when the pattern appears can provide information that intellectual understanding alone hasn’t been able to provide.
Is CBT only about changing thoughts?
No. The behavioral part of Cognitive Behavioral Therapy is equally important.
What we do (and what we avoid doing) affects what we feel, expect, and learn. Avoiding something can bring immediate relief while strengthening the expectation that the situation was dangerous or unmanageable. Trying a different behavior can give us new information.
Depending on the problem, CBT may involve changing a behavior, approaching something you’ve been avoiding, practicing a skill, solving a practical problem, or testing what happens when you respond differently.
What are automatic thoughts?
Automatic thoughts are thoughts or interpretations that arise quickly and spontaneously, often without deliberate effort.
Because they happen so quickly, they can feel less like an interpretation and more like an obvious description of reality: She’s annoyed with me. I messed that up. I should be able to handle this. Something is going to go wrong.
CBT helps you become better at noticing these thoughts rather than automatically treating them as facts. From there, we can look more closely at what the thought is responding to, what information it includes or leaves out, and whether there may be another way to understand the situation.
Do I have to complete CBT homework?
Using what we’re working on outside our sessions is an important part of CBT because the patterns we’re addressing usually happen in your everyday life.
That might mean noticing a particular pattern during the week, practicing a skill, trying a different response, approaching something you’ve been avoiding, or paying attention to what happens when you test an assumption.
We’ll decide together what would be useful. Between-session practice should have a clear purpose and relate directly to what you’re working on in therapy.
Is CBT very structured?
CBT can be structured without being rigid.
We usually have a clear idea of what we’re working on and why. We may identify goals, pay attention to particular patterns, practice skills, and check whether what we’re doing is useful.
At the same time, sessions remain responsive to what’s happening in your life and what needs attention. The structure gives us a framework for the work rather than determining everything that happens within it.
How long does CBT take to work?
There isn’t one standard timeline. CBT is often used as a relatively focused treatment, but how long therapy takes depends on what you’re working on, how long the patterns have been present, your goals, and whether we’re addressing one specific concern or several interconnected ones.
You may begin noticing patterns and understanding what’s happening relatively early. Other changes take repetition and real-life practice before they begin to feel natural.
We’ll pay attention to how the work is helping and adjust as needed rather than expecting change to follow a predetermined schedule.
Can CBT help if I've already tried therapy before?
Yes. Previous therapy may have given you insight, language, coping skills, or a better understanding of how your experiences have affected you. That understanding can be useful even when something is still difficult.
CBT can be particularly helpful when you understand a problem quite well but keep finding yourself in the same response. We can look more closely at what keeps the pattern going now.
The next step may involve practicing something different, testing an expectation, working with avoidance, building a skill, or helping a new response become familiar enough to use when you need it.
Can CBT be combined with other kinds of therapy?
Yes. CBT can be a primary approach or one part of a broader therapy.
I often integrate CBT with mindfulness, somatic approaches, Brainspotting, and other ways of working depending on what we’re addressing. At times examining a thought or behavior may be useful; at others, paying attention to your body, regulation, present moment experience, or something that hasn’t shifted through insight alone may give us a better way to work with what’s happening.
We can draw from different approaches while keeping the work coherent and focused on what is useful for you.
Does CBT work online?
Yes. CBT can work well through telehealth. Much of the work involves conversation, noticing patterns, learning and practicing skills, and applying what you’re learning in your everyday life.
Meeting online also allows us to talk about situations and practice strategies while you’re in the environment where many of those patterns might occur.
I provide online CBT and integrative therapy for women in Washington DC and Virginia.
Licensed Professional Counselor
Cheryl Zandt
Telehealth Counseling in Washington DC and Virginia
Cheryl Zandt is a Licensed Professional Counselor providing online therapy for women in Virginia and Washington DC. For more than 20 years, she has worked with women experiencing anxiety, burnout, panic, relationship challenges, life transitions, and other sources of stress and overwhelm.
Her approach is thoughtful, collaborative, and grounded in curiosity about why we think, feel, and respond the way we do. She brings clinical experience and research-informed approaches to the work while recognizing that each client is the expert on her own experience.
Cheryl helps clients better understand what has been shaping their experiences, develop practical ways to respond differently, and have more choice in what happens next.
