Cognitive Behavioural Therapy (CBT)
| What is CBT? | The treatment |
| An overview | Who can it help? |
| A vicious circle | Effectiveness |
| The History of CBT | Suitability |
| How does it work? | Useful contacts |
| Negative thoughts | See also |
- How you think about yourself, the world and other people
- How what you do affects your thoughts and feelings.
It has been found to be helpful in:
- Anxiety
- Depression
- Panic
- Agoraphobia and other phobias
- Social phobia
- Bulimia
- Obsessive compulsive disorder
- Post traumatic stress disorder
- Schizophrenia
CBT can help you to make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you. These parts are:
- A Situation - a problem, event or difficult situation
- From this can follow:
- Thoughts
- Emotions
- Physical feelings
- Actions
An example
There are helpful and unhelpful ways of reacting to most situations, depending on how you think about them:
Situation: You've had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you.
Unhelpful thoughts: He/she ignored me - they don't like me
Helpful Thoughts: He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?
Emotional:
Unhelpful Feelings: Low, sad and rejected
Helpful feelings: Concerned for the other person
Physical:
Unhelpful: Stomach cramps, low energy, feel sick
Helpful: None - feel comfortable
Action:
Unhelpful: Go home and avoid them
Helpful: Get in touch to make sure they're OK
The same situation has led to two very different results, depending on how you thought about the situation. How you think has affected how you felt and what you did.
In the example in the left hand column, you've jumped to a conclusion without very much evidence for it - and this matters, because it's led to:
- a number of uncomfortable feelings
- an unhelpful behaviour.
This is a simplified way of looking at what happens. The whole sequence, and parts of it, can also feedback like this:
CBT can help you to break this vicious circle of altered thinking, feelings and behaviour. When you see the parts of the sequence clearly, you can change them - and so change the way you feel. CBT aims to get you to a point where you can "do it yourself", and work out your own ways of tackling these problems.
"Five areas" Assessment
This is another way of connecting all the 5 areas mentioned above.
It builds in our relationships with other people and helps us to see how these can make us feel better or worse. Other issues such as debt, job and housing difficulties are also important. If you improve one area, you are likely to improve other parts of your life as well. "5 areas" diagram.
What does CBT involve?
The sessions
CBT can be done individually or with a group of people. It can also be done from a self-help book or computer programme. If you have individual therapy:
You will usually meet with a therapist for between 5 and 20, weekly, or fortnightly, sessions. Each session will last between 30 and 60 minutes.
In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and you will check that you feel comfortable with it.
The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.
You decide what you want to deal with in the short, medium and long term.
You and the therapist will usually start by agreeing on what to discuss that day.
The Work
With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you to identify your individual patterns of thoughts, emotions, bodily feelings and actions.
Together you will look at your thoughts, feelings and behaviours to work out:
- - if they are unrealistic or unhelpful
- - how they affect each other, and you.
It's easy to talk about doing something, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend "homework" - you practice these changes in your everyday life. Depending on the situation, you might start to:
- Question a self-critical or upsetting thought and replace it with a positive (and more realistic) one that you have developed in CBT
- recognise that you are about to do something that will make you feel worse and, instead, do something more helpful.
They will not ask you to do things you don't want to do - you decide the pace of the treatment and what you will and won't try. The strength of CBT is that you can continue to practice and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.
How effective is CBT?
- It is one of the most effective treatments for conditions where anxiety or depression is the main problem
- It is the most effective psychological treatment for moderate and severe depression
- It is as effective as antidepressants for many types of depression
CBT is used in many conditions, so it isn't possible to list them all in this leaflet. We will look at alternatives to the most common problems - anxiety and depression.
- CBT isn't for everyone and another type of talking treatment may work better for you.
- CBT is as effective as antidepressants for many forms of depression. It may be slightly more effective than antidepressants in treating anxiety.
- For severe depression, CBT should be used with antidepressant medication. When you are very low you may find it hard to change the way you think until antidepressants have started to make you feel better.
- Tranquillisers should not be used as a long term treatment for anxiety. CBT is a better option.
If you are feeling low and are having difficulty concentrating, it can be hard, at first, to get the hang of CBT - or, indeed, any psychotherapy
This may make you feel disappointed or overwhelmed. A good therapist will pace your sessions so you can cope with the work you are trying to do
It can sometimes be difficult to talk about feelings of depression, anxiety, shame or anger
How long will the treatment last?
A course may be from 6 weeks to 6 months. It will depend on the type of problem and how it is working for you. The availability of CBT varies between different areas and there may be a waiting list for treatment.
What if the symptoms come back?
- There is always a risk that the anxiety or depression will return.
- If they do, your CBT skills should make it easier for you to control them. So, it is important to keep practicing your CBT skills, even after you are feeling better.
- There is some research that suggests CBT may be better than antidepressants at preventing depression coming back. If necessary, you can have a "refresher" course.
Depression and anxiety are unpleasant. They can seriously affect your ability to work and enjoy life. CBT can help you to control the symptoms. It is unlikely to have a negative effect on your life, apart from the time you need to give up to do it.
What will happen if I don't have CBT?
You could discuss alternatives with your doctor. You could also:
- Read more about the treatment and its alternatives
- If you want to "try before you buy", get hold of a self-help book or CD-Rom and see if it makes sense to you
- Wait to see if you get better anyway - you can always ask for CBT later if you change your mind
- Williams C J. (2001). Overcoming Depression: A Five Areas
approach. London Hodder Arnold.
- Department of Health (2001). Treatment choice in psychological therapies and counselling. London: HMSO.
- NICE (2004). CG9 Eating disorders: Core interventions in
the treatment and management of anorexia nervosa, bulimia nervosa and
related eating disorders - NICE guideline January 2004
- NICE (2004). Anxiety: management of anxiety (panic
disorder, with or without agoraphobia, and generalised anxiety
disorder) in adults in primary, secondary and community care.
- NICE (2004) Depression: Management of depression in primary
and secondary care. NICE Guideline December 2004.
In the 1960s, a US psychiatrist and psychotherapist called Aaron T. Beck observed that, during his analytical sessions, his patients tended to have an 'internal dialogue' going on in their minds, almost as if they were talking to themselves. But they would only report a fraction of this kind of thinking to him.
For example, in a therapy session the client might be thinking to him- or herself: 'He (the therapist) hasn't said much today. I wonder if he's annoyed with me?' These thoughts might make the client feel slightly anxious or perhaps annoyed. He or she could then respond to this thought with a further thought: 'He's probably tired, or perhaps I haven't been talking about the most important things'. The second thought might change how the client was feeling.
Beck realised that the link between thoughts and feelings was very important. He invented the term 'automatic thoughts' to describe emotion-filled or 'hot' thoughts that might pop up in the mind. Beck found that people weren't always fully aware of such thoughts, but could learn to identify and report them. If a person was feeling upset in some way, the thoughts were usually negative and neither realistic nor helpful. Beck found that identifying these thoughts was the key to the client understanding and overcoming his or her difficulties.
Beck called it cognitive therapy because of the importance it places on thinking. It's now known as CBT because the therapy employs behavioural techniques as well. The balance between the cognitive and the behavioural elements varies among the different therapies of this type, but all come under the umbrella term cognitive behaviour therapy. CBT has since undergone successful scientific trials in many places by different teams, and has been applied to a wide variety of problems.
How does CBT work?
CBT is quite complex. There are several possible theories about how it works, and clients often have their own views. Perhaps there is no one explanation. But CBT probably works in a number of ways at the same time. Some it shares with other therapies, some are specific to CBT. The following illustrate the ways in which CBT can work.
Learning coping skills
CBT tries to teach people skills for dealing with their problems. Someone with anxiety may learn that avoiding situations helps to fan their fears. Confronting fears in a gradual and manageable way helps give the person faith in their own ability to cope. Someone who is depressed may learn to record their thoughts and look at them more realistically. 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.
Changing behaviours and beliefs
A new strategy for coping can lead to more lasting changes to basic attitudes and ways of behaving. The anxious client may learn to avoid avoiding things! He or she may also find that anxiety is not as dangerous as they assumed. Someone who’s depressed may come to see themselves as an ordinary member of the human race, rather than inferior and fatally flawed. Even more basically, they may come to have a different attitude to their thoughts – that thoughts are just thoughts, and nothing more.
A new form of relationship
One-to-one CBT brings the client into a kind of relationship they may not have had before. The 'collaborative' style means that they are actively involved in changing. The therapist seeks their views and reactions, which then shape the way the therapy progresses. The person may be able to reveal very personal matters, and to feel relieved, because no-one judges them. He or she arrives at decisions in an adult way, as issues are opened up and explained. Each individual is free to make his or her own way, without being directed. Some people will value this experience as the most important aspect of therapy.
Solving life problems
The methods of CBT may be useful because the client solves problems that may have been long-standing and stuck. Someone anxious may have been in a repetitive and boring job, lacking the confidence to change. A depressed person may have felt too inadequate to meet new people and improve their social life. Someone stuck in an unsatisfactory relationship may find new ways of resolving disputes. CBT may teach someone a new approach to dealing with problems that have their basis in an emotional disturbance.
What's so important about negative thoughts?
CBT is based on a 'model' or theory that it's not events themselves that upset us, but the meanings we give them. If our thoughts are too negative, it can block us seeing things or doing things that don't fit – that disconfirm – what we believe is true. In other words, we continue to hold on to the same old thoughts and fail to learn anything new.
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 well 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, instead, she stays at home, brooding about her failure to go in and ends 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.' So, that woman probably ends up feeling worse, and has 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.
How does this kind of problem start?
Beck suggested that these thinking patterns are set up in childhood, and become automatic and relatively fixed. So, a child who didn't get much open affection from their parents but was praised for 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 do well for the person a lot of the time and help them to work hard.
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 like, 'I've completely failed. No one will like me. I can't face them'.
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. CBT would encourage the depressed woman mentioned earlier to examine real-life experiences to see what happens to her, or to others, in similar situations. Then, in the light of a more realistic perspective, she may be able to take the chance of testing out what other people think, by revealing something of her difficulties to friends.
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.
What form does treatment take?
CBT differs from other therapies because sessions have a structure, rather than the person talking freely about whatever comes to mind. At the beginning of the therapy, the client meets the therapist to describe specific problems and to set goals they want to work towards. The problems may be troublesome symptoms, such as sleeping badly, not being able to socialise with friends, or difficulty concentrating on reading or work. Or they could be life problems, such as being unhappy at work, having trouble dealing with an adolescent child, or being in an unhappy marriage.
These problems and goals then become the basis for planning the content of sessions and discussing how to deal with them. Typically, at the beginning of a session, the client and therapist will jointly decide on the main topics they want to work on this week. They will also allow time for discussing the conclusions from the previous session. And they will look at the progress made with the 'homework' the client set for him- or herself last time. At the end of the session, they will plan another assignment to do outside the sessions.
Doing homework
Working on homework assignments between sessions, in this way, is a vital part of the process. What this may involve will vary. For example, at the start of the therapy, the therapist might ask the client to keep a diary of any incidents that provoke feelings of anxiety or depression, so that they can examine thoughts surrounding the incident. Later on in the therapy, another assignment might consist of exercises to cope with problem situations of a particular kind.
The importance of structure
The reason for having this structure is that it helps to use the therapeutic time most efficiently. It also makes sure that important information isn't missed out (the results of the homework, for instance) and that both therapist and client think about new assignments that naturally follow on from the session.
The therapist takes an active part in structuring the sessions to begin with. As progress is made, and clients grasp 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.
Group sessions
CBT is usually a one-to-one therapy. But it's also well suited to working in groups, or families, particularly at the beginning of therapy. Many people find great benefit from sharing their difficulties with others who may have similar problems, even though this may seem daunting at first. The group can also be a source of specially valuable support and advice, because it comes from people with personal experience of a problem. Also, by seeing several people at once, service-providers can offer help to more people at the same time, so people get help sooner.
What kind of people benefit?
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.
It's likely to be more helpful for anyone who can relate to CBT's ideas, its problem-solving approach and the need for practical self-assignments. People tend to prefer CBT if they want a more practical treatment, where gaining insight isn't the main aim.
CBT can be an effective therapy for the following problems:
- anger management
- anxiety and panic attacks
- child and adolescent problems
- chronic fatigue syndrome
- chronic pain
- depression
- drug or alcohol problems
- eating problems
- general health problems
- habits, such as facial tics
- mood swings
- obsessive-compulsive disorder
- phobias
- post-traumatic stress disorder
- sexual and relationship problems
- sleep problems
It's less easy to solve problems that are more severely disabling and more long-standing through short-term therapy. But people can often learn principles that improve their quality of life and increase their chances of making further progress. There is also a wide variety of self-help literature. It provides information about treatments for particular problems and ideas about what people can do on their own or with friends and family.
How effective is it?
CBT can substantially reduce the symptoms of many emotional disorders – clinical trials have shown this. In the short term, it's just as good 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 a marked advantage for CBT. For example, having just 12 sessions of CBT can be as helpful in tackling depression as taking medication throughout the two-year follow-up period. This research suggests that CBT helps bring about a real change that goes beyond just feeling better while the patient stays in therapy. This has fuelled interest in CBT.
Comparisons with other types of short-term psychological therapy aren't quite so clear-cut. Therapies such as inter-personal therapy and social skills training are also effective. The drive is now to make all these interventions as effective as possible, and also, perhaps, to establish who responds best to which type of therapy.
Limitations
CBT is not a miracle cure. The therapist needs to have considerable expertise – and the client must be prepared to be persistent, open and brave. Not everybody will benefit, at least not to full recovery, in a short space of time. It's unrealistic to expect too much.
At the moment, experts know quite a lot about people who have relatively clear-cut problems. 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. One fact is also clear, though. CBT is rapidly developing. All the time, new ideas are being researched to deal with the more difficult aspects of people’s problems.
Not surprisingly, most human problems have this vicious cycle as the basis of the difficulty. It is very important though, to remember that something very bad might have happened to start off the cycle, a very bad event, or something traumatic, and this too needs to be resolved, along with the negative thinking and everything that came afterwards. Try the cycle yourself on these problems to see if the cycle idea works:
Stress
- Being stressed out and wanting to run away or take something to feel better ·
- Being off work ' sick ' because you avoid going in ·
- Being irritable and impatient with everyone at work because you feel so overloaded ·
- Suffering nightmares, numbness and other symptoms of Post Trauma Stress Disorder because of one or more traumatic events ·
- Being trapped in the memory of psychological or physical abuse
- Being so socially anxious that hobbies or friends are unobtainable and work difficult ·
- Worrying and feeling anxious so often, that it dominates your whole life ·
- Panicking all the time, about going out for a meal or other social events that other people are happy to experience ·
- Being anxious about sex in a relationship so that it spoils your time together ·
- Feeling anxious about the future
- Being stuck and unable to change or move forward ·
- Not having any interests or goals ·
- Being unable to make and keep friends ·
- Feeling generally unhappy, and often or always dissatisfied with life ·
- Having overcome problems and being afraid that you will relapse ·
- Lacking confidence or having low ' self-esteem '
- Being aggressive openly or secretly because you cannot manage anger effectively ·
- Being angry towards everyone, including yourself ·
- Being violent and hurting those you love ·
- Being angry at work with clients or members of the public ·
- Feelings of resentment towards people with whom you would not usually experience such feelings
- Being anorexic and unable to face life, food or oneself without fear and anxiety ·
- Being bulimic and unable to face eating or emotional discomfort in life without sickness ·
- Comfort eating so much that it is unhealthy
- Having such low self-esteem that you let other people treat you badly - always ·
- Being unable to build an intimate, committed relationship with an adult companion when you would like to do so ·
- Being unable to love people and have friendships without sexual involvement ·
- Being unable to sustain a relationship when you are in it ·
- Being so bitter and angry about a bereavement or break up that you cannot move forward ·
- Getting intimately involved with the wrong people ·
- Lack of assertiveness in relationships, so you are walked on - a doormat ·
- Co-dependency in relationships ·
- Not being able to communicate with one another ·
- Not being able to be alone in life so you are always going from one relationship to another ·
- Being overly controlling towards your partner
- Procrastinating or ' putting things off ' so that you are behind in your work or study ·
- Poor time management ·
- Being chaotic and disorganised at work ·
- Lacking confidence so that you avoid projects or responsibility you think you could manage ·
- Being overly controlling or tending to be weak, as a manager
- Being so miserable that life seems pointless ·
- Thinking you are worthless ·
- Being on medication for depression but not getting better
What Cognitive Behaviour Therapy suggests is that however bad the problem, the rider of the horse - you - can take the reins - and you can manage and change the thinking, and learn to understand the emotions and behaviour that are part of the problem cycle - so that the problems are either resolved completely or managed so well that they do not get in the way of life and being happy. .
Why Have A CBT Therapist or Counsellor?
It is helpful, in these kinds of problems, to work with a skilled and well-trained CBT psychotherapist or counsellor. The most important reason is that when any of us is stuck, and feeling very bad about life, and ourselves, it can be impossible to see any way out. And a good CBT psychotherapist or counsellor is genuinely interested in the problems, will not judge you, and being human herself, has great empathy for your suffering. The therapist can understand and be merciful, when you are judging yourself and have condemned yourself. And, the therapist will be able to understand you particularly - how you tick - and teach you lots of ways to help yourself. You see, crazy as it seems, the aim of CBT is to help you become your own counsellor or therapist, so that you do not fall victim to the vicious cycle again!
Becoming Your Own Therapist And Teacher
Crazy as it seems, the aim of CBT is to help you become your own counsellor or therapist, so that you do not fall victim to the vicious cycle again!
Calipso website (www.calipso.co.uk)
Mood Gym: http://moodgym.anu.edu.au Information, quizzes, games and skills training to help prevent depression
Living Life to the Full: www.livinglifetothefull.com Free online life skills course for people feeling distressed and their carers. Helps you understand why you feels as you do and make changes in your thinking, activities, sleep and relationships.
Depression Alliance,
35 Westminster Bridge Road, London SE1 7JB
tel. 0845 123 2320, fax: 020 7633 0559
email: information@depressionalliance.org web: www.depressionalliance.org
Support and understanding to anyone affected by depression
National Phobics Society,
Zion Community Resource Centre
339 Stretford Road, Hulme, Manchester M15 4ZY
helpline: 0870 7700 456, fax: 0161 227 9862
email: nationalphobic@btconnect.com web: www.phobics-society.org.uk
A national registered charity run by sufferers and ex-sufferers of anxiety disorders. Provides support and help if you have been diagnosed with or suspect you may have an anxiety condition or specific phobias.
Mind
0845 766 0163
mind.org.uk
Royal College of Psychiatrists
020 7235 2351
rcpsych.ac.uk
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
01254 875277
babcp.com
UK Council for Psychotherapy (UKCP)
020 7436 3002
psychotherapy.org.uk
Association for Cognitive Analytic Therapy
3rd Floor, South Wing, Division of Academic Psychiatry, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH
tel. 020 7928 9292
web: www.acat.org.uk or www.acat.me.uk
Information about Cognitive Analytic Therapy, developed by Dr Anthony Ryle. Information and help in finding private or NHS therapists
Association for Rational Emotive Behaviour Therapy
PO Box 39207, London SE3 7XH
tel. 0114 271 8699, fax: 020 8293 1441
web: rebt.bizland.com
Maintains a register of professionally trained Rational Emotive Behaviour Therapists and Counsellors
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
The Globe Centre, PO Box 9, Accrington BB5 0XB
tel. 01254 875 277, fax: 01254 239 114
email: babcp@babcp.com web: www.babcp.com
Promotes the development of the theory and practice of behavioural and cognitive psychotherapies. Can provide details of accredited therapists. Full directory of psychotherapists available online
The British Psychological Society
St Andrews House, 48 Princess Road East, Leicester LE1 7DR
tel. 0116 254 9568, fax: 0116 247 0787
email: mail@bps.org.uk web: www.bps.org.uk
Publishes a directory of chartered psychologists across the UK, who may practice CBT. Available on the web and in public libraries
Centre for Personal Construct Psychology
The Sail Loft, Mulberry Quay, Falmouth TR11 3HD
email: fransella@aol.com web: www.centrepcp.ndirect.co.uk
Information and resources on Personal Construct Psychology
First Steps to Freedom
1 Taylor Close, Kenilworth, Warwickshire CV8 2LW
helpline: 01926 851 608, tel./fax: 01926 864 473
email: first.steps@btconnect.com web: www.first-steps.org
Offers help to those who suffer from phobias, panic attacks, general anxiety and obsessive-compulsive disorders
No Panic
93 Brands Farm Way, Randlay, Telford, Shropshire TF3 2JQ
helpline: 0808 808 0545
email: ceo@nopanic.org.uk web: www.nopanic.org.uk
Runs local self-help groups and produces a range of leaflets, information, audio and video cassettes
Oxford Cognitive Therapy Centre
Psychology Deparment, Warneford Hospital, Oxford OX3 7JX
tel: 01865 223 986, fax: 01865 226 411
web: www.octc.co.uk
Aims to provide cognitive therapy training and other resources to NHS and other professionals, voluntary organisations, and clients
United Kingdom Council for Psychotherapy (UKCP)
167–169 Great Portland Street, London W1W 5PF
tel. 020 7436 3002, fax: 020 7436 3013
email: ukcp@psychotherapy.org.uk web: www.psychotherapy.org.uk
Regional lists of psychotherapists are available free
See also
S A D
Anxiety
Schizophrenia
Spinning the blues
In search of a buzz
Mental Health day the news
Virtual life
Autism To be or not to be
Why we worry
A Caffeine High
Happiness