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The idea that our thoughts, attitudes, and beliefs have a profound influence on the way we feel and react to what life throws at us has been around for centuries; since the early Greek philosophers. The scientific discipline of psychology has however only recently given attention to this phenomenon as a means of understanding and treating psychological problems. While the initial psychological theory of human emotion and behaviour (originally based on the work of Sigmund Freud), certainly made significant contributions toward the development of the profession, few theoretical frameworks have had as significant an impact on the treatment of psychological distress as cognitive behaviour therapy (CBT). The primary difference between CBT and other psychotherapy models is based on the notion that emotional and behavioural disturbance is essentially driven by the way in which we think about that with which we are confronted. The fictitious scenario below provides an example of the type of thinking that would typically be associated with depressed mood.

Example: Joe fails his economics exam and thinks "I am such a failure; I'll never manage to get through this degree; the rest of my life is ruined". As a result Joe (1) feels depressed, (2) withdraws himself, (3) renders himself helpless and his situation hopeless and (4) drops out prematurely from his studies.
Alternatively, if Joe was able to think in a more helpful and realistic manner and consider the following thoughts such as, "oh well, I failed, but then who hasn't? This is a real inconvenience, but is it really a catastrophe? I could certainly learn from my mistakes and try again; this isn't the only thing I can study or do with my life", then he'd be more likely to (1) feel sad or disappointed but not feel depressed, (2) not withdraw himself or (3) not give up prematurely.
His disappointment would be considered healthy and may actually help motivate him to try harder next time. This fictitious account provides for a typical example of how our emotional and behavioural reactions to difficult circumstances are determined to a large degree by the way in which we think about our circumstances, and not merely by those circumstances themselves. In other words, Joe's emotional and behavioural reaction is determined by how he thinks about the fact that he failed, and not solely his failure.

CBT theory proposes that if we are able to identify those thinking and behavioural patterns that are contributing toward our distress, restructure and alter these, then one would be better equipped to reduce or eliminate psychological distress. The CBT model thus encourages "emotional responsibility" by encouraging individuals to identify and alter the way in which they think so as to feel and react in a more appropriate way. This also provides for a more optimistic view regarding the potential for human beings to alter their emotional and behavioural reactions to difficult circumstances. The model proposes that individuals can effectively and successfully influence their own emotional well-being, irrespective of the situation with which they are confronted.

CBT is practical, goal orientated and based on objective, measurable concepts that have been verified scientifically (empirically). For instance, behaviour can be observed, measured and studied, as can thought, which we are typically able to articulate through language. Scientific investigation has shown that our thoughts are very much associated with our emotional states and behavioural reactions and that restructuring of our thoughts typically alters the way we feel. Thousands of well designed, peer-reviewed research papers have verified the central tenets of CBT. CBT-based intervention is based on what we now know works regarding the treatment of a wide variety of psychological disorders. There is ample scientific evidence that CBT is effective in the treatment of mood disorders, anxiety disorders, interpersonal problems, eating disorders, substance-related problems, psychotic disorders, impulse control disorders, insomnia and behavioural problems. Treatment is often based on a specific protocol, with brief, direct, and time-limited treatments for specific psychological disorders.

The CBT model typically uses a schematic commonly referred to as the A-B-C model of emotional and behavioural disturbance. (A) in the model typically refers to the Activating Event or adverse situation with which the individual is confronted. This could be a difficult interpersonal interaction, a stressful situation at work, a physical sensation, thought or emotional reaction. (B) refers to the thoughts or Beliefs that one then responds to the activating event with, which is then seen as responsible for initiating or maintaining (C), the Emotional and Behavioural Consequences to these beliefs. The three examples below illustrate the model using a typical scenario with panic disorder, OCD and depression.
Driving on the N1 in the car.
Slight increase in body temperature + the thought - "what if I have a panic attack".
"I have to control this anxiety".
"I'm not in control of myself".
"I will have an accident"
Increased Anxiety & Panic
Pull car over
Use of a tranquiliser
Avoid driving on the N1

Sitting in the kitchen with a loved one, close to a large knife and the thought "what if I stab my wife" pops into my head "This is an abnormal thought that I shouldn't be having".
"This thought makes me dangerous".
"Thinking this increases the chance of acting on it".
Escape from Room
Prayer to get rid of thought

Recently rejected by a boyfriend.
Feeling sad and disappointed
"I should have been able to prevent this if I was good enough."
"If I was a worthwhile partner then this wouldn't have happened."
"I'm unlovable."
"I can't handle feeling this way"
"I'm never going to find someone"
Socially withdrawn
Ruminating about why this happened.

The schematic would often include a second section with typical questions aimed at cognitive restructuring or Cognitive Disputation (D) that assists clients in evaluating the helpfulness of their beliefs and then provides them with an opportunity for developing new Effective Beliefs (E) that would then lead to more Functional Emotional or Behavioural Reactions (F).

Almost all individuals who present for psychotherapy, present with some sort of an emotional or behavioural problem. Even those individuals who think that their greatest problem is a practical one (disciplining their children/making a decision/dealing with difficult people) are typically prevented from managing their practical dilemma as a result of their emotional disturbance about it. One of the primary goals of CBT is thus to assist individuals in reducing emotional distress, thereby experiencing more appropriate, healthy emotional reactions. Those who seek 'happiness' continuously are essentially misguided in the sense that positive emotions such as happiness, joy or calmness, whilst pleasurable, are typically short-lived and unsustainable for longer periods of time. CBT therapists prefer to consider emotional reactions as either helpful and functional or unhelpful and dysfunctional. The goal is to assist clients in shifting from unhelpful emotional states to more appropriate, manageable ones.

As an example, many individuals who struggle with assertiveness are often inhibited by intense guilt about the way in which others may feel in response to their decisions. While having sensitivity to other's feelings is certainly admirable and quite appropriate, feeling intense guilt about others' feelings is often unhealthily inhibiting. In such a situation, one would typically want to reduce the likelihood of feeling guilt and shift such an emotional response to something more moderate and tolerable such as regret or disappointment. Guilt in such a situation would typically be fueled by beliefs such as "I must never do anything that others may not like" or that "I am personally responsible for others feelings".

Regret on the other hand, would be based on more flexible, realistic beliefs such as "while I'd prefer to always make decisions that others are happy with, there is no rule that states that I have to always place others satisfaction above my own and I am not personally responsible for others' happiness". Such a shift in belief allows one to be sensitive to others feelings, but not see their reactions as always more important that what may be in ones own best interest. Such a restructuring of one's thinking would thus help to reduce the presence of unnecessary guilt and enable one to then act in a more assertive manner, thereby also addressing the practical problem.

Below is a table of positive emotions, healthy negative emotions and unhealthy negative emotions:

Calm Concern Clinical Anxiety
Joy Sadness Depression
Excitement Annoyance Clinical Anger
Relief Regret / Remorse Guilt
Euphoria Disappointment Shame
Inspired Disappointment Hurt

Simultaneously, behaviour may often also be targeted during intervention, but this is often (but not always) secondary to the initial emotional goal. Many behavioural interventions target specific behaviours without any initial emotional goals. This would typically be the case with substance related problems, procrastination, habit related disorders like tics, skin picking or trichotillomania, and insomnia. Behavioural reactions associated with depression or anxiety-related problems may often also be targeted directly, with a change in one's emotional state being seen as secondary to this. For instance, prolonged exposure to feared situations tends to result in a decrease in anxiety and becoming more actively involved in pleasurable activities tends to reduce feelings of depression.

Cognitive restructuring is aimed at identifying those thoughts, attitudes and assumptions that create, exacerbate or maintain intense, unhealthy negative emotion such as severe anxiety or panic, shame, guilt, jealousy, envy, intense anger, excessive shyness, and depression. Some of the cognitions or thinking patterns associated with emotional disturbance may be automatic and conscious and thus easily articulated; whilst others may be so well rehearsed that they do not form part of conscious awareness. Once elicited and identified, these beliefs are evaluated in a scientific manner with regards to the following general principles:

  • Whether they are merely subjective opinions or based on some sort of objective evidence that suggests that they are more like facts than mere opinions. In other words, are they in line with reality?
  • Whether they help us to achieve our emotional or practical goals or result in self-defeating emotional and behavioural reactions.
  • Whether they follow logical reasoning.

Thoughts that (1) do not follow logical reasoning, (2) that represent subjective opinion as oppose to being based on factual evidence and that (3) are likely to lead to excessive emotional arousal or self-destructive behaviour are considered dysfunctional, inaccurate or irrational. It is these sorts of thinking errors or dysfunctional beliefs that are identified and targeted throughout intervention. What we now know is that specific sorts of cognitive errors are associated with specific emotional states and behavioural responses. Well trained CBT therapists would often be able to help their clients quickly identify which clinically relevant beliefs are perpetuating their problem.

A variety of different dysfunctional beliefs have been identified and conceptualized as contributing toward various forms of psychological distress. Ellis, Beck and others have proposed somewhat different beliefs and belief systems responsible for psychological disturbance. Beck typically considers cognitive errors to be responsible for emotional distress and Cognitive Therapy tends to focus mainly on the attributions or meanings that individuals make about themselves, others or the world in response to specific situations or stressors. Ellis' REBT model (Ellis & Harper, 1961) proposes that four specific types of beliefs, otherwise known as evaluative beliefs, underly psychological distress. These are further described below.

  1. Demands, result from our tendency to take healthy preferences or desires and turn them into unrealistic, perfectionistic, rigid and absolute rules and expectations of one's self, others or the world. Demandingness is typically reflected in language which incorporates words such as 'must, ought to, should, have to and need'. A typical demand associated with performance anxiety would be, "I absolutely must do well in that exam and at the very least end up in the top three in my class".
  2. Awfulizing, which reflects an exaggeration of the badness or negative consequences associated with a particular situation or event such that a bad, inconvenient or uncomfortable situation is seen as terrible, horrible or awful. For instance, "It would be terrible if I didn't do well in my exam. It will be the end of my studies and I'll never be able to achieve anything in my life".
  3. Low frustration tolerance (LFT) beliefs typically stem from demands for ease and comfort, and reflect an intolerance of discomfort or frustration. For example,"I would not be able to handle failing that test; I couldn't stand the embarrassment. That, would be intolerable".
  4. Global evaluations of human worth, either of self or others, refer to a set of beliefs that imply that our value and worth can be objectively rated and that some people can be evaluated as objectively worthless (including yourself) or at least less worthy than others. Typically, individuals neglect merely judging their behaviour or performance (which is objectively possible) and end up judging their entire selves instead. For instance, "I would really be a complete failure and a worthless idiot if I were to fail this test".

There are unfortunately very few CBT therapists in South Africa. A study by Möller and van Tonder (1999) suggested that only about 6% of South African clinical psychologists could be regarded as cognitive behaviour therapists. As of the time of this study, only 20% of clinical psychologists had had any training in CBT, only 5% used CBT more than 50% of the time, and only 4% regularly consulted CBT journals or literature.

As of 2011, no formal minimum training standards are provided for CBT therapists in South Africa and there is no formal national CBT organization or training standards committee. It may thus be most helpful to consider psychotherapists as belonging to 1 of 4 categories with respect to their proficiency and experience in using CBT:

(1) No experience or interest in the use of CBT as a therapeutic model.

(2) Some interest in and experience with the use of CBT.

(3) Primarily uses CBT as a therapeutic approach and has significant experience in using CBT, has attended international conferences and workshops in CBT but does not have any specific international certification as a CBT therapist.

(4) Internationally certified CBT therapists, with specific qualifications based on supervised practice by an international training standards committee.

It is most probably wise, when seeking a therapist who provides CBT to try and assess which of the above-mentioned categories they may fall into. Many therapists will report that they use CBT, but few have actually had specific supervised training in the model and many do not provide cutting edge treatments for specific disorders. In addition, it would also be important to check whether or not the therapist has specific experience in your area of concern. For instance, an individual may have plenty of experience in working with anxiety or depression, but little experience or expertise in treating tic disorders, insomnia or psychosis, for example. Below is a list of reasonable questions that one could ask a therapist prior to making an appointment or during an initial appointment aimed at assessing their experience with CBT.


Have you received any training in CBT?

Training could vary from an introduction during a Masters-program to an internationally certified qualification.

Did your training include individual supervision of case material from an experienced or internationally certified CBT therapist?
It is important to distinguish between theoretical training and practical supervised training that includes individual supervision in the use of CBT in working with clients.

Does your CBT training include international certification from an international training standards committee?
Typical international certification is from the Beck Institute or the Albert Ellis Institute. Other training centres in the USA and the UK also exist.

How many years experience do you have in practising CBT?
We all start with little experience and build our knowledge base. It would be wise not to doubt a well trained and supervised CBT therapist with 1 or 2 years experience. It however goes without saying that those therapists with greater practical experience, bring the expertise accumulated from this experience to helping you.

In what way do you use CBT in your practice?
Many people will tell you that they integrate CBT into their practice. This typically would entail using skills or techniques from more than one theoretical orientation at the same time. This approach is known as eclecticism. This is not unethical nor an unacceptable practice. Should you look for a CBT therapist specifically, this is obviously not the type of service provided by a therapist with an eclectic approach. Therapist will also tell you that they use different theoretical approaches to treat different clients and problems. This is also an acceptable approach, it would however be important to determine if the therapist is sufficiently trained in CBT and if the therapist would suggest CBT for your specific problem.

Ask if the therapist has training in the CBT treatment of your specific disorder.

It important to know that the therapist has disorder specific training in the condition that you require help with.

Ask the CBT therapist to explain the specific treatment to be employed to treat your specific condition.
Inform yourself via recognised CBT websites about the newest treatments available and the researchers responsible for the development of this treatment. You will find a list of helpful links to international CBT training and research facilities on our website (

The theoretical contributions of the cognitive theorists (Beck, Ellis etc.), together with the initial contributions of the behavioural theorists (Pavlov, Skinner, Wolpe etc.) provided for the foundation of modern-day CBT theory and practice. Modern-day CBT-based treatments for emotional and behavioural disorders are however, continually being altered and revised. These revisions are the product of what we are continually learning from research about which factors are primarily responsible for the onset and maintenance of psychological disorders. The recommended treatment guidelines for CBT-based interventions with anxiety disorders, depression, borderline personality disorder, insomnia, anger, substance use disorders, habit disorders and schizophrenia have changed substantially over the last twenty and even the last ten years. For instance, we now know that using controlled breathing and relaxation training as a primary intervention strategy for panic disorder is not the most useful way of tackling this highly treatable condition and may even reduce long-term prognosis. We also now know that trying to reduce, suppress or remove negative thoughts is less helpful than what we once thought when working with individuals with depression. We know that how individuals react to their negative thoughts and emotions is of greater importance than whether or not they have negative thoughts or emotions in the context of anxiety or depression, for example. There have been a number of more recent theoretical models that have gained momentum over the course of the last decade, many of which are considered as part of "the third wave" movement within the CBT tradition. Dialectical Behaviour Therapy (DBT), Metacognitive Therapy (MCT) and Acceptance and Commitment Therapy (ACT) would be typical examples thereof. Each of these "newer" models within the CBT tradition emphasize the notion of non-judgmental acceptance, awareness of and mindfulness toward negative thoughts and emotional states as a means of reacting in a more functional manner toward these states. The concept of mindfulness is regularly cited within modern-day CBT treatment models and is often a significant treatment component that is introduced earlier on in treatment but is not considered a means of treatment itself, in isolation. Mindfulness is typically used as a means of emotional regulation and in reducing emotionally driven behaviours that perpetuate emotional disturbance.

The table below provides a short summary of the most prominent treatment components associated with modern-day CBT. These core treatment components would typically be accompanied by standard treatment components such as psychoeducation, motivational enhancement and relapse prevention.

Panic Disorder Cognitive Restructuring, Mindfulness, Interoceptive and Situational Exposure Barlow
PTSD Cognitive Restructuring, Prolonged Imaginal and Situational (in vivo) Exposure Foa
Ehlers & Clark
Social Phobia Cognitive Restructuring, Mindfulness, Interoceptive and Situational Exposure Heimberg
Clarke and Wells
Hoffman, Albano
Obsessive Compulsive Disorder Cognitive Restructuring, Mindfulness, Imaginal or Cognitive or Situational Exposure and Response Prevention Foa, Abramowitz
Salkovskis, Rachman, Radomsky, Piacentini, Whittal
Phobias Cognitive Restructuring, Mindfulness, Interoceptive and Prolonged Situational Exposure Ollendick and Ost
Generalized Anxiety Disorder Cognitive Restructuring, Meta-cognitive Therapy, Mindfulness, Imaginal/Cognitive Exposure, Situational (Uncertainty) Exposure Wells, Dugas, Ladouceur, Borkovec
Depression Cognitive Restructuring, Mindfulness, Behavioural Activation, Behavioural Assignments Beck, Hollon, Freeman
Insomnia Cognitive Restructuring, Sleep Hygiene, Stimulus Control, Graded Sleep Restriction Edinger, Carney
Tic Disorders Mindfulness, Awareness Training, Habit Reversal, Cognitive Restructuring Woods, Piacentini
Schizophrenia Activity Monitoring, Behavioural Activation, Cognitive Restructuring, Behavioural Assignments/Evidence Gathering Kingdon, Beck, Turkington, Grant
Bipolar Mood Disorder Psychoeduction, Cognitive Restructuring aimed at Enhancing Adjustment, Mood Awareness Training, Stimulus Control, Cognitive Restructuring, Relapse Prevention Basco, Rush, Otto, Knauz
Anger Related Problems Cognitive Restructuring, Mindfulness/Relaxation Training, Situational Exposure Di Giuseppe, Tafrate, Kassinove
Substance Related Disorders Cognitive Restructuring, Mindfulness, Stimulus Control, Urge/Interoceptive and Situational Exposure, Contingency Management, Carrol, Miller, Rollnick, Petry
Compulsive Gambling Cognitive Restructuring, Mindfulness, Stimulus Control, Urge Interoceptive and Situational Exposure, Contingency Management Ladouceur
Habit Disorders (Skin Picking, Trichotillomania) Mindfulness, Stimulus Control, Habit Reversal, Acceptance Practices Woods, Piancentini, Tolin, Franklin
Borderline Personality Disorder Dialectical Behaviour Therapy, Schema Therapy Linehan, Young
ADHD (Adults) Behavioural Intervention aimed at enhancing Organization and Planning, Reducing Distractibility, Reducing Procrastination. Cognitive Restructuring Safren, Otto
Anorexia Nervosa Behavioural Planning aimed at Weight Gain, Systematic Exposure, Motivational Enhancement, Monitoring, Cognitive Restructuring, Fairburn, Wilson, Agras
Bulimia Nervosa Psychoeducation, Motivational Enhancement, Monitoring, Stimulus Control, Cognitive Restructuring, Urge Tolerance and Mindfulness Fairburn, Wilson, Agras
Hypochondriasis Cognitive Restructuring, Mindfulness, Imaginal/Cognitive Exposure/Situational (Uncertainty) Exposure and Response Prevention, Interoceptive Exposure Salkovskis, Barsky


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