Cognitive and behavioural therapies

What are cognitive and behavioural therapies?

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 the separate article Psychotherapy and its Uses.)

Definitions

Behavioural therapy

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.

Cognitive therapy

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.¹ 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.²

  • 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.²

  • 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).

CBT

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 mental health problems.

Examples of conditions that can be treated by CBT include:

• Depression - CBT may be provided as part of guided self-help, individual or group therapy, and may be combined with antidepressant medication.³

• Generalised anxiety disorder (GAD) and panic disorder - CBT may again be provided as part of guided self-help, individual or group therapy.⁴

• OCD⁵ - 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)⁵ - 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)⁶ - 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:
  

  • Bulimia.

  • Chronic fatigue syndrome.

  • Drug dependence and alcohol dependence.

  • Chronic pain.

  • Schizophrenia.

  • Bipolar disorder.

  • Learning disability.

  • Sexual and relationship problems.

  • Habits.

  • Anger problems.

  • Sleep problems.

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.

Different approaches

• 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.

The therapists

• 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.⁷

• 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 2008.

• 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.

Delivery of computerised cognitive behavioural therapy (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. There are a number of programmes available, including:

  • Beating the Blues: an online CBT programme for people with mild to moderate depression and anxiety.⁸

  • Silvercloud: an online CBT programme incorporating mindfulness and positive psychology. It is aimed at people affected by anxiety, depression and mental health issues related to long-term health conditions.⁹