Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is a way of talking about:
- how you think about yourself, the world and other people
- how what you do affects your thoughts and feelings.
CBT can help you change how you think (‘cognitive’) and what you do (‘behaviour)’. These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the ‘here and now’ problems and difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.
When does CBT help?
CBT has been shown to help with many different types of problems. These include: anxiety, depression, panic, phobias, eating disorders, bipolar disorder and psychosis. CBT may also help if you have difficulties with anger, a low opinion of yourself or physical health problems, like pain or fatigue.
How does CBT work?
CBT can help you to make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they’re connected and how they affect you. So from an original situation (a problem, event or difficult situation) can follow:
- physical feelings
Each of these areas can affect the others. How you think about a problem can affect how you feel physically and emotionally. There are helpful and unhelpful ways of reacting to most situations, depending on how you think about them.
For example: You’ve had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you.
How you proceed to process this event can be divided into two categories:
When it comes to your thoughts about the event, unhelpful thoughts could include thinking the person ignored you or that they don’t like you. Helpful thoughts could include thinking the person looks wrapped up in themselves, so perhaps there’s something wrong.
When it comes to your emotions, unhelpful emotions could include feeling low, sad and rejected. Helpful thoughts could include feeling concerned for the other person.
Unhelpful physical feelings could include stomach cramps, a sick feeling and low energy while helpful physical feelings could just be a neutral feeling of comfort.
An unhelpful action would be to go home and avoid the person in the future, while a helpful action would be to seek them out and make sure they were ok.
The same situation has led to two very different results, depending on how you thought about the situation. How you think has affected how you felt and what you did. In the examples of unhelpful behaviour, you’ve jumped to a conclusion without very much evidence for it. This matters, because it’s led to a number of uncomfortable feelings, plus unhelpful behaviour.
You’ll probably brood on what has happened and feel worse. However, if you get in touch with the other person, there’s a good chance you’ll feel better about yourself. If you don’t, you won’t have the chance to correct any misunderstandings about what they think of you – and you will probably feel worse.
This ‘vicious circle’ can even create new situations that make you feel worse. You can start to believe quite unrealistic (and unpleasant) things about yourself. This happens because, when we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways.
CBT can help you break this vicious circle of altered thinking, feelings and behaviour. When you see the parts of the sequence clearly, you can change them – and so change the way you feel. CBT aims to get you to a point where you can ‘do it yourself’, and work out your own ways of tackling these problems.
Five areas assessment
This is another way of connecting all the five areas mentioned above. It builds in our relationships with other people and helps us see how these can make us feel better or worse. Other issues such as debt, job and housing difficulties are also important. If you improve one area, you’re likely to improve other parts of your life as well.
What does CBT involve?
CBT can be done individually or with a group of people. It can also be done from a self-help book or computer. programme.
You’ll usually meet with a therapist for between five and 20, weekly, or fortnightly, sessions. Each session will last between 30 and 60 minutes. In the first two to four sessions, the therapist will check you can use this sort of treatment and you’ll check you feel comfortable with it.
The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.You decide what you want to deal with in the short, medium and long term. You and your therapist will usually start by agreeing on what to discuss that day.
With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you identify your individual patterns of thoughts, emotions, bodily feelings and actions.Together you will look at your thoughts, feelings and behaviours to work out if they are unrealistic or unhelpful, and how they affect each other, and you.
The therapist will then help you to work out how to change unhelpful thoughts and behaviours. It’s easy to talk about doing something, but much harder to actually do it. So, after you’ve identified what you can change, your therapist will recommend ‘homework’ – so you can practise these changes in your everyday life.
Depending on the situation, you might start to question self-critical or upsetting thoughts and replace them with more helpful (and more realistic) ones that you have developed in CBT. You’ll begin to recognise you’re about to do something that will make you feel worse and, instead, you’ll try to do something more helpful.
At each meeting you discuss how you’ve got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don’t seem to be helping. They won’t ask you to do things you don’t want to do – you decide the pace of the treatment and what you will and won’t try. The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.
How effective is CBT?
CBT is one of the most effective treatments for conditions where anxiety or depression is the main problem. It’s the most effective psychological treatment for moderate and severe depression and is as effective as antidepressants for many types of depression.
Is it for me?
CBT isn’t for everyone and another type of talking treatment may work better for you. It’s generally understood to be as effective as antidepressants for many forms of depression. It may be slightly more effective than antidepressants in treating anxiety.
For severe depression, CBT should be used with antidepressant medication. When you’re very low you may find it hard to change the way you think until antidepressants have started to make you feel better. Tranquillisers should not be used as a long term treatment for anxiety. CBT is a better option.
Is it difficult?
CBT isn’t a quick fix. A therapist is like a personal trainer that advises and encourages – but can’t ‘do’ it for you. If you’re feeling low, it can be difficult to concentrate and get motivated. To overcome anxiety, you need to confront it. This may lead you to feel more anxious for a short time. A good therapist will pace your sessions. You decide what you do together, so you stay in control.
How long does it last?
A course may be from six weeks to six months. It will depend on the type of problem and how it’s working for you. The availability of CBT varies between different areas and there may be a waiting list for treatment.
What if the symptoms come back?
There’s always a risk that the anxiety or depression will return. If they do, your CBT skills should make it easier for you to control them. So it’s important to keep practising your CBT skills, even after you’re feeling better. There’s some research that suggests CBT may be better than antidepressants at preventing the return of depression. If necessary, you can have a ‘refresher’ course.
Depression and anxiety can be pretty hard to deal with. They can seriously affect your ability to work and enjoy life. CBT can help you to control the symptoms. It’s unlikely to have a negative effect on your life, apart from the time you need to give up to do it.
How can I get CBT?
Speak to your GP. They may refer you to someone trained in CBT – for example, a psychologist, nurse, social worker or psychiatrist. The Counselling Directory lists accredited counsellors and explains more about the counselling process generally.
You can try ‘self-help’ – using a book, internet programme or computerised CBT. This is more likely to work if you also receive support from a professional.
Acknowledgements: Adapted from the Royal College of Psychiatrists