Cognitive behaviour therapy
Explains what Cognitive Behaviour Therapy (CBT) is, what it is for, what happens during therapy and how to find a therapist.
How it works
What is cognitive behaviour therapy?
Cognitive Behaviour Therapy (CBT) is a form of talking therapy that combines cognitive therapy and behaviour therapy. It focuses on how you think about the things going on in your life – your thoughts, images, beliefs and attitudes (your cognitive processes) – and how this impacts on the way you behave and deal with emotional problems. It then looks at how you can change any negative patterns of thinking or behaviour that may be causing you difficulties. In turn, this can change the way you feel.
CBT tends to be short, taking six weeks to six months. You will usually attend a session once a week, each session lasting either 50 minutes or an hour. Together with the therapist you will explore what your problems are and develop a plan for tackling them. You will learn a set of principles that you can apply whenever you need to. You may find them useful long after you have left therapy.
CBT may focus on what is going on in the present rather than the past. However, the therapy may also look at your past and how your past experiences impact on how you interpret the world now.
CBT and negative thoughts
CBT theory suggests that it isn't events themselves that upset you, but the meanings you give to them. Your thoughts can block you seeing things that don't fit in with what you believe to be true. You may continue to hold on to these thoughts and not learn anything new.
For example, if you feel low or depressed, you may think, "I can't face going into work today. I can't do it. Nothing will go right." As a result of these thoughts – and of believing them – you may call in sick.
By doing this you are likely to continue to feel low and depressed. If you stay at home, worrying about not going in, you may end up thinking: "I've let everyone down. They will be angry with me. Why can't I do what everyone else does?" Consequently, you may judge yourself as being a failure and give yourself more negative feedback such as: "I'm so weak and useless."
You will probably end up feeling worse, and have even more difficulty going to work the next day. Thinking, behaving and feeling like this may start a downward spiral. It may be part of an automatic negative way of thinking.
By continuing to think and behave in this way, you won't have the chance to find out that your thinking and prediction may be wrong. Instead, the way you think and act can lead you to be more convinced that what you are thinking is true. In CBT, you will learn to recognise how you think, behave and feel. You will then be encouraged to check out other ways of thinking and behaving that may be more useful.
How does negative thinking start?
Negative thinking patterns can start in childhood, and become automatic and relatively fixed. For example, if you didn't get much open affection from your parents but were praised for doing well in school, you might think: "I must always do well. If I do well, people will like me; if don't, people will reject me." If you have thoughts like these, this can work well for you a lot of the time; for example, it can help you to work hard and do well at your job. But if something happens that's beyond your control and you experience failure, then this way of thinking may also give you thoughts like: "If I fail, people will reject me." You may then begin to have 'automatic' thoughts like, "I've completely failed. No one will like me. I can't face them."
CBT can help you understand that this is what's going on and can help you to step outside of your automatic thoughts so you can test them out. For example, if you explain to your CBT therapist that you sometimes call in sick because you feel depressed, the therapist will encourage you to examine this experience to see what happens to you, or to others, in similar situations. You may agree to set up an experiment where you will agree to go to work one day when you feel depressed and would rather stay at home. If you go to work, you may discover that your predictions were wrong. In the light of this new experience, you may feel able to take the chance of testing out other automatic thoughts and predictions you make. You may also find it easier to trust your friends, colleagues or family.
Some of the work we did involved looking at the way I interacted with people, e.g. if somebody had seemed to reject me, I’d write a list of all the reasons against why the way I was thinking might be incorrect. This helped me see things from the other person’s perspective, and realise I might be wrong in my assumptions.
Of course, negative things can and do happen. But when you feel depressed or anxious, you may base your predictions and interpretations on a 'faulty' view of the situation. This can make any difficulty you face seem much worse. CBT helps you to understand that if things go wrong or you make a mistake, this does not mean that you are a failure or that others will see you as a failure.
What it helps with
What type of problems can CBT help with?
CBT can be an effective therapy for a number of problems:
- anger management
- anxiety and panic attacks
- chronic fatigue syndrome
- chronic pain
- drug or alcohol problems
- eating problems
- general health problems
- habits, such as facial tics
- mood swings
- obsessive-compulsive disorder (OCD)
- post-traumatic stress disorder
- sexual and relationship problems
- sleep problems.
CBT does not claim to be able to cure all of the problems listed. For example, it does not claim to be able to cure chronic pain or disorders such as chronic fatigue syndrome. Rather, CBT might help someone with arthritis or chronic fatigue syndrome, to find new ways of coping while living with those disorders.
There is also a new and rapidly growing interest in using CBT (together with medication) with people who suffer from hallucinations and delusions, and those with long-term problems in relating to others.
It's less easy to solve problems that are severely disabling and long-standing through short-term therapy. But you can still learn principles that improve your quality of life and increase your chances of making further progress.
Experts know quite a lot about how they can help people who have relatively clear-cut problems, eg if you know your problem is a fear of spiders. They know much less about how the average person may do – somebody, perhaps, who has a number of problems that are less clearly defined. Sometimes, therapy may have to go on longer to do justice to the number of problems and to the length of time they've been around.
CBT may be less suitable if you feel generally unhappy or unfulfilled but don't have troubling symptoms or a particular aspect of your life you want to work on.
What happens in a CBT session?
CBT sessions have a structure. At the beginning of the therapy, you will meet with the therapist to describe specific problems and to set goals you want to work towards.
When you have agreed what problems you want to focus on and what your goals are, you start planning the content of sessions and discuss how to deal with your problems. Typically, at the beginning of a session, you and the therapist will jointly decide on the main topics you want to work on that week. You will also be given time to discuss the conclusions from the previous session. With CBT you are also given homework, and you will look at the progress made with the homework you were set last time. At the end of the session, you will plan another homework assignment to do outside the sessions.
The importance of structure
This structure helps to use the therapeutic time efficiently. It also makes sure that important information isn't missed out (the results of the homework, for instance) and that both you and the therapist have a chance to think about new assignments that naturally follow on from the session.
To begin with, the therapist takes an active part in structuring the sessions. As you make progress and grasp the ideas you find helpful, you will take more and more responsibility for the content of the sessions. By the end, you should feel able to continue working on your own.
Learning coping skills
CBT teaches skills for dealing with different problems. For example:
- If you feel anxious, you may learn that avoiding situations actually increases fears. Confronting fears in a gradual and manageable way can give you faith in your own ability to cope.
- If you feel depressed, you may be encouraged to record your thoughts and explore how you can look at them more realistically. This helps to break the downward spiral of your mood.
- If you have long-standing problems in relating to other people, you may learn to check out your assumptions about other people's motivation for doing things, rather than always assuming the worst.
The client-therapist relationship
CBT favours an equal relationship. It is focused and practical. One-to-one CBT can bring you into a kind of relationship you may not have had before. The 'collaborative' style means that you are actively involved in the therapy. The therapist seeks your views and reactions, which then shape the way the therapy progresses. The therapist will not judge you. This may help you feel able to open up and talk about very personal matters. You will learn to make decisions in an adult way, as issues are opened up and explained. Some people will value this experience as the most important aspect of therapy.
CBT is usually a one-to-one therapy. But you may also be offered group sessions. You may find it helpful to share your difficulties with others who have similar problems, even though this may seem difficult at first. The group can also be a source of valuable support and advice, because it comes from people with personal experience of a problem.
How effective is CBT?
Clinical trials have shown that CBT can reduce the symptoms of many emotional disorders. For some people it can work just as well as drug therapies at treating depression and anxiety disorders. The National Institute for Health and Clinical Excellence (NICE) recommends CBT via the NHS for common mental disorders, such as depression and anxiety.
Comparisons with other types of short-term psychological therapy aren't clear-cut. Other therapies, e.g. inter-personal therapy and social skills training, are also effective. The challenge is to make all talking therapies as effective as possible, and also, perhaps, to establish who responds best to which type of therapy.
I attribute the success of CBT to the skills of my therapist; my starting therapy at a time when I was motivated to change; a structured programme tailored to my individual needs; and my determination.
Is it for me
Is CBT for me?
CBT is more likely to be helpful to you if can relate to its ideas around thought and behaviour patterns, its problem-solving approach and the need for homework. People tend to prefer CBT if they want a more practical treatment – where gaining insight isn't the main aim.
The importance of doing homework
The sessions provide invaluable support. But most of the life-changing work takes place between sessions.
You are most likely to benefit from CBT if you are willing to do assignments at home.
For example, if you experience depression you may feel that you are not able to take on social or work activities until you feel better. CBT may introduce you to an alternative viewpoint – that trying some activity of this kind, however small-scale to begin with, will help you feel better. If you are open to testing this out, you could agree to do a homework assignment, say to go to the cinema with a friend.
You may make faster progress, as a result, than someone who feels unable to take this risk.
Making a decision
If you are referred for a treatment through the NHS, you will usually be assessed before you are allocated a treatment or a therapist. The assessor will check out what your problems are, and can then decide with you if CBT is likely to be helpful for you.
If you choose to see a therapist privately, many will offer a free consultation, so you get a chance to discuss directly with the therapist what you want help with. You can then decide if you feel this therapy might be right for you.
Don't be afraid to ask questions during the assessment. It will be helpful for both you and the therapist if you raise any concerns before therapy starts.
Finding a therapist
How can I find a CBT therapist?
You can get CBT on the NHS in several places. The NHS provision of CBT is developing fast under the government funded programme 'Improved Access to Psychological Therapies' (IAPT). However, in some areas the service is still patchy. In addition to the services offered via IAPT, some counsellors and psychologists offer CBT under the NHS, for example at GP surgeries. Some nurses, doctors, occupational therapists and clinical psychologists working in community mental health teams can also provide CBT. Some NHS Trusts will have specialist therapy services.
Your GP may be in the best position to give you information about local services. There is no legal requirement for therapists to register and be approved, but the British Association of Behavioural and Cognitive Therapy (BABCP) has a register of its members. Therapists on the register have to present detailed information on their CBT training and experience, supported by a qualified practitioner. They have to agree to conditions of ethical practice, including supervision and continuing professional education. A copy of this register can be obtained from the BABCP.
CBT via computer
Can I learn CBT techniques by myself?
Since CBT has a highly educational component, the therapist will often suggest that you read through relevant material between sessions – there is a large selection of self-help books available. Some people find this helpful. How useful it is will depend on how severe your problem is and how long it's been going on. There are some interactive CD-ROMs and online programmes, e.g. Beating the Blues and MoodGYM which can help with depression; and FireFighter for panic, anxiety and phobias.
MoodGYM is available from the web and is free to use. If you want to use Beating the Blues or FireFighter, you will need a referral from your GP or other service-providers. Some people may prefer them to seeing a therapist, particularly as a first step. They can help with creating useful activities and monitor your progress with graphs, which may be encouraging.
Association for Cognitive Analytic Therapy
tel. 0844 800 9496
Information and help in finding private or NHS therapists.
Association for Rational Emotive Behaviour Therapy
Has a register of therapists and counsellors.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 705 4304
Details of accredited therapists.
The British Psychological Society
tel. 0116 254 9568
Publishes a directory of chartered psychologists across the UK – some may practise CBT.
British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300
Online search facility for accredited counsellors and psychotherapists in the UK.
Useful and free self help material, including on CBT.
The International Association for Cognitive Psychotherapy
Oxford Cognitive Therapy Centre
tel. 01865 738 816
Aims to provide cognitive therapy training and other resources to NHS and other professionals, voluntary organisations, and clients.
A website where you can learn CBT and get help to learn how to deal with depression. It is free to use.
National Institute for Health and Clinical Excellence
Reports and guidelines on various mental disorders and treatments.
United Kingdom Council for Psychotherapy (UKCP)
tel. 020 7014 9955
Regional lists of psychotherapists are available free.
To be revised 2014
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