Cognitive-behavioural therapy (CBT)

Summary
Cognitive-behavioural therapy – the most researched and validated psychotherapeutic technique in the world – provides:
• A collaborative, non judgemental therapeutic environment
• Clear and quantifiable treatment goals
• Concrete, practical techniques for breaking harmful thought patterns
• Change in thoughts, emotions and behaviour
• Empirically proven fast results
• Long-term change

 

Cognitive–behavioural therapy (CBT) is a short- to medium-term, problem-focused, empirically validated psychosocial intervention. Evidence from randomised controlled trials and meta-analyses shows that it is an effective intervention for a range of different disorders, including the likes of depression, panic disorder, generalised anxiety disorder, obsessive–compulsive disorder, hypochondriasis, social phobia, schizophrenia and bipolar disorders. Schema therapy (which forms a part of CBT) has been shown by research to be effective in personality disorders.

The CBT model is fully compatible with the use of medication, and studies examining depression confirm that CBT used together with antidepressant medication is more effective than either treatment alone and that CBT treatment can lead to a reduction in future relapse. Generic CBT skills provide a readily accessible model for patient assessment and management and can usefully inform general clinical skills in everyday practice. Psychological treatments such as CBT are in great demand, but access to psychotherapy services is often limited.

A fundamental principle of CBT is recognising that people get into maintaining cycles of thoughts, cognitions, emotions and physiological sensations, where these areas affect each other, thereby maintaining both functional and dysfunctional patterns. Therefore, what people think affects their emotions, physiology and behaviour. Thinking can become extreme and unhelpful – focusing on themes in which individuals see themselves as worthless, incompetent, failures, bad or vulnerable. Equally, behaviour patterns can become unhelpful, with reduced or avoided activity, and/or the commencement of destructive behaviours.

Altering these dysfunctional maintaining cycles forms the focus for CBT assessment and intervention.

 

Some of the distortions to people’s cognitions include the following:

  1. They overlook their strengths, become very self-critical and have a bias against themselves, thinking that they cannot tackle difficulties
  2. They unhelpfully dwell on past, current or future problems; they put a negative slant on things, using a negative mental filter that focuses only on their difficulties and failures
  3. They have a gloomy view of the future and get things out of proportion; they make negative predictions about how things will work out and jump to the very worst conclusion (catastrophise) that things have gone or will go very badly wrong
  4. They mind-read and second-guess that others think badly of them, rarely checking whether this is true
  5. They unfairly feel responsible if things do not turn out well (bearing all responsibility) and take things to heart
  6. They make extreme statements and have unhelpfully high standards that are almost impossible to meet; they hold rules such as ‘I should/must/ought/have got to ...’.
  7. Overall, thinking becomes extreme, unhelpful and out of proportion

Unhelpful thinking styles are important because they tend to reflect habitual, repetitive and consistent thought patterns that occur during times of anxiety or depression. As a result, many everyday situations are misinterpreted. As problems are focused on and blown out of proportion, and their own strengths and ability to cope are overlooked or downplayed, individuals become increasingly distressed. During times of greater anxiety or depression, these unhelpful thinking styles become more frequent, last longer, and are more intense, more intrusive, more repetitive and more believable. As a result, more helpful (balanced) thoughts are crowded out. Over time these dysfunctional (irrational) beliefs become reinforced and less permeable to change. Dysfunctional thinking can worsen how people feel emotionally and physically, and also cause them to act in ways that add to their problems.

 

When people feel depressed or anxious, it is normal for them to experience difficulty doing things. In depression, this reduced activity may be because of:
• Low energy and tiredness
• Negative thinking and reduced enthusiasm for doing things
• Low mood and little sense of enjoyment or achievement when things are done
• A feeling of guilt and belief that they do not deserve any pleasure

Anxiety may also cause people to reduce what they do. In this case they tend to avoid doing certain things or going into particular places. When people become anxious or depressed, it is also normal for them to alter their behaviour to try to improve how they feel. This altered behaviour may be helpful (positive actions to cope with their feelings) or unhelpful (negative actions that block their feelings). All of these actions may further worsen how they feel by undermining self-confidence and increasing self-condemnation as negative beliefs about themselves or others seem to be confirmed.

A vicious circle may result, where the reduced or avoided activity exacerbates the feelings of depression and anxiety, or where the unhelpful behaviour exacerbates the feelings of anxiety and depression, thus maintaining them. In CBT, vicious circles are seen as the central mechanism by which current illness is maintained, and the goal of CBT is to identify and break any that are part of the present problem.

 

Unhelpful behaviours might include:

  1. Misusing alcohol or drugs
  2. Seeking excessive reassurance
  3. Anxiety-reducing behaviours that are ultimately self-defeating (‘safety behaviours’, for example never going out unless accompanied by someone else)
  4. Going on a spending spree to buy new clothes or goods in order to cheer themselves up (‘retail therapy’)
  5. Harming themselves (such as cutting or scratching their bodies or taking an overdose of tablets)
  6. Pushing family and friends away (for instance, through rudeness)
  7. Becoming very promiscuous
  8. Actions designed to set themselves up to fail and push others away

CBT is the most researched psychotherapeutic technique in the world, with a host of research studies both being used to create evidence based, idiosyncratic treatment strategies and formulations, as well as providing overwhelming evidence of its effectiveness with many different psychological and even physical conditions.