Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is probably the most widely used form of talking therapy available in the NHS.

What is cognitive behavioural therapy?

CBT is a type of talking therapy. 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.

Cognitive therapy

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.

Behavioural therapy

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.

Patient picks for Mental health therapy

Treatment and medication

What is psychodynamic therapy?

If you're thinking of trying therapy, the number of different types can seem overwhelming. Although therapy is a catch-all term, approaches and styles can differ considerably - and the kind you may benefit from can depend on lots of factors. This series will look at the various options, so you can find the therapy suitable for you.

by Lydia Smith

Treatment and medication

Anger management

All human beings experience anger. Anger is a normal, natural emotion which helps us recognise that we, or people and things we care about, are being treated badly. It is a hostility which we can feel towards people, but also towards animals and inert objects. Anger can be an urgent feeling, which can arise quickly and which feels it demands us to act, or a slow burn which constantly affects our thoughts. It is often physically as well as emotionally uncomfortable, as it has physical as well as psychological components. Anger can be good if it helps you right wrongs, deal with problems and express negative feelings. However, it can also be bad, as it can be harmful both to you and to others, damaging relationships and affecting your ability to succeed as you hope. The way we manage anger is something learned through life, and is affected by our experiences. However, human beings are constantly capable of learning better strategies to deal with anger, to use anger more positively and to both recognise and avoid, its possible harmful effects. This leaflet describes some anger management strategies. However, if you feel your anger is, or is at risk of, harming you or others, then consider seeking help through anger management counselling, which will help you understand the source of your anger and to put these, and other, strategies into practice.

by Dr Mary Elisabeth Lowth, FRCGP

How does cognitive behavioural therapy 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:

• Situations.

• Thoughts.

• Emotions.

• Physical feelings.

• Actions.

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, and helps you to develop coping skills.

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

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.

Which conditions can be helped using cognitive behavioural therapy?

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.

• Depression.

• Eating disorders - for example, bulimia nervosa.

• OCD.

• Body dysmorphic disorder.

• Anger.

• Post-traumatic stress disorder.

• Sexual and relationship problems.

• Habits such as facial tics.

• Drug or alcohol misuse.

• Some sleep problems.

• Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).

• Persistent (chronic) pain.

• Irritable bowel syndrome.

• Post-traumatic stress disorder (PTSD).

Benefits of CBT

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.

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 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.

What happens during cognitive behavioural therapy treatment?

You can have CBT with a therapist either one-to-one or in a group. If you have one-to-one 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 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 cognitive behavioural therapy without a therapist?

Although CBT often works best with the help of a trained therapist, some people prefer to tackle their problems themselves. For some people, self-help therapy can be as effective as CBT with a therapist.

If you have an assessment through the national NHS system Improving Access to Psychological Therapies (IAPT), your counsellor may suggest one of these treatments. Otherwise, it's still very important to see your doctor to make sure CBT is right for you.

Self-help books

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.

Computerised CBT

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.

Computerised CBT for young people

Several forms of digital CBT, using computer, tablet or phone, have been designed specifically for young people. They have been developed to help with relaxation, dealing with strong emotions, problem solving, mindfulness, communicating and interacting with other people.

They can also work in the same way as more 'traditional' CBT, but helping young people to identify unhelpful or negative thoughts and challenge them.

They are now recommended by the National Institute for Health and Care Excellence (NICE) as one of the first-line treatments for young people aged 5-18 years who have mild depression.

Computerised CBT for sleep

Sleepio is a form of online CBT which is specifically aimed at those with insomnia who are 18 or over - it is available on the NHS in some areas.

How can I find a therapist?

If you think you have a problem that may benefit from treatment with CBT, the first step is usually to speak with 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.

In England, it is possible to refer yourself for counselling on the NHS. This does not always mean you will be offered CBT. You will usually have a telephone assessment with a trained counsellor. They will agree with you what the best form of treatment for you is. This could mean directing you to self-help, sessions with a trained mental health worker, group counselling or 1-1 CBT.

Other forms of therapy

Other forms of talking therapy include:

• Behavioural activation - this aims to help you to take positive, manageable steps to meeting specific goals you set with your therapist. These help you to engage with pleasurable activities, which in turn can help you move towards enjoying life again.

• Interpersonal therapy - this aims to help you identify and manage problems in your relationships.

• Mindfulness-based therapy - this helps you learn to focus on the here and now. It can be particularly helpful in keeping depression and anxiety at bay once you have recovered. It may be combined with cognitive therapy.

• Psychoanalytic therapy - this looks more at the importance of early relationships and how these templates affect your behaviour in the present.

There are also different types of specialists in mental health - they include psychotherapists, psychologists, psychiatrists, psychoanalysts and counsellors. Psychiatrists are the only one of this list who are medically qualified doctors, but some other professionals may use the title doctor if they have a PhD (doctoral degree). You can find out more about how to choose the therapist who might be best for you from our leaflet.