A Guide to Cognitive Behavioural Therapy (CBT)
This reference guide is for people who want to learn more about cognitive behavioural therapy (CBT) . It will discuss what CBT is, how it works, what it can treat, how effective it is, and how it compares to other treatments.
This guide can be useful to people who are considering whether CBT might help them deal with particular issues. It may also be helpful to family members or friends of people undergoing this type of therapy, who wish to understand CBT better.
This guide will address the following common questions regarding CBT:
What is Cognitive Behavioural Therapy?
Is This a New Type of Therapy?
What Conditions Can Cognitive Behavioural Therapy Treat?
What Does Cognitive Behavioural Therapy Entail?
What Are the Benefits of Cognitive Behavioural Therapy?
How Effective is Cognitive Behavioural Therapy?
How Long Does it Take for CBT to Work?
What Are the Challenges and Limitations of Cognitive Behavioural Therapy?
How Does it Compare to Alternative Treatments?
How Can a Person Get Cognitive Behavioural Therapy?
Cognitive behavioural therapy is a goal-orientated, short-term type of talking therapy that helps individuals identify and correct harmful thought patterns that can lead to conditions such as depression, anxiety, and a number of other psychological problems.
There are two main components to Cognitive Behavioural Therapy:
- The cognitive component is concerned with a person’s thoughts, specifically how they evaluate and interpret the things that happen to them and how these perceptions affect their emotions and behaviours.
- The behavioural component is concerned with a person’s actions and how their behaviours might affect their feelings and impact their life.
CBT is a combined approach, and both components do not always get equal emphasis. Depending on the problem at hand, one component might be emphasised over the other. For example, the cognitive aspect may be emphasised in treating depression because depression mainly involves a person’s thoughts and feelings. On the other hand, the behavioural aspect may play a bigger role in treating obsessive-compulsive disorder because this disorder deals with repeated actions.
The objective of CBT is to replace destructive thought patterns with constructive ones. A secondary objective is to give clients the skills needed to deal with future situations on their own so they can remain mentally healthy.
Although CBT is a type of talk therapy, it should not be confused with other psychotherapies , which include a more in-depth exploration of one’s life in childhood. In contrast, CBT is concerned mainly with the person’s state of mind today. It looks at an individual’s current problems and seeks to improve their current state of mind. In some cases, it might be necessary to review past incidents that could have influenced a client’s current state of mind, but this is not the primary focus of CBT.
The premise of cognitive therapy – the idea that a person’s feelings are related to their interpretation of a situation rather than the nature of the situation itself – can trace its roots to ancient Western and Eastern philosophies. Behavioural therapy, which aims to change unhelpful or harmful behaviours, was developed based on the findings of classical conditioning and desensitisation. Combining the two areas into cognitive behavioural therapy became a mainstream approach in the 1960s and was pioneered by Dr Aaron T. Beck . It gained popularity in the 1980s and has taken off since then. Today it is increasingly the first course of action recommended on the NHS to patients suffering from depression or anxiety.
Cognitive behavioural therapy is considered an effective treatment for the following disorders:
- Anxiety disorders (including social anxiety and generalized anxiety)
- Panic disorders
- Bipolar disorder
- Personality disorders
- Eating disorders (including binge eating and bulimia)
- Substance abuse (including smoking, alcohol, and other drugs)
- Sleep disorders
- Obsessive-Compulsive disorder
- Post-Traumatic Stress Disorder
In addition, CBT can help alleviate problems such as:
- Relationship problems
- Intimacy issues
- Nervous habits such as skin picking, tics, and hair pulling
- Chronic pain
During the first session a cognitive behavioural therapist works with the client to reach an understanding of what problems the individual is facing. Once the client’s goals and priorities have been clearly identified, the CBT therapist will develop a plan and give the client a timeline for treatment. The therapist will also assess whether the client is a good candidate for this type of treatment and ensure that he or she feels comfortable with everything that the therapy entails.
The first part of cognitive behavioural therapy is identifying thought patterns and assessing their helpfulness and validity. A person who is suffering from depression might constantly think they are worthless, whereas a person with panic disorder might constantly think they are in danger. These individuals truly believe their thoughts. In CBT, the therapist will challenge these thoughts and help the client see them for the irrational beliefs that they really are.
The therapist might ask the client to think of these thoughts as hypotheses rather than facts, and then the therapist and client will work together to test these hypotheses. If they are found to be untrue, new thought patterns will be developed.
Automatic thoughts are a core component of CBT. These are the immediate thoughts that enter a person’s mind when an incident takes place, and they directly influence his or her emotional and behavioural reactions to the incident.
A person’s reaction to the sound of their window opening in the middle of the night can be used to illustrate the concept of automatic thoughts. Here are four different automatic thoughts and behaviours that can shape a person’s response to the situation:
- Person A assumes the window is being opened by an intruder who is coming to rob and murder him. He will feel frightened and try to arm himself or escape as quickly as possible.
- Person B automatically assumes it is her boyfriend letting himself in for a midnight rendezvous. She is happy about the window opening and responds with excitement.
- Person C assumes it is just his roommate, who often locks himself out of the house and forgets the keys. He is annoyed and angry with his absent-minded roommate and subsequently berates him.
- Person D believes that aliens must be coming to bring him to another planet. He feels fearful and powerless and might remain in bed paralysed by fear.
As you can see, the situation is the same in all of these examples; it is the individual’s interpretation of it that results in his or her response.
Some people’s automatic thoughts are unhelpfully negative and not based on the reality of a situation; these are known as thinking errors.
Some of the most common types of thinking errors are:
- Disqualifying the positive: This involves constantly disregarding good things that happen or downplaying their significance in order to hold onto and reaffirm a negative belief.
- Overgeneralising: An individual takes the negative outcome of a one-off incident to heart and acts as though future incidents will yield the same unpleasant result, even when evidence is presented to the contrary.
- Mental filter: This involves fixating on the negatives of a situation, however minor they might be, and inflating their importance. Anything good or positive aspects are completely pushed aside in favour of dwelling on the negatives.
- All or nothing thinking: An individual sees every situation in black and white. If he doesn’t win first place, he is a complete failure even if he came in second. If a woman resists his advances, he must be ugly and is destined to die alone.
- Personalising: This occurs when a person believes that everything that happens is his fault, even if he had nothing to do with the situation or only played a minor role.
- Unreal ideal: An individual is constantly comparing herself to someone else and always coming up short because the other person typically has a specific advantage in the area in question. She is making an unfair comparison at her own expense.
- Mind reading: This occurs when a person believes that another person’s actions are based on negative feelings toward him or her. For example, thinking that a friend didn’t return her phone call because he hates her, or being convinced that the group of people speaking another language nearby are talking badly about her appearance.
Streams of negative automatic thoughts and habitual thinking errors are not unusual in people suffering from disorders such as anxiety and depression. These people often have negative views of the world, themselves, or the future.
Oftentimes, individuals are not aware of the automatic thoughts that take place and subconsciously govern their behaviours. CBT helps people recognise and evaluate their automatic thoughts in order to understand why they reacted to a situation in the way that they did.
CBT therapists then help clients uncover and question any patterns of erroneous or distorted automatic thoughts that lead them to react to situations in undesirable ways and embark on the task of replacing these faulty automatic thoughts with more realistic and balanced ones. This, in turn, leads to a more appropriate and balanced response in future interactions.
CBT typically entails several of the following strategies:
- Recording thoughts: Individuals who are undergoing CBT are often asked to keep a journal of the thoughts that enter their mind during situations that inspire strong emotions. In some cases, the therapist will provide a worksheet with labelled columns that need to be filled out. The client and therapist will then review the worksheet together to look for patterns in the person’s thoughts and find healthier ways of thinking and reacting.
- Behavioural experiments: These experiments give clients a chance to test out their beliefs to find out if they are accurate or not. For example, a socially anxious woman who thinks everyone will laugh at her if she makes a mistake might be asked to spill her purse on the subway on purpose. This not only enables her to see how many people actually notice and how many people truly do laugh at her, but it also serves as a chance for her to see how well she can cope with this situation. This type of experiment is only used after coping strategies for any possible outcomes have been put in place and the client and therapist both feel the client is ready to try it out.
- Role playing: Role-playing exercises allow the therapist to demonstrate appropriate responses to difficult situations. Both the client and the therapist adopt roles in order to give the client a realistic example of a positive interaction. The client will then be able to model his or her behaviour accordingly and apply it to future interactions.
- Relaxation techniques: The therapist will teach the client some techniques that can be used to help relax during distressing or anxiety-inducing situations. For example, she might demonstrate gradual muscle relaxation or guide the client through deep breathing exercises. Meditation is also sometimes used to help clients relax. The client must typically practice these techniques at home and will then be prepared to employ them to successfully manage physical responses to upsetting situations, such as panic attacks, when they subsequently strike.
- Testing assumptions: This strategy involves testing a person’s firm belief by looking for exceptions that make his or her “hard and fast rule” untrue. For example, a person who is convinced she will never find a husband because she is boring and impossible to love might be asked to name friends and family members who seem to enjoy her company or care about her. This shows her that her belief is irrational and gives her a starting point for a more balanced belief; she can see some evidence that demonstrates she actually is loveable and fun and start to consider it may not be impossible to find a mate eventually.
Additional components might be employed depending on the specific problem being treated. For example, exposure therapy might be used as part of CBT for those suffering from a specific phobia. Because avoiding fears can often make them stronger, the idea is to expose the client to whatever triggers his fear to help him overcome it. Therefore, a person who is afraid of spiders might be gradually exposed to them over a period of time, increasing the level of exposure to help the client build sensitivity to spiders until being around them no longer triggers a response of fear or panic.
- It works in a relatively short period of time.
- It teaches clients skills that can be used to manage thoughts and behaviours in everyday life even after therapy has ended.
- It can be just as effective as medication for treating certain disorders.
- It is a flexible therapy that can be adapted to suit each individual’s particular needs.
- It helps people learn how to view situations in a realistic way that is less likely to cause negative feelings than their previous patterns of thought.
- It is based on the client’s goals.
- It can be used to help a variety of people regardless of culture, religion, gender, age, or socioeconomic status. It is based on the universal laws of human behaviour and is therefore suited to many individuals.
Hundreds of clinical trials have demonstrated the efficacy of CBT in treating a variety of disorders. It is considered one of the most effective treatments for conditions involving anxiety and/or depression.
The effectiveness of CBT can be attributed to the following characteristics:
- It is goal-orientated and problem-focussed.
- It teaches clients strategies and skills that have been proven to be effective.
- It is highly structured.
- It emphasises a strong relationship between the client and the therapist.
A typical course of cognitive behavioural therapy will entail weekly sessions over a time period of around two months. However, the exact number of sessions can vary depending on the individual. Whilst some people feel better after as little as six weeks, others might continue going to therapy for six months or more.
Some people might opt to have maintenance sessions a few times per year or every few years after the initial treatment has ended to ensure they are on the right track and address any new issues that have arisen. Others find that they have mastered the skills they learned and are able to apply them to the point that future visits are no longer required.
Some of the factors that influence the length of treatment are:
- The individual needs of the client
- How long the problem has been present
- The severity of the issues faced
- The frequency of sessions
- The length of each session
- The progress made by the client outside of the therapist’s office
Although many people successfully treat a host of psychological issues with cognitive behavioural therapy, this type of therapy is not for everyone, nor will it work in every single case.
Here is a look at a few of the potential challenges and limitations of CBT:
- It requires the client to do some work. The therapist acts much like a personal trainer might act at a gym; he or she will advise and encourage the client but the client must be willing to do his or her part to see results. This approach doesn’t suit everybody and some people may prefer other psychotherapies that have a more flexible structure.
- It does not work overnight. A steady commitment to regular appointments over the course of a few months is typically required with cognitive behavioural therapy. It normally works quickly, but those who are expecting instant results might feel discouraged.
- It requires some motivation on the part of the client. Going to regular sessions and doing the required homework do take some motivation on the part of the client, which is something many depressed people struggle with. Therapists are prepared to deal with this, but the client will have to muster a desire to follow through if he wants to see results. For some people this may feel like too much pressure and therefore, not the best approach. Other psychotherapy approaches, which have a more flexible structure may feel more appropriate to such clients.
- There might be uncomfortable moments. Generally speaking, CBT thrives on a positive relationship between the therapist and client. However, there might be times where a person has to step outside of his or her comfort zone in order to confront issues such as phobias or anxiety. This is always done in a controlled manner and with the ultimate goal of helping to fix the problem.
Cognitive behavioural therapy compares favourably to other treatments for anxiety and depression such as medication and other forms of psychotherapy.
Some studies have shown CBT to be as effective as antidepressants for certain kinds of depression, and there are indications that it might work better than medication when it comes to preventing a relapse of depression. It can also be used in conjunction with medication to improve the likelihood of successful treatment and give clients coping mechanisms that can be used after stopping the medication.
Because CBT is chiefly concerned with the “here and now”, people who are dealing with issues that have a component which is also related to experiences earlier in life, might glean better results from other psychotherapy approaches.
Cognitive behavioural therapy can be done individually or in a group setting. Many people prefer the one-on-one attention they receive in individual therapy sessions. Other people like the camaraderie of group therapy. There are self-help books, websites and software programs that can guide a person through the steps involved in CBT on their own, but seeing a therapist can ensure that a person’s treatment is tailored to his or her specific needs. As the therapy gains popularity, more and more insurance companies are covering treatment with CBT.
CBT can be accessed in different settings including, private practice, the NHS and mental health charities. On the NHS CBT is typically administered in an outpatient setting such as a doctor’s office or clinic. CBT therapists on the NHS and in charities may be qualified or in training and not yet qualified. People can find NHS CBT therapists via referrals from their general practitioner or self refer through the governments IAPT scheme. Private therapists who offer a CBT approach can be found online see Klearminds CBT Therapists and via accredited psychological associations such as the British Association for Behavioural & Cognitive Psychotherapies , UKCP and the BACP
Further Reading and Self Help on CBT: