Cognitive Behavioral Therapy (CBT) for Breast Cancer

It's understandable if a cancer diagnosis or treatments have you feeling sad and scared. Some of these feelings may pass with time, but others can linger, making everyday life hard. 

A type of talk therapy called cognitive behavioral therapy (CBT) may be able to help.

Researchers from Michigan and Texas recently analyzed the findings of 130 clinical trials involving people with cancer who received CBT. The results show that many people with cancer who receive CBT (either in-person, virtually, or a combination of both) experienced improvements in mental health and quality of life. These findings were published in the journal Cancer Medicine.

Through regular sessions with a trained therapist, cognitive behavioral therapy helps you to identify unhelpful thoughts and behaviors that are making you feel down or worried. Then you work together to change those thinking patterns and behaviors. 

For people who have been diagnosed with cancer, Anao Zhang, MSW, PhD, says he helps them pinpoint their core assumptions about themselves and about their cancer and then tweak their day-to-day automatic thinking about them. Zhang led the Cancer Medicine study and is a social worker and clinical director at the University of Michigan Health Adolescent and Young Adult Oncology Program in Ann Arbor. 

Based on his experience as a social worker, Zhang says CBT can be most effective for people who are looking for ways to cope with short- and long-term side effects of cancer treatment. 

A cognitive behavioral therapy session typically lasts 40 to 50 minutes. It can be done in person, on the phone, or virtually. It can also occur in a group setting.

CBT begins by talking with a trained therapist about the challenges you’re experiencing in your life and your goals for therapy. You and your therapist will look at how your thoughts — including thoughts you might not even notice (also called automatic thoughts) — and actions may be playing a role in these problems. In between sessions, you’ll be asked to pay attention to your feelings and practice new approaches to your problems using the techniques you learn.  

At each session, the therapist will start by checking in about how things are going and then discuss what you want to work on. During most of the session, you and the therapist might work on one or two issues.

There are a lot of techniques that can be used in CBT, from mindfulness exercises to journaling to role playing. One approach a therapist might use is called downward arrow technique. It helps you identify and challenge deeply held beliefs that are bothering you, Zhang says.

Steps in downward arrow might include

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  The therapist asks you to describe an automatic thought. For example, “What if the cancer comes back?”

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  Then the therapist encourages you to ask yourself questions about why that thought is upsetting. For example, “If the cancer returns, what would that mean?”

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  You and the therapist might work together to elicit deeper beliefs, including core beliefs. Core beliefs are firmly rooted ideas about oneself, others, and the world. For example, If the cancer returns, it means I’ve failed and I’ll always be sick.

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  Then you might discuss how to develop a more balanced view to challenge those core beliefs that you’ve failed and you’ll always be sick. The therapist might ask you to examine evidence to the contrary, such as past successes or times you’ve felt sick but healed.

In the final part of each individual session, the therapist might ask you how the session has been going. You might be asked to share feedback about what’s working and not working. Toward the end, the therapist might give an assignment about what to do before the next session.

“A lot of growth and learning happens between sessions,” Zhang says. “The session is a protected environment for the patient and client to explore what they’ve tried and what they’ve learned.”

Cognitive behavioral therapy may be able to help reduce symptoms of cancer and side effects from treatment.

As many as a third of people who’ve been diagnosed with breast cancer experience depression and more than 40% experience anxiety. A 2023 study of 60 clinical trials including almost 8,000 people found that after participating in CBT, women with breast cancer had lower levels of depression, anxiety, and stress than they had at the start of therapy. The clinical trials included many different kinds of interventions, and most were in-person and in groups. The study included only women with early-stage breast cancer, so it’s unclear if the same results would be found in women who had metastatic disease.

Insomnia from the stress of a breast cancer diagnosis or treatments can affect your mood, pain, and quality of life. Cognitive behavioral therapy for insomnia (sometimes called CBTI) is a type therapy that helps you identify and change behaviors to improve sleep. This could include creating calming bedtime rituals or reducing sleep-related concerns.

An analysis of 16 studies found that CBT was effective for people with insomnia who were diagnosed with cancer. The meta-analysis showed CBTI improved the percentage of time asleep in bed by 10%, increased total sleep time by 22 minutes, and reduced wake-ups after sleep onset by 24 minutes compared to not doing any therapy. However, most results had a moderate or low certainty of evidence, according to the authors.

The National Comprehensive Cancer Network, American College of Physicians, and American Academy of Sleep Medicine all recommend cognitive behavioral therapy as a first treatment for insomnia.

Hot flashes and night sweats are common side effects of breast cancer treatment that CBT can help manage. In a small study, women with breast cancer who received 6 weeks of CBT (self-guided or led by a therapist) had fewer problems with hot flashes and night sweats than the women who didn’t receive the therapy even months after CBT stopped. 

Zhang says cognitive behavioral therapy can also help to reduce nausea and fatigue. The American Society of Clinical Oncology (ASCO) in May 2024 updated its guideline for managing cancer-related fatigue to include CBT. 

A small study published in 2017 found that people who had breast, prostate, or colorectal cancer who received CBT had less fear of recurrence than those who did not have CBT.  

Social workers, psychologists, psychiatrists, and licensed professional counselors can all be certified to practice cognitive behavioral therapy. It can take time to find a therapist who is covered by your insurance, practices CBT, and -- importantly -- who you get along with, so there is some work to do up front before getting started. 

To get started, ask your healthcare team to recommend someone. You can also ask your family, friends, or others you know who’ve faced a cancer diagnosis about therapists they’ve liked working with. Your health insurance company can help you get a sense of the costs of therapy and may be able to send you a list of mental health specialists that are in your network that provide in-person or virtual care.

Two organizations that offer training and certification in CBT also have searchable databases of therapists: The Academy of Cognitive and Behavioral Therapies and the Beck Institute. Other resources available to connect you with mental health providers include psychological associations in your state and cancer support help lines.