Ask anyone on the street what they imagine when they hear the words “therapy” or “psychologist” and you’ll likely hear something along the lines of lying on a long couch, talking about the past, and some form of analysis, whether it be your dreams, childhood, unconscious, or relationship with your mother.

When new patients come in for therapy, they often do not know what to expect. And they often come in with these preconceptions. However, when it comes to mental health treatment, there is a significant amount of variety, from level of training (masters, doctorate) to type of provider (counselor, social worker, physician, psychologist) to treatment approach (psychoanalysis, cognitive behavioral therapy).

We know from research that the single most important factor associated with treatment success is the strength of relationship between patient and therapist, something called therapeutic alliance. However, therapeutic alliance by itself is only one piece of the puzzle, as there are a number of other factors also associated with treatment success. One of these factors is treatment approach, also called theoretical orientation. This refers to how a therapist generally understands and explains a patient’s symptoms or difficulties, and importantly, guides how the therapist will provide treatment.

Cognitive behavioral therapy (CBT) is a treatment approach that assumes emotions, thoughts, and behaviors are connected and influence one other. Patients typically come in for therapy because of unpleasant or painful emotions, such as anger, depression, anxiety, or worry. But the problem is this: Telling someone, including ourselves, not to feel a certain way has little or no effect. Just think of the last time you were angry and someone asked you to calm down, or feeling depressed and told you to cheer up.

Put simply, we can’t change the way we feel just by choosing to feel differently. However, we can change the way we think and we can change the way we behave. And because these are related to our emotions, we can target how we feel.

For example, say your friend is feeling depressed. Simply telling them “don’t be sad” wouldn’t have much success. But suppose your friend is also having thoughts such as “I can’t seem to do anything right,” “things will never get better,” or “I’m a failure.” And suppose they’re isolating themselves, not exercising, or socializing with friends or family. It’s no surprise these patterns would make your friend’s depression worse.

A cognitive behavioral therapist would challenge these thoughts: Is it really true you can’t do anything right? What evidence do you have that nothing will get better? Have things ever been difficult in the past and actually did get better? And what does being a failure even mean? Living under I-10 addicted to heroin? The therapist would also target the behaviors maintaining depression. In-between sessions, they would assign homework to increase more adaptive behaviors, perhaps call one friend each day, walk/run around the block three times this week, or engage in activities they used to find pleasurable.

The take home message is this: Our thoughts and behaviors are not written in stone. They are malleable. Changeable. And behaviors can be learned. Unlearned. Relearned. And it is this very process of change that lies at the core of cognitive-behavioral therapy, and why it is so often successful.

Tyson Reuter, Ph.D.