What is Cognitive Behavioural Therapy (CBT)?

Cognitive Behavioural Therapy (CBT) is an approach to help people who experience a wide range of mental health difficulties. The basis of CBT is that what people think affects how they feel emotionally and also alters what they do.

During times of mental distress the way someone perceives people and situations becomes distorted. This can make them feel worse and cause them to act in ways that keep their distress going.

CBT practitioners aim to work jointly with the person to help them begin to identify and then change their extreme thinking and unhelpful behaviour. By doing this, the result is a significant improvement in how the person feels and lives their day to day life.

Further explanation of the principles lying behind CBT can be found at the end of this document ('The importance of negative thinking', 'Learning coping skills', and 'Changing patterns of behaviour and deeper beliefs').

Advantages of CBT

It is based on common sense and easy to use principles, such as the importance of how a person thinks and acts in overcoming emotional or behavioural problems.
Its effectiveness has been confirmed in large numbers of studies comparing CBT with other treatments, such as antidepressants.
It provides clients with tools, skills and principles to tackle their problems, which they can continue to use after therapy has ended.
The National Institute for Health and Clinical Excellence (NICE) consistently recommends CBT as the most effective treatment in all its guidelines for treatment of emotional disorders.
For this reason, CBT has been chosen as the therapy of choice in the new government-funded IAPT programme, which aims to improve patients' access to psychological therapies.
CBT tends to be short-term or medium-term, taking three to six months for most emotional problems.
It is collaborative - in the sessions the client and therapist are working together to understand what the problems are and to develop a new strategy for tackling them.
In CBT there is an equal relationship between client and therapist. The therapist seeks the client's views and reactions, which then shape the way the therapy progresses. There is little danger of the client becoming dependant on the therapist, as the aim is to enable the client to become their own therapist.
CBT focuses on what is going on in the present rather than the past, as its aim is to enable clients to manage their urgent emotional problems. However, CBT does not ignore the past, but takes proper account of how our key experiences have shaped our deeper beliefs and patterns of behaviour.

What happens in the sessions

Clients attend one session a week, usually lasting 50 or 60 minutes. Rather than the client simply talking about whatever comes to mind, each session has a structure. At the beginning of the therapy, the client describes his or her specific problems and sets the goals they want to work towards. These problems and goals then become the basis for planning the content of sessions and discussing how to deal with them.

So at the beginning of a session, the client and therapist will jointly decide on the main topics they want to work on that week. These topics will build on three things - any learning from the previous session, the 'homework' set at the end of that session (see below) and the client's experiences in the week. At the end of the session, they will plan another assignment to do outside the sessions.

The therapist takes an active part in structuring the sessions to begin with. As progress is made, and the client grasps the principles they find helpful, they take more and more responsibility for the content of sessions. So by the end, the client feels empowered to continue working independently.

Doing homework

A homework assignment will be jointly agreed on at the end of each session. This may involve recording specific thoughts or triggers for emotional difficulties in the week. Or it may require carrying out a carefully discussed experiment to test a new way of acting in certain situations.

Working on homework assignments between sessions is a vital part of the process. It allows the client to put into practice, or to try out, the learning from the session. It also moves the therapy on efficiently by not restricting it to the 50 minute weekly sessions.

People who are willing to do assignments at home seem to get the most benefit from CBT. For example, many people with depression say they don't want to take on social or work activities until they are feeling better. CBT may introduce them to an alternative viewpoint - that trying some activity of this kind, however small-scale to begin with, will help them feel better.

What kind of problems can CBT help with?

People who describe having particular problems are often the most suitable for CBT, because it works through having a specific focus and goals. It may be less suitable for someone who feels vaguely unhappy or unfulfilled, but who doesn't have troubling symptoms or a particular aspect of their life they want to work on.

CBT can be an effective therapy for a number of problems:

anger management
anxiety and panic attacks
depression
drug or alcohol problems
eating problems
habits, such as facial tics
hyperchondriasis (health anxiety)
mood swings
obsessive-compulsive disorder
phobias
post-traumatic stress disorder
self-esteem
sexual and relationship problems
social anxiety
worry

How effective is CBT?

CBT can substantially reduce the symptoms of many emotional disorders. Clinical trials have shown this. For some people it can work just as well as drug therapies at treating depression and anxiety disorders. And the benefits may last longer. All too often, when drug treatments finish, people relapse, and so practitioners may advise patients to continue using medication for longer.

When patients are followed up for up to two years after therapy has ended, many studies have shown an advantage for CBT. This research suggests that CBT helps bring about a real change that goes beyond just feeling better while the patient stays in therapy. The National Institute for Health and Clinical Excellence (NICE) recommends CBT via the NHS for common mental disorders, such as depression and anxiety.

Identifying negative thinking

CBT places a great importance on our thinking skills. It is a basic psychological fact that it is our thoughts that predominantly cause our feelings. When a person is feeling upset in some way, their thoughts are usually negative, unrealistic and unhelpful. Some of the most important thoughts are 'automatic' - we aren't fully aware of them. Learning to identify and challenge these thoughts is the key to us understanding and overcoming our difficulties.

For example, a depressed woman may think, 'I can't face going into work today: I can't do it. Nothing will go right. I'll feel awful.' As a result of having these thoughts - and of believing them - she may ring in sick. By behaving like this, she won't have the chance to find out that her prediction was wrong. She might have found some things she could do, and at least some things that were OK. But if she stays at home, brooding about her failure to go in, she may end up thinking: 'I've let everyone down. They will be angry with me. Why can't I do what everyone else does? I'm so weak and useless.' She will probably end up feeling worse, and have even more difficulty going in to work the next day. Thinking, behaving and feeling like this may start a downward spiral. This vicious circle can apply to many different kinds of problems.

Often these thinking patterns are set up in childhood, and become automatic and relatively fixed. For example, a child who got little open affection from their parents but was praised for achievement such as school work, might come to think, 'I have to do well all the time. If I don't, people will reject me'. Such a rule for living (known as a 'dysfunctional assumption') may work well for the person a lot of the time and help them to achieve high standards.

But if something happens that's beyond their control and they experience failure, then the dysfunctional thought pattern may be triggered. The person may then begin to have 'automatic' thoughts such as, 'I've completely failed. No one will like me. I can't cope.’

CBT acts to help the person understand that this is what's going on. It helps him or her to step outside their automatic thoughts and test them out. Clearly, negative things can and do happen. But when we are in a disturbed state of mind, we may be basing our predictions and interpretations on a biased view of the situation, making the difficulty that we face seem much worse. CBT helps people to correct these misinterpretations.

Learning coping skills

CBT teaches people skills for dealing with their problems. Some of these problems may be of very long-standing - clients may be 'stuck' in a cycle that they think they cannot break themselves. For example:

Someone with anxiety may learn that avoiding situations actually increases their fears. Confronting fears in a gradual and manageable way, after discussion with their therapist, helps give the person faith in their own ability to cope.
Someone who is depressed may learn to notice their thoughts in order to think in a more realistic and helpful way. This helps them to break the downward spiral of their mood.
Someone with long-standing problems in relating to other people may learn to check out their assumptions about other people's motivation, rather than always assuming the worst.
'Mindfulness' approaches will help anyone take a more objective view of their worrying or insistent thoughts, and allow them to respond in a more grounded and less reactive way.

Changing patterns of behaviour and deeper beliefs

Often these new coping skills lead to more lasting changes to basic attitudes and ways of behaving. For example:

The anxious client may learn to stop avoiding things. He or she may also find that anxiety is not as dangerous as they assumed. They may discover that just because their mother or father acted in an extremely anxious way doesn’t mean they are doomed to repeat this behaviour.
Someone who's depressed may come to see themselves as an ordinary member of the human race, rather than inferior and fatally flawed. They may come to have a different attitude to their thoughts - that thoughts are just mental events, not ‘facts’.
Someone who is angry may realise that their anger is actually a 'cover' for some difficult feelings, for example fear of criticism or fear of rejection. Changing their angry responses requires identifying and challenging these basic beliefs about themselves and the world.

Case study

Greg had suffered disabling bouts of depression on several occasions in his life, which caused him to make several career changes. He twice tried to commit suicide. He also suffered from a great deal of anxiety and stress, had some drink problems and found it difficult to control his temper, especially when drinking.

Greg was referred for CBT after a typical episode was triggered by stress at work. At his first meeting with his therapist, Greg already knew what he wanted to work on. He had a great sense of failure over his history of depression and what he called his lack of success in his career ('I've really messed up'). He was anxious about his job prospects. He felt unattractive and was worried about ageing and about further losing his physical appeal. He felt his angry impulses were in danger of getting out of control.

In therapy, Greg learned to monitor his actions and his emotional responses. He began to plan activities that gave him a boost and to deal with situations that he had avoided through fear. He learned to identify when he was being extreme or biased in his thinking. He became good at examining his emotion-driven thoughts and reasoning them out so that he got things into proper perspective.

His mood noticeably improved, and he began to tackle longer standing problems. He began looking at job prospects, by planning a more realistic choice of career, and sending in applications. He established a more equal relationship with his partner. He dealt with social situations, without demanding attention and special treatment from friends. Greg had to face up to problems that were difficult to deal with, such as his perfectionism and the unreasonable demands he made on other people. But he was highly motivated by the crisis in his life to find alternatives.

This is what Greg wrote towards the end of his therapy:

I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family.

CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis.

The work has moved on to look at deeper beliefs, which can dominate one's life and cause loads of problems. For example, I have found that I have a strong entitlement belief [a belief that he is entitled to expect certain things from other people]. This is characterised by low frustration tolerance, anger, and inability to control impulses or be told what to do. It has been a revelation to look back on one's life and see how this pattern has dominated a lot of what I have done.

CBT has given me a feeling of being more in control of my life. I am now coming off medication and, with the support of my therapist and partner, I am learning new ways of being in the world. The challenge remains to change these thoughts and behaviours. It will not happen overnight.

Kim Richardson - working for clients in Stroud, Gloucester, Cheltenham and across Gloucestershire