Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you feel, think and act. CBT aims to find practical ways to help you deal with problems in a more positive way by breaking them down into smaller parts.
What is cognitive behavioural therapy (CBT)?
Cognitive means the way we think about things. Cognitive therapy helps us to understand our thoughts so that we can think about things more positively. Behavioural therapy helps us to change any of our actions that cause us harm or are unhelpful (for example, staying at home all the time because of a fear of something outside). Cognitive and behavioural therapies are often used together because how we behave often depends on how we think about certain things or situations.
What conditions can be helped by this treatment?
Read more about CBT and which conditions it can help to treat.
How does it work?
Your feelings often affect your thoughts - for instance, if you're feeling depressed and someone you know rushes past you without saying hello, you might think it's because they're deliberately blanking you. This can lead to a vicious cycle of thoughts - they're ignoring me because they don't like me; maybe other people feel the same; maybe I'm just a bad person. This can make you feel worse and behave in ways that can reinforce your feelings. If you have a particular fear, you may change your behaviour to avoid whatever you're scared of. This can have a major impact on what you can do and how you live your life.
Cognitive behavioural therapy (CBT) aims to stop these negative cycles by helping you to recognise and challenge these negative thoughts and behaviours, and replace them with more positive ones.
CBT deals with any problems you have now, rather than focusing on issues from your past. It doesn't suit everyone and it isn't helpful for all conditions. You need to be committed to tackling and improving your health problem with the help of the therapist. It can be hard work. It can also be difficult and challenging. But it can also be very effective and worth every minute.
Find out more about how CBT works.
What happens during therapy sessions?
You can have cognitive behavioural therapy (CBT) with a therapist either one-to-one or in a group. If you have one-to-one CBT with a therapist this usually involves a number of therapy sessions (often somewhere between 5 and 20 sessions). The therapy sessions are usually in a clinic but can take place in other places such as your own home if you have conditions like agoraphobia or obsessive-compulsive disorder (OCD).
After an initial assessment period, the therapist will gradually help you to break down problems into their separate parts. This helps you to identify ways that you can make changes to the ways you think and act, and so help to make you feel better. Your therapist won't ask you to do things you don't want to do and will only work at a pace you're comfortable with.
How can I find a therapist?
If you think you have a problem that may benefit from treatment with cognitive behavioural therapy (CBT), the first step is usually to speak to your doctor. This is important so you can check that CBT is right for you. Your doctor may also be able to refer you to a therapist or recommend one. In the UK, the British Association for Behavioural & Cognitive Psychotherapies (BABCP) keeps a register of all accredited therapists. The British Psychological Society (BPS) has a directory of chartered psychologists, which includes psychologists who specialise in CBT.
Find out more about CBT with a therapist.
What about the options without seeing a therapist?
You don't have to see a therapist to have cognitive behavioural therapy (CBT). For some people, self-help therapy can be as effective as CBT with a therapist. The options for self-help CBT include books, online mental health services, phone or email CBT, and computerised CBT.
Read more about self-help CBT.
Which conditions can be helped using CBT?
Cognitive behavioural therapy (CBT) is used to deal with how you feel, think and act now. CBT aims to find ways to change your current thoughts and behaviours so that you can function better now and in the future.
CBT is a mixture of cognitive and behavioural therapies. They are often combined because how we behave often reflects how we think about certain things or situations.
The emphasis on cognitive or behavioural aspects of therapy can vary, depending on the condition being treated. For example, there is often more emphasis on behavioural therapy when treating obsessive-compulsive disorder (OCD) - where repetitive compulsive actions are often one of the main problems. The emphasis may be on cognitive therapy for other situations - for example, when treating depression.
Our thoughts include our ideas, mental images, beliefs and attitudes. These are called cognitive processes. Cognitive therapy is designed to help you to understand your current thoughts. It can help you identify any harmful, unhelpful and false ideas or thoughts that you have. The aim is then to change the way you think so that you can avoid these ideas. Cognitive therapy helps your thought patterns to be more realistic and helpful.
This aims to change any behaviours that are harmful or not helpful. For example, a common unhelpful behaviour is to avoid situations that can make you anxious. In some people with phobias the avoidance can affect day-to-day life. A type of behavioural therapy called exposure therapy may be used to help. This involves you being gradually exposed more and more to the feared situation. The therapist will show you how to control anxiety and how to cope when facing up to the feared situations.
CBT has been shown to help people with many different conditions - both mental health conditions and physical conditions. For example:
- Certain anxiety disorders, including phobias, panic attacks and panic disorder.
- Eating disorders - for example, bulimia nervosa.
- Body dysmorphic disorder.
- Post-traumatic stress disorder.
- Sexual and relationship problems.
- Habits such as facial tics.
- Drug or alcohol abuse.
- Some sleep problems.
- Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).
- Persistent (chronic) pain.
- Irritable bowel syndrome.
CBT can help people cope better with their symptoms. As a rule, the more specific the problem, the more likely that CBT may help. This is because it is a practical therapy which focuses on particular problems and aims to overcome them. CBT is sometimes used as the only treatment and sometimes used in addition to medication, depending on the type and severity of the condition being treated.
How does CBT work?
Cognitive behavioural therapy (CBT) can help you make sense of difficult problems by breaking them down into smaller parts. In CBT, problems are broken down into five main areas:
- Physical feelings
CBT is based on the idea that these five areas affect each other. For example, your thoughts about a certain situation can often affect how you feel physically and emotionally, as well as how you act in response. CBT helps you to identify specific problems so that you can try to solve them.
Stopping negative thought cycles
There are helpful and unhelpful ways of reacting to a situation. Some thoughts, feelings, physical sensations and actions can trap you in a negative cycle and even create new situations that make you feel worse about yourself. This can make you feel hopeless, lonely, depressed and tired. You may become trapped in a negative cycle, sitting at home alone and feeling bad about yourself.
CBT aims to stop negative cycles such as these by breaking down the things that make you feel bad, anxious or scared. By making your problems more manageable, CBT can help you change your negative thought patterns and improve the way you feel.
Exposure therapy is a form of CBT that is mainly used for people with phobias or obsessive compulsive disorder (OCD). Exposure therapy involves starting with items and situations that cause anxiety, but the anxiety is kept at a level that you feel able to cope with. You need to stay in this situation for one to two hours or until the anxiety reduces for a prolonged period. You will need to repeat this exposure exercise regularly. After the first few times, you'll find your anxiety isn't as bad and doesn't last as long. You'll then be ready to move to a more difficult situation. This process should be continued until you have tackled all the situations you want to overcome.
Who can work as a therapist in CBT?
Cognitive behavioural therapy (CBT) can be carried out with a therapist in one-to-one sessions or in groups with other people in a similar situation to you. Your CBT therapist is usually a healthcare professional who has been specially trained in CBT, such as a psychiatrist, psychologist, mental health nurse or family doctor. You can also do CBT without a therapist (see below).
What happens during CBT treatment?
If you have one-to-one cognitive behavioural therapy (CBT) with a therapist, you'll usually have between five and 20 weekly or fortnightly sessions, with each session lasting 30-60 minutes. Exposure therapy sessions usually last longer to make sure your anxiety reduces during the session. The therapy may take place in a clinic or in another place, such as your own home if you have agoraphobia or obsessive compulsive disorder (OCD) involving a specific fear when at home.
The first few sessions will be spent making sure CBT is the right therapy for you, and that you're comfortable with the process. The therapist will ask questions about your life and background. After the initial assessment period, you'll start working with your therapist to break down problems into their separate parts, including your thoughts, physical feelings and actions. To help with this, your therapist may ask you to keep a diary or write down your thoughts and behaviour patterns.
You and your therapist will analyse your thoughts, feelings and behaviours to work out if they're unrealistic or unhelpful and to determine the effect they have on you. Your therapist will then be able to help you work out how to change unhelpful thoughts and behaviours.
How do I make progress?
After working out what you can change, your therapist will ask you to practise these changes in your daily life. This may involve:
- Questioning upsetting thoughts and replacing them with more helpful ones.
- Recognising when you're going to do something that will make you feel worse and to be able to do something more helpful instead.
At each session, you'll discuss with your therapist how you've got on with putting the changes into practice and what it felt like. Your therapist will be able to make other suggestions to help you.
Confronting fears and anxieties can be very difficult. Your therapist won't ask you to do things you don't want to do and will only work at a pace you're comfortable with.
What about CBT without a therapist?
Although cognitive behavioural therapy (CBT) often works best with the help of a trained therapist, some people prefer to tackle their problems themselves. It's still very important to see your doctor to make sure CBT is right for you.
There are many self-help books available. Some are excellent, but many are not. If in doubt look for self-help books that have been recommended by a professional organisation or by a health professional. For example:
- 'Overcoming' self-help books. In the UK, the Royal College of Psychiatrists endorses the Overcoming self-help series. These books and CDs are based on CBT and cover more than 30 common mental health problems. Titles include 'Overcoming Anxiety', 'Overcoming Low Self-Esteem' and 'Overcoming Grief'. They are available from bookshops and libraries. You can also download them from the Overcoming.co.uk website.
- Books on Prescription. You can also find NHS-endorsed books for common emotional and mental health problems on the 'Reading Well Books on Prescription' website.
Online mental health services
In the UK, some online mental health services have been approved for use by the NHS. Research shows that these can be just as effective as face-to-face therapy with a therapist for depression, anxiety and other mental health problems. The kind of support offered by online mental health services varies. Some allow you to work through a self-help course online with support from a health professional. Others offer live therapy with a therapist via instant messaging or a webcam.
You can also join an anonymous online community where you can meet and interact with other people who have similar mental health problems to you. You don't need much experience with computers or technology to use them.
Phone and email CBT
Phone and email CBT can be ideal if you're shy or don't want to meet the therapist, or if you can't find one in your area. They save travelling time, can avoid the problem of finding childcare and are available during evenings and weekends. Phone or email CBT is just like having a face-to-face session, except that you talk to a trained therapist over the phone. Phone and email CBT are increasingly being offered by private therapists and sometimes by workplaces and charities.
There are a number of interactive programs available that allow you to benefit from CBT with little or no contact with a therapist. In the UK, Beating the Blues (beatingtheblues.co.uk) is approved for treating mild-to-moderate depression. However, there are many similar computerised CBT packages that may also be effective. Some people prefer using a computer rather than talking to a therapist about their private feelings. However, you may still benefit from occasional meetings or phone calls with a therapist to guide you and to monitor your progress.
Further reading & references
- Computerised cognitive behaviour therapy for depression and anxiety; NICE Technology Appraisal Guidance, February 2006 (last updated May 2013)
- Gartlehner G, Gaynes BN, Amick HR, et al; Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Mar 1;164(5):331-41. doi: 10.7326/M15-1813. Epub 2015 Dec 8.
- Pompoli A, Furukawa TA, Imai H, et al; Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. Cochrane Database Syst Rev. 2016 Apr 13;4:CD011004. doi: 10.1002/14651858.CD011004.pub2.
- James AC, James G, Cowdrey FA, et al; Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2015 Feb 18;2:CD004690. doi: 10.1002/14651858.CD004690.pub4.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Dr Laurence Knott