What is cognitive behaviour therapy?
Cognitive behaviour therapy (CBT) describes a number of therapies that all have a similar approach to solving problems - these can range from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people's attitudes and their behaviour. The therapies focus on the thoughts, images, beliefs and attitudes that we hold (our cognitive processes) and how this relates to the way we behave, as a way of dealing with emotional problems.
An important advantage of CBT is that it tends to be short, taking three to six months for most emotional problems. Clients attend a session a week, each session lasting either 50 minutes or an hour. During this time, the client and therapist are working together to understand what the problems are and to develop a new strategy for tackling them. CBT introduces them to a set of principles that they can apply whenever they need to, and which will stand them in good stead throughout their lives.
CBT is a form of psychotherapy which combines cognitive and behavioural therapy. Cognitive therapy looks at how our thoughts can create our feelings and mood. Behavioural therapy pays close attention to the relationship between our problems, our behaviour and our thoughts. CBT may focus on what is going on in the present rather than the past, but often the therapy will also look at how thinking patterns may have begun in early childhood and the impact patterns of thinking may have on how we interpret the world as adults.
What's the history of CBT?
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 incorporated 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 general term 'cognitive behaviour therapy'. CBT has since undergone scientific trials in many places by different teams, and has been applied to a wide variety of problems.
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. Our thoughts can block us seeing things that don't fit with 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 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.
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 that 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.
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 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.
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.
How else does it differ from other therapies?
CBT also differs from other therapies in the nature of the relationship that the therapist will try to establish. Some therapies encourage the client to be dependent on the therapist, as part of the treatment process. The client can then easily come to see the therapist as all-knowing and all-powerful. The relationship is different with CBT.
CBT favours a more equal relationship that is, perhaps, more business-like, being problem-focused and practical. The therapist will frequently ask the client for feedback and for their views about what is going on in therapy. Beck coined the term 'collaborative empiricism', which emphasises the importance of client and therapist working together to test out how the ideas behind CBT might apply to the client's individual situation and problems.
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 a number of problems:
anxiety and panic attacks
child and adolescent problems
chronic fatigue syndrome
drug or alcohol problems
general health problems
habits, such as facial tics
post-traumatic stress disorder
sexual and relationship problems
CBT does not claim to be able to cure all of the above problems. For example, it does not claim to be able to cure chronic pain or disorders such as chronic fatigue syndrome. Rather, CBT might help people with, for example, arthritis or chronic fatigue syndrome, to find new ways of coping while living with the disorders.
There is 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 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.
Why do I need to do homework?
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.
If that individual is open to testing this out, they could agree to do a homework assignment (say to go to the cinema with a friend). They may make faster progress, as a result, than someone who feels unable to take this risk.
How effective is it?
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. This has fuelled interest in CBT. The National Institute for Health and Clinical Excellence (NICE) recommends CBT via the NHS for common mental disorders, such as depression and anxiety. (See Useful websites.)
Comparisons with other types of short-term psychological therapy aren't 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.
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; for example, post-traumatic stress.
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 actually increases 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 can bring 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.
How can I find a therapist?
It's possible to get CBT on the NHS in several places, and 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.