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Cognitive Behavioral Therapy

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy

Cognitive-Behavioral Therapy is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.

Definition of Cognitive Behavioral Therapy

Cognitive-behavioral therapist teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings and behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions.

Cognitive therapy or cognitive behavior therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, delusional disorder and other forms of mental disorder.

It involves recognizing unhelpful or destructive patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that clinical depression is typically associated with (although not necessarily caused by) negatively biased thinking and irrational thoughts. Cognitive therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

Cognitive Behavioral Therapy

This following information has been adapted from a variety of sources, the main ones being wikipedia and the Albert Ellis Foundation.

Cognitive Behavior Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior. Therefore, negative thoughts can cause us distress and result in problems.

One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on mood, making the person feel depressed; the problem may be worsened if the individual reacts by avoiding activities. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks in response to similar situations and by developing more flexible thought patterns, along with reducing the avoidance of activities. If, as a result, the client escapes the negative thought pattern, the feelings of depression may be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.

Thoughts as the cause of emotions

With thoughts stipulated as being the cause of emotions rather than the outcome or by-product, cognitive therapists reverse the causal order more generally used by psychotherapists. Therefore, the therapy is to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts.

Cognitive therapy is not an overnight process. Even after patients have learned to recognize when and where their thought processes go awry, it can take months of concerted effort to replace an irrational thought process or habit with a more reasonable, salutary one. With patience and a good therapist, however, cognitive therapy can be a valuable tool in recovery.

Cognitive behavioral therapy

While similar views of emotion have existed for millennia, cognitive therapy was developed in its present form by Albert Ellis, who developed his Rational Emotive Behavioral Therapy, or REBT, in the early 1950s, as a reaction against popular psychoanalytic and increasingly humanistic methods at the time [2], and Aaron T. Beck, who followed up Ellis' approach in the 1960s. It rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.

A sub-field of cognitive behavior therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia and Panic Disorder.

CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse and has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.

Cognitive Therapy and/or Cognitive Behavioral Therapy most closely ally with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment.


Negative thinking in depression can result from biological sources (i.e., endogenous depression), modeling from parents, peers or other sources. The depressed person experiences negative thoughts as being beyond their control: the negative thought pattern can become automatic and self-perpetuating.

Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.

Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad."

The ABCs of Irrational Beliefs

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs[2]. The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to them.
C - Consequence. The third column is for the negative feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc.
For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.

Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.

Another way of viewing the ABC's of Cognitive Behavioral Therapy

A - Activating Stimulus This is the stimulus that activates the irrational fear or anxiety in the person.
B - Blank This is the blank process that lies in between the stimulus and the irrational thinking. The person would have to identify this gap and create a bridge in their thought process in order to be able to be treated.
C - Conditioned Response This is the irrational fear or anxiety with which the person has conditioned themself to respond with to the stimulus.
The way the treatment works is that by going back and thinking over what the stimulus was and the irrational reaction to it and then try to follow the chain events that led from one to another, thereby filling in the blank in between, the person can identify what causes their thinking to become irrational.

For example;

A person walks out of his home and hears an ambulance siren. The person gets anxious from this and runs back into his home. The Activating Stimulus was the ambulance siren. The Conditioned Response was severe anxiety and running into his home. The person now has to fill in the Blank and try to understand what was the exact thought process that went through his mind that caused the irrational response to take place. By bridging this gap in his thought, he is identifying the faulty thought process that caused the extreme response. The person can now work on replacing these faulty thoughts with realistic ones, thereby correcting the undesired chain of thoughts and activating a functional one.


Albert Ellis Foundation and REBT

The following description of REBT comes from the website of the Albert Ellis Foundation.

What is REBT?
Rational Emotive Behavior Therapy (REBT) is a form of psychotherapy created by Albert Ellis in the 1950's.

REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc. The idea that our beliefs upset us was first articulated by Epictetus around 2,000 years ago: "Men are disturbed not by events, but by the views which they take of them."

The Goal of Happiness
According to Albert Ellis and to REBT, the vast majority of us want to be happy. We want to be happy whether we are alone or with others; we want to get along with others—especially with one or two close friends; we want to be well informed and educated; we want a good job with good pay; and we want to enjoy our leisure time.

Of course life doesn't always allow us to have what we want; our goal of being happy is often thwarted by the "slings and arrows of outrageous fortune." When our goals are blocked, we can respond in ways that are healthy and helpful, or we can react in ways that are unhealthy and unhelpful.

The ABC Model
Albert Ellis and REBT posit that our reaction to having our goals blocked (or even the possibility of having them blocked) is determined by our beliefs. To illustrate this, Dr. Ellis developed a simple ABC format to teach people how their beliefs cause their emotional and behavioral responses:

A. Something happens.
B. You have a belief about the situation.
C. You have an emotional reaction to the belief.

For example:

A. Your employer falsely accuses you of taking money from her purse and threatens to fire you.
B. You believe, “She has no right to accuse me. She's a bitch!”
C. You feel angry.

If you had held a different belief, your emotional response would have been different:

A. Your employer falsely accuses you of taking money from her purse and threatens to fire you.
B. You believe, “I must not lose my job. That would be unbearable.”
C. You feel anxious.

The ABC model shows that A does not cause C. It is B that causes C. In the first example, it is not your employer's false accusation and threat that make you angry; it is your belief that she has no right to accuse you, and that she is a bitch. In the second example, it is not her accusation and threat that make you anxious; it is the belief that you must not lose your job, and that losing your job would be unbearable.

The Three Basic Musts
Although we all express ourselves differently, according to Albert Ellis and REBT, the beliefs that upset us are all variations of three common irrational beliefs. Each of the three common irrational beliefs contains a demand, either about ourselves, other people, or the world in general. These beliefs are known as "The Three Basic Musts."

I must do well and win the approval of others for my performances or else I am no good.
Other people must treat me considerately, fairly and kindly, and in exactly the way I want them to treat me. If they don't, they are no good and they deserve to be condemned and punished.
I must get what I want, when I want it; and I must not get what I don't want. It's terrible if I don't get what I want, and I can't stand it.
The first belief often leads to anxiety, depression, shame, and guilt. The second belief often leads to rage, passive-aggression and acts of violence. The third belief often leads to self-pity and procrastination. It is the demanding nature of the beliefs that causes the problem. Less demanding, more flexible beliefs lead to healthy emotions and helpful behaviors

The goal of REBT is to help people change their irrational beliefs into rational beliefs. Changing beliefs is the real work of therapy and is achieved by the therapist disputing the client's irrational beliefs. For example, the therapist might ask, "Why must you win everyone's approval?" "Where is it written that other people must treat you fairly?" "Just because you want something, why must you have it?" Disputing is the D of the ABC model. When the client tries to answer the therapist's questions, s/he sees that there is no reason why s/he absolutely must have approval, fair treatment, or anything else that s/he wants.

Albert Ellis and REBT contend that although we all think irrationally from time to time, we can work at eliminating the tendency. It's unlikely that we can ever entirely eliminate the tendency to think irrationally, but we can reduce the frequency, the duration, and the intensity of our irrational beliefs by developing three insights:

We don't merely get upset but mainly upset ourselves by holding inflexible beliefs.
No matter when and how we start upsetting ourselves, we continue to feel upset because we cling to our irrational beliefs.
The only way to get better is to work hard at changing our beliefs. It takes practice, practice, practice.
Emotionally healthy human beings develop an acceptance of reality, even when reality is highly unfortunate and unpleasant. REBT therapists strive to help their clients develop three types of acceptance: (1) unconditional self-acceptance; (2) unconditional other-acceptance; and (3) unconditional life-acceptance. Each of these types of acceptance is based on three core beliefs:

Unconditional self-acceptance:

I am a fallible human being; I have my good points and my bad points.
There is no reason why I must not have flaws.
Despite my good points and my bad points, I am no more worthy and no less worthy than any other human being.
Unconditional other-acceptance:

Other people will treat me unfairly from time to time.
There is no reason why they must treat me fairly.
The people who treat me unfairly are no more worthy and no less worthy than any other human being.
Unconditional life-acceptance:

Life doesn't always work out the way that I'd like it to.
There is no reason why life must go the way I want it to
Life is not necessarily pleasant but it is never awful and it is nearly always bearable.

REBT Today

Clinical experience and a growing supply of experimental evidence show that REBT is effective and efficient at reducing emotional pain. When Albert Ellis created REBT in the 1950's he met with much resistance from others in the mental health field. Today it is one of the most widely-practiced therapies throughout the world. In the early days of REBT, even Dr. Ellis did not clearly see that consistent use of its philosophical system would have such a profound effect on the field of psychotherapy or on the lives of the millions of people who have benefited from it.


The National Association of Cognitive-Behavioral Therapists that most cognitive-behavioral therapies have the following characteristics:

1. CBT is based on the Cognitive Model of Emotional Response.
Cognitive-behavioral therapy is based on the scientific fact that our thoughts
cause our feelings and behaviors, not external things, like people, situations,
and events. The benefit of this fact is that we can change the way we think to
feel / act better even if the situation does not change.

2. CBT is Briefer and Time-Limited.
Cognitive-behavioral therapy is considered among the "fastest" in terms of
results obtained. The average number of sessions clients receive (across all
types of problems) is only 16. Other forms of therapy, like psychoanalysis,
can take years. What enables CBT to be briefer is its highly instructional
nature and the fact that it makes use of homework assignments.

3. A sound therapeutic relationship is necessary for effective therapy, but
not the focus.
Some forms of therapy assume that the main reason people get better in
therapy is because of the positive relationship between the therapist and
client. Cognitive-behavioral therapists believe it is important to have a good,
trusting relationship, but that is not enough. CBT therapists believe that the
clients change when they learn to think differently; therefore, CBT therapists
focus on teaching rational self-counseling skills.

4. CBT is a collaborative effort between the therapist and the client.
Cognitive-behavioral therapists seek to learn what their clients want out of life
(their goals) and then help their clients achieve those goals. The therapist's
role is to listen, teach, and encourage, while the client's roles is to express
concerns, learn, and implement that learning.

5. CBT is based on stoic philosophy.
Cognitive-behavioral therapy does not tell people how they should feel.
However, most people seeking therapy do not want to feel they way they do.
CBT teaches the benefits of feeling, at worst, calm when confronted with
undesirable situations. It also emphasizes the fact that we have our
undesirable situations whether we are upset about them or not. If we are
upset about our problems, we have two problems -- the problem, and our
upset about it. Most sane people want to have the fewest number of problems

6. CBT uses the Socratic Method.
Cognitive-behavioral therapists want to gain a very good understanding of
their clients' concerns. That's why they often ask questions. They also
encourage their clients to ask questions of themselves, like, "How do I
really know that those people are laughing at me?" "Could they be laughing
about something else?"

7. CBT is structured and directive.
Cognitive-behavioral therapists have a specific agenda for each session.
Specific techniques / concepts are taught during each session. CBT
focuses on helping the client achieve the goals they have set. CBT is
directive in that respect. However, CBT therapists do not tell their clients
what to do -- rather, they teach their clients how to do.

8. CBT is based on an educational model.
CBT is based on the scientifically supported assumption that most emotional
and behavioral reactions are learned. Therefore, the goal of therapy is to
help clients unlearn their unwanted reactions and to learn a new way of
reacting. While CBT therapists do not present themselves as "know-it-alls",
the assumption is that if clients knew what the therapist had to teach them,
clients would not have the emotional / behavioral problems they are

Therefore, CBT has nothing to do with "just talking". People can "just talk"
with anyone.

The educational emphasis of CBT has an additional benefit -- it leads to
long term results. When people understand how and why they are doing
well, they can continue doing what they are doing to make themselves well.

9. CBT theory and techniques rely on the Inductive Method.
A central aspect of Rational thinking is that it is based on fact, not simply
our assumptions made. Often, we upset ourselves about things when, in
fact, the situation isn't like we think it is. If we knew that, we would
not waste our time upsetting ourselves.

Therefore, the inductive method encourages us to look at our thoughts as
being hypotheses that can be questioned and tested. If we find that our
hypotheses are incorrect (because we have new information), then we can
change our thinking to be in line with how the situation really is.

There are over 25 very common mental mistakes that people make that cause
them to not have the facts straight.

10. Homework is a central feature of CBT.
If when you attempted to learn your multiplication tables you spent only one
hour per week studying them, you might still be wondering what 5 X 5
equals. You very likely spent a great deal of time at home studying your
multiplication tables, maybe with flashcards. The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if all a person were only to think about the techniques and topics taught for one hour per week. That's why CBT
therapists assign reading assignments and encourage their clients to practice the techniques learned.

Additional Information

For more information about Cognitive Behavioral Therapy and other therapeutic approaches, please click on the linked websites listed below.

 National Association of Cognitive-Behavioral Therapists
 An Introduction to Cognitive Therapy & Cognitive Behavioral Approach

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