Cognitive Behavioural Therapy (CBT) in Canada

Cognitive behavioural therapy (CBT) is a structured, short form therapeutic approach that helps individuals overcome challenges in their day-to-day lives. 

If you’re looking for CBT in Canada, you have many options. Because of its proven effectiveness, CBT is a popular modality for treating a wide range of conditions. Most therapists in Canada have at least some experience administering CBT.

Here’s what to know before you begin your search for a CBT therapist in Canada, including how CBT works, how long CBT takes, and what conditions CBT treats.

What is CBT?

During CBT therapy, a therapist guides their client in identifying the thoughts, sensations, and behaviours that trigger symptoms. By learning to monitor, assess, and reframe these triggers, the client can reduce their symptoms. 

Because CBT can be applied to a wide range of conditions, these symptoms may range from overwhelming emotions, to anxiety attacks or depressive episodes, to disordered eating or substance abuse. 

Regardless of the specific triggers or symptoms involved, CBT works with a core set of principles and techniques. It’s highly adaptable, and a number of specialized forms of CBT have been developed to treat different conditions.

The origins of CBT

CBT grew out of two trends in psychotherapy: behaviourism, and the cognitive-based approach. 

Behaviourism used techniques like exposure therapy, desensitization, and reinforcement to help patients overcome phobias and anxieties. 

The cognitive-based approach taught patients to challenge and change their beliefs and thought processes.

In the 1970s and ‘80s, researchers fused these two schools of thought to lay the groundwork for what developed into CBT.

Today, CBT is sometimes referred to as the gold standard for evidence-based psychotherapy. Many studies have proven its effectiveness and it is widely accepted by the therapeutic community. And other major modalities, like dialectal behaviour therapy (DBT) and acceptance and commitment therapy (ACT), have grown out of it.

How does CBT work?

CBT is based on three core principles:

1. Psychological problems are partly based on flawed or unhelpful ways of thinking
2. They are also partly based on learned patterns of unhelpful behaviour
3. By learning to manage these thought patterns and behaviours, individuals with psychological problems can relieve their symptoms and improve their quality of life

The CBT triangle

CBT also draws on a model called the cognitive triangle. This model shows the interrelationship between thoughts, behaviours, and emotions when dealing with situations.

First, a difficult situation triggers the triangle. Then:

• Thoughts arise in response to the situation
• Emotions arise from thoughts
• Behaviour—the individual’s response to the situation—arises from emotions

CBT recognizes that emotions also affect thoughts, and that behaviour triggers thoughts and emotions. A basic CBT worksheet can help to illustrate this.

The bottom line is that, by changing their thoughts, an individual can change how they feel and behave.

The Five Aspects Model

The Five Aspects Model (sometimes “Five Areas Model”) elaborates upon—and complements—the cognitive triangle.

It organizes an individual’s life and experiences into five aspects or areas that mutually influence one another:

1. Situations: Life events.
2. Thoughts: Interpretations or meanings attached to situations.
3. Emotions: Responses to situations triggered by thoughts.
4. Physical sensations: The effect of emotions as they are felt in the body.
5. Behaviours: Actions, often based on coping strategies, that emerge from situations, thoughts, emotions, and physical sensations. 

Three levels of cognition in CBT

CBT divides thought into three levels of cognition. As with the points of the CBT triangle, these thoughts feed into each other while also mutually reinforcing one another.

• Automatic thoughts: Knee-jerk mental reactions to situations.‍
• ‍‍Example: A person is walking down the street. They walk past a friend, but the friend doesn’t acknowledge them. The person’s automatic thought is, “They don’t want to be my friend after all.”
• Intermediate thoughts: Assumptions and expectations about ourselves, our relationships, and the world. These can form rules and guidelines to follow.‍
• Example: “I should avoid making friends because friends always turn on me.”
• Core beliefs: Deep-seated perceptions of the self. These usually have an absolute quality, and define a person as they see themselves.‍
• Example: “I can’t have friends.”

Using CBT methods, a therapist will help their client recognize thoughts at each of these three levels of cognition, see how they feed into one another, and help their client change them.

For instance:

“They don’t want to be my friend after all.” → “They must be distracted or busy.”

“I should avoid making friends because friends always turn on me.” → “Even if my friends sometimes act differently than I would like, their friendship is valuable.”

“I can’t have friends.” → “I have friends.”

Exposure therapy

When a therapist uses CBT to treat their client’s anxiety, phobias, obsessive compulsive disorder (OCD), or post-traumatic stress disorder (PTSD), they may employ exposure therapy.

Individuals often avoid situations that trigger strong negative thoughts and emotions. This avoidance offers short-term relief, but in the long run it makes fear of the situation stronger.

With exposure therapy, the client is gradually exposed to difficult situations. This helps to counteract and undo the fear built up by avoidance. It also gives them the chance to put to work some of the reframed thought patterns they develop in therapy.

Exposure therapy may take the form of:

• Imaginal exposure: Imagining the situation vividly.
• Interoceptive exposure: Undergoing negative physical sensations resulting from the situation.
• Virtual reality exposure: Using simulations to act out the situation.
• In vivo exposure: Putting themselves in the actual feared situation.

Example: A CBT therapist’s client has a career where they are often required to make presentations to an audience, but they have severe anxiety about public speaking.

• Imaginal: The therapist talks their client through a closed-eye visualization of standing up in front of an audience and making the presentation.
• Interoceptive: Because the client often feels dizziness as a symptom of their anxiety, and this sensation triggers more anxiety, they practice spinning in an office chair.
• Virtual reality: The client wears a VR headset and completes a presentation in front of a simulated audience.
• In vivo: The client makes a presentation in front of a group of people in a non-professional setting.

CBT worksheets and workbooks

CBT therapy often involves “homework.” Numerous worksheets and workbooks have been developed for therapy clients to take home and complete by themselves. 

Worksheets usually match with different stages in the course of CBT treatment. They’re designed to encourage clients’ self-reflection and awareness, allow them to practice skills learned in therapy, and help provide structure and accountability.

A workbook may encompass a full course of CBT treatment, and include pages for journaling, recording progress, and setting therapy goals. Workbooks designed for self-directed treatment—without direct input from a therapist—also include instructional material.

Both worksheets and workbooks help a client to “be their own therapist”—to develop practices and skills that they can use outside of therapy to manage and direct their lives.

How long does CBT take?

A typical course of CBT lasts 12 to 16 weeks, with one 50-minute therapy session per week, plus take-home work. At their discretion, a therapist may recommend extending this period. 

Why your doctor may recommend CBT

If you go to a medical doctor for a referral to a therapist, they may encourage or instruct you to work with a therapist experienced in CBT.

That’s because, more than any other modality or therapeutic framework, CBT is supported by decades of research. It has a documented history of proven effectiveness, and has found widespread support outside of the therapeutic community.

However, the fact that a doctor recommends CBT doesn’t guarantee it will be the most effective treatment for you. A therapist may determine that you would benefit from a different course of treatment, or that CBT should be supplemented by other forms of therapy.

When looking for a therapist in Canada, it’s best to find one whose background and approach fit your needs. You should feel comfortable building a strong therapeutic alliance with your therapist and working with them to set goals and choose a course of treatment.

Why CBT might not be right for you

While CBT has been effective in treating a wide range of conditions and helped many people, that doesn’t necessarily mean it’s the right fit for you.

A few of the reasons therapy clients quit CBT, or choose therapy under a different modality, include:

• The amount of take-home work, which some people find difficult to complete (this can be exacerbated by conditions like ADHD)
• The rigid structure of CBT, with its planned progression through different stages, which may not fit what you are looking for in a therapy experience
• Inadequate attention to past trauma—treatment may come to a standstill if you need to account for suppressed memories, or memories that trigger a trauma response

Also, there are some conditions that CBT has simply proven ineffective at treating. For instance, for people with borderline personality disorder (BPD), an offshoot of CBT—DBT, covered below—is more likely to be successful.

Other alternatives to CBT include:

• ACT
• Eye motion detection and reprogramming (EMDR)
• Dialectical Behavior Therapy (DBT)
• Internal family systems (IFS)
• Somatic experiencing (SE)
• Schema therapy
• Compassion-focused therapy (CFS)
• Person-centred therapy (PCT)
• Cognitive processing therapy (CPT)
• Emotion-focused therapy (EFT)
• Narrative therapy
• Interpersonal therapy (IPT)

What is the difference between CBT and DBT?

Dialectical behaviour therapy (DBT) grew out of CBT as a means of treating individuals with BPD and those who struggle with self-harm and suicidal ideation.

While CBT does not have a proven track record of treating these conditions, DBT has shown to be effective. For that reason, psychologists and psychiatrists diagnosing clients with BPD are most likely to recommend DBT for treatment.

DBT is not designed to treat the wide range of conditions CBT is often used to address. In fact, it was developed in order to treat patients who did not respond to CBT. 

The clinician and researcher Dr. Marsha Linehan discovered, early in her clinical work in the ‘70s and ‘80s, that people with extreme emotional sensitivity, patterns of impulsive behaviour, and profound feelings of invalidation saw little improvement using CBT methods. In response, she developed DBT.

Broadly, DBT aims to help with the development of mindfulness, stress tolerance, and emotional regulation. It also puts emphasis on developing interpersonal effectiveness (building healthy relationships while maintaining self-respect). The term “dialectical” refers to the need to balance two opposing forces—change and acceptance.

DBT does not focus on reconfiguring or reframing the client’s perceptions of themselves and the world in the same way that CBT does. Instead, the focus is on developing coping mechanisms, partly with the help of exposure therapy and interpersonal exercises.

A course of DBT typically lasts six months or more. Each week, the client completes one session of one-on-one therapy and one session of group therapy. These group therapy sessions help them practice and develop interpersonal effectiveness.

While some clients may undergo both CBT and DBT treatment at the same time—the modalities can complement one another—they are two distinct forms of treatment.

What conditions does CBT help treat?

Therapists often recommend:

• CBT for anxiety
• CBT for depression 
• CBT for insomnia (CBT-i)
• CBT for eating disorders
• CBT for substance abuse
• CBT for ADHD
• CBT for obsessive compulsive disorder (OCD)

CBT can also benefit those with chronic pain conditions, including fibromyalgia, chronic fatigue, irritable bowel syndrome, and migraines. It may also be used by individuals with cancer, HIV, diabetes, and heart disease to help them manage the emotional impact of their illnesses.

Where can I access CBT in Canada?

You can access CBT through a physician-referred therapist or through a therapist you seek out yourself. First Session features an extensive, searchable directory of CBT therapists in Canada.

Or browse therapists for:

• CBT Toronto
• CBT Calgary
• CBT Vancouver
• CBT Ottawa
• CBT Montreal
• CBT Kelowna
• CBT Edmonton

How much does CBT cost in Canada?

Therapists providing CBT therapy charge their normal session rates. Therapy rates in Canada vary widely, according both to your location and to the certifications and experience level of therapist you see. For therapists other than psychologists and psychiatrists, the hourly session rate ranges from $100 to $200 per session.

How do I choose a CBT therapist?

The typical guidelines for how to find a therapist in Canada also apply to therapists offering CBT.

Because CBT is a popular and widely-used modality, virtually every therapist licensed to practice has some background and experience using it. A therapist offering a specialized form of CBT (eg. CBT-i, for insomnia) may note the fact on their First Session page.

Can CBT be done online?

As with other forms of talk therapy, you can do CBT remotely, via a telehealth platform, with a qualified therapist.

There are also numerous self-help books, workbooks, worksheets, and flashcards that you can use to supplement your CBT sessions with a therapist or use to administer CBT on your own. And some developers now offer apps designed to help you go through the process of CBT without the help of a therapist.

As always, working directly with a professional trained in CBT guarantees the best therapeutic outcome. However, if you decide to self-administer CBT, invest time researching the workbooks, apps, or other tools you use. Make sure that they were created with the input of a registered therapist, psychologist, or psychiatrist.

Is CBT covered by OHIP, MSP, Alberta health, or other provincial healthcare plans in Canada?

Therapy, including CBT, is only covered by public health insurance when it is provided on a doctor’s referral. It’s often very difficult to get CBT therapy covered under Canadian provincial Health care plans like OHIP or MSP. If you do get a doctor’s referral for CBT, you may have a hard time finding a therapist who is fully funded.

That being said, if you have private health insurance, it will specify which designations or licenses a therapist needs to have in order to be covered, as well as to what extent out-of-network treatment is covered by the plan. In most cases, insurance plans do not specify CBT therapy as a specific treatment that is covered. Rather, your coverage depends on your therapist’s designation.

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Considering seeing a therapist for the first time? Check out How to Find a Therapist in Canada.