Cognitive and behavioural therapies are both forms of psychotherapy (a psychological approach to treatment) and are based on scientific principles that help people change the way they think, feel and behave. They are problem-focused and practical. (See separate article Psychotherapy and its Uses.)
In 2005 the Government made a commitment to improve the availability of psychological therapies, the preferred method being cognitive behavioural therapy (CBT) for patients, especially in depressive and anxiety disorders. This led to the launch of the Improving Access to Psychological Therapies (IAPT) programme in 2007, the benefits of which are beginning to come to fruition.
This is a treatment approach based on clinically applying theories of behaviour that have been extensively researched over many years. It is thought that certain behaviours are a learned response to particular circumstances and these responses can be modified. Behavioural therapy aims to change harmful and unhelpful behaviours that an individual may have.
This was developed later and focuses on clinically applying research into the role of cognitions in the development of emotional disorders. It looks at how people think about and create meaning about, situations, symptoms and events in their lives and develop beliefs about themselves, others and the world.These ways of thinking (harmful, unhelpful or 'false' ideas and thoughts) are seen as triggers for mental and physical health problems. By challenging ways of thinking, cognitive therapy can help to produce more helpful and realistic thought patterns.
Cognitive therapy was developed in the 1960s by Aaron Beck, an American psychiatrist. He felt that his patients were not improving enough through simple analysis and believed that it was their negative thoughts that were holding them back. At around the same time, another therapist, Albert Ellis, was also realising that people's negative thoughts and irrational thinking could be underpinning mental health problems. He developed a form of cognitive therapy that has come to be known as rational emotive behavioural therapy (REBT).
Subtypes of cognitive therapy
- REBT: this is based on the belief that we all have sets of very rigid,and perhaps illogical, beliefs that can make us mentally unhealthy. It teaches the patient to recognise and spot the beliefs that could be causing them harm and to replace them with more logical and flexible ones.
- Cognitive analytic therapy (CAT): this is another form of cognitive therapy that combines some of the ideas of cognitive therapy with the more analytical approach of psychodynamic psychotherapy. The client and the therapist work together to look at what has hindered changes in the past, in order to understand better how to move forward in the present. It was founded by Dr Anthony Ryle in the 1970s. The therapy sessions explore the patient's past and childhood and determine why any problems have happened. They will then look at the effectiveness of any current coping mechanisms that the patient may have and will help the patient find ways to improve these. The work is very active. Diagrams and written outlines may be created to help recognise and challenge old patterns and coping mechanisms that do not work well, and provide revised mechanisms. There is a professional organisation known as the Association for Cognitive Analytic Therapy (ACAT) with a wealth of explanation about the therapy on the website (see link under 'Further reading & references', below).
The term 'cognitive behavioural therapy' (CBT) has come to be used to refer to behavioural therapy, cognitive therapy and therapy that combines both of these approaches. The emphasis on the type of therapy used by a therapist can vary depending on the problem being treated. For example, behavioural therapy may be the main emphasis in phobia treatment or obsessive-compulsive disorder (OCD) because avoidance behaviour or compulsive actions are the main problems. For depression the emphasis may be on cognitive therapy.
The rest of this article focuses on CBT.
Conditions that can be treated by cognitive behavioural therapy
There is a strong evidence base for the effectiveness of CBT. It can be used in a wide number of mental health and physical conditions. The National Institute for Health and Care Excellence (NICE) has recommended its use as a treatment option for a number of diagnoses.
Examples of conditions that can be treated by CBT include:
- Depression - low-intensity CBT (eg, 6-8 sessions over 10-12 weeks) is recommended for mild- and moderate-severity depression. Computerised CBT (cCBT) is also recommended for both these severities. Severe depression will need high-intensity CBT, ie 16-20 sessions over 6-9 months, in combination with antidepressants. A cCBT package called 'Beating the Blues®' is one option recommended by NICE to deliver CBT in mild and moderate depression.
- Generalised anxiety disorder (GAD) and panic disorder - high-intensity CBT is recommended for GAD and low-intensity for panic disorder. There are cCBT packages available for panic disorder.
- OCD - mild OCD should be treated with low-intensity CBT, with which accompanying exposure and relapse prevention (ERP) is recommended. CBT can take the form of brief, individual CBT, using self-help materials, or by the telephone or, alternatively, by group CBT, which may help. If this fails, or OCD leading to moderate functional impairment is present, then high-intensity CBT (including ERP) with medications is advised by NICE.
- Body dysmorphic disorder (BDD) - mild functional impairment caused by this disorder should be treated with CBT (including ERP). Moderate functional impairment will require more intensive CBT or medical therapy, and severe functional impairment will usually require a combination of these.
- Post-traumatic stress disorder (PTSD) - all those experiencing PTSD should be offered trauma-focused CBT on a regular and continuous basis (usually 8-12 sessions).
- Other conditions where CBT maybe useful, but NICE guidance is lacking, include:
The nature of cognitive behavioural therapy
- CBT can be delivered to individuals, couples, families or groups.
- It can be used alone, or in conjunction with medication.
- A therapeutic alliance is formed between the client(s) and the therapist.
- Together, the therapist and client identify the client's problems in terms of the relationship between thoughts, feelings and behaviour. A shared understanding of the problems is developed.
- Therapy is focused on the present rather than the past; it is orientated towards solving the client's current problems and initiating behavioural change so that the client can function better in the future.
- Goals and strategies of how to achieve them, are set and regularly reviewed.
- The therapy is aimed at encouraging empowerment of the client so that they can solve their problems using their own resources.
- The client will learn specific skills that they can use for the rest of their lives. This is the main advantage of CBT over medication.
- 'Homework' is set so that the client can apply what they have learnt in their sessions to real life.
- The number of therapy sessions depends on the client's problems and need. Typically, sessions usually last about an hour and are once a week. A course of 10-15 sessions is the average.
- Follow-up sessions are agreed and planned at the end of therapy to help maintain progress.
- Books and leaflets may give additional help and support.
- Cognitive therapy uses a style of questioning called 'guided discovery'. This helps clients to reflect on their ways of reasoning and thinking and helps them to consider the possibilities of thinking differently and more helpfully. In their 'homework', clients can then test out these alternatives and learn to change their perceptions and actions.
- Behavioural therapy looks at the way people act and respond when they are distressed or under pressure. It helps to modify unhelpful behaviours such as avoidance, which may exacerbate the problems or the way the client feels. This usually means gradually facing up to feared and avoided situations. As a consequence, anxiety is reduced and new behaviours to deal with problems and situations are learned. This type of therapy is known as exposure therapy.
Different levels of cognitive behavioural therapy
- Formulation-driven CBT: refers to psychotherapy that involves assessment, formulation and intervention, with a therapeutic alliance between the therapist and the client being paramount.
- CBT approaches: refers to specific CBT interventions for problem areas such as anger, anxiety and pain management groups. It is not psychotherapy, as it just involves implementing the intervention. Practitioners delivering the interventions will have had specific training in the CBT intervention and should also receive supervision.
- Assisted self-help CBT: this includes cCBT - see below and self-help material presented to a group/individual by a health worker. No specific formal CBT training is necessary.
- Self-help books/other resources: this is not a form of psychotherapy. No CBT skills or training are needed by the individual using the material.
- These are usually psychiatrists, psychologists, mental health nurses, social workers, counsellors, GPs or occupational therapists who have received extra training and undergo supervision in cognitive and/or behavioural therapy.
- Therapy is available on the NHS and privately.
- It is important that CBT be administered by a trained and qualified professional.
- The IAPT training programme seeks to develop the competencies previously identified by NICE guidelines required to deliver effective CBT for people with depression and with anxiety disorders.
- The British Association for Behavioural and Cognitive Psychotherapies (BABCP) keeps a register of approved and qualified therapists (see link under 'Further reading & references', below).
Making cognitive behavioural therapy more available
- Historically there has been scepticism surrounding CBT. There may be a number of reasons for this:
- GPs understand drugs and how to use them. They may not understand the potential and the limitations of other therapies.
- Prescribing drugs is easy; referring patients to other therapies may be difficult and takes time before treatment starts.
- Face-to-face for one hour a week with a healthcare professional is costly.
- To increase the availability of CBT, the Department of Health brought out its 'Improving Access to Psychological Therapies' (IAPT) programme in 2005. This is now beginning to have an impact on the delivery of services.
- The two key principles for this programme are promoting choice and expanding access to talking therapies.
- The programme provides advice and guidance on how clinical commissioning groups (CCGs) may provide computerised delivery of CBT to their local communities (see 'Delivery of cCBT', below). This means that therapy can be delivered in a wider range of settings, including non-clinical ones,and also allows patients to have greater control over the timing of therapy.
- By July 2011, more than 3,400 new CBT workers had successfully completed training. A further 53,821 new trainees entered training in the academic year 2011/12.
Delivery of cCBT
- This involves CBT delivered either via a computer or over the telephone with a computer-led response.
- The computer programme is interactive so that appropriate responses are made to the person using it.
- NICE has issued guidance on the use of cCBT.primary care trusts (PCTs) were expected to be able to offer the recommended cCBT programmes by 31st March 2007. The appraisal recommended:
- 'Beating the Blues®' as an option for delivering cCBT in the management of mild and moderate depression.
- 'FearFighter®' as an option for delivering cCBT in the management of panic and phobia.
At least some CCGs have continued to commission these services.
Further reading and references
Generalised anxiety disorder and panic disorder in adults: management; NICE Clinical Guideline (January 2011)
What is CBT?; British Association for Behavioural and Cognitive Psychotherapies
Computerised cognitive behaviour therapy for depression and anxiety; NICE Technology Appraisal Guidance, February 2006 (last updated May 2013)
Obsessive Compulsive Disorder - core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder; NICE Clinical Guideline (November 2005)
Post-traumatic stress disorder: management; NICE Clinical Guideline (March 2005)
IAPT three-year report. The first million patients; Improving Access to Psychological Therapies (IAPT), November 2012.