Government initiatives have increased interest in cognitive behavioural therapy to treat people with mental health issues by helping them solve problems themselves
In this article…
- What is cognitive behavioural therapy?
- How CBT works and its history
- CBT techniques used by therapists and how these work
- Who can provide CBT?
Simon Grist is lecturer in mental health and Improving Access to Psychological Therapies programme lead, University of Southampton.
Grist S (2011) Exploring the role of CBT in mental health. Nursing Times; 107: 34, early online publication.
Cognitive behavioural therapy (CBT) is a talking therapy used to treat patients with mental health problems. While it has been around for many years, recent government initiatives to improve services for mental health patients has raised interest in it.
This article describes the therapy, explores its history and how it works, and explains who can provide CBT and where it can be practised.
Keywords: Cognitive behavioural therapy, Mental health, Therapist
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- At least one in four people will suffer a mental health problem
- Cognitive behavioural therapy (CBT) has been used in acute mental health care for many years and there are many CBT practitioners in both acute and community mental health teams
- CBT addresses the interaction of thoughts, emotions, physical sensations and behaviours, helping clients find solutions to problems and develop problem-solving skills
- CBT uses two psychological techniques: cognitive processing helps clients to recognise negative thoughts; behavioural strategies help them identify helpful and unhelpful behaviour
- CBT can be practised by many professions, including nurses who have attended a registered CBT course and have done a minimum amount of practice supervised by a registered CBT therapist
At least one in four people will suffer a mental health problem during their lifetime, and one in six will have a mental health problem at any one time (Department of Health, 2011a). This highlights the need for evidence-based, effective and easily accessible treatments across a range of disorders and severity.
Cognitive behavioural therapy (CBT) has been growing in popularity in the UK for a number of years. This is largely due to the 2007 introduction of Improving Access to Psychological Therapies (IAPT), an NHS programme intended to improve the care of people with depression and anxiety disorders (www.iapt.nhs.uk). Recent DH initiatives designed to raise awareness of mental health issues and improve services have also raised interest in CBT. It is also recommended by the National Institute of Health and Clinical Excellence for the treatment and management of depression in adults (NICE, 2010).
No Health Without Mental Health identifies six shared objectives to making mental health everyone’s business (DH, 2011a), and the supporting document, Talking Therapies: a Four-Year Plan of Action, aims to increase access to a range of psychological therapies, including CBT (DH, 2011b). The government believes psychological therapies can be used to help “heal emotional wounds” alongside the economic recovery (DH, 2011b).
CBT has been used in acute care for many years to enhance the quality of life of patients with mental health issues. Various third-wave CBT therapies have been developed, including dialectical behaviour therapy, acceptance and commitment therapy, and mindfulness.
Many CBT practitioners work in acute and community mental health teams.
What is CBT?
The CBT we recognise today comes from the work of Albert Ellis (1962) and Aaron T Beck (1975), but some of the principles can be identified in the theories of the very early philosophers, such as Epictetus and Socrates: “Men are disturbed not by things but by the views which they take of them” (Epictetus, AD 55-135).
This demonstrates a cornerstone of CBT; it is not the event, such as the bereavement, the job loss, or the marriage breakdown that dictates how we react, but what the individual believes about it.
A technique attributed to Socrates has become pivotal to CBT. Socratic questioning is a way of asking questions that allows the recipient not only to come to an answer but also to gain a deeper understanding of the problem in the process (Westbrook et al, 2011).
CBT is the interaction of thoughts, emotions, autonomic (physical) sensations and behaviours, which all link together and interact with each other (Padesky and Greenberger, 1995). A good example of this is Padesky and Greenberger’s (1995) “hot cross bun” (Fig 1). Box 1 shows how the hot cross bun can work in practice.
Box 1. Example of the hot cross bun in practice
I am walking down the street and I see my friend on the other side of the road. I wave but she does not wave back:
- I might assume that she does not like me, I have upset her, or I am not worthy of her friendship (thoughts);
- This understandably makes me feel sad and anxious (emotions);
- I recognise the anxiety by the butterflies in my stomach, my raised pulse and my sweaty palms (physical symptoms);
- As a result of this, I return home and ignore her calls, or do not try and contact her (behaviours).
It is easy to see how this could escalate further, with the addition of other avoidances (behaviours) or feelings (emotions), such as embarrassment, guilt and anger.
CBT identifies these interacting systems to help clients to make sense of how they process the world, and whether some of their behaviours and thought processes are maladaptive. Socratic questioning allows clients to come to their own decision about the helpfulness of the thoughts or behaviours, and allows therapists to explain the problem in a diagram, like the hot cross bun. This is then used to inform treatment, and function as a readily accessible explanation for the client. It must be clear so the client can understand it and avoid jargon.
How does CBT work?
CBT uses two psychological techniques: cognitive processing; and behavioural strategies.
The aim of cognitive processing is to examine clients’ thoughts and help them to learn the skill of recognising negative thoughts, often referred to as negative automatic thoughts (NATs).
They will then be able re-evaluate these thoughts using an objective framework. This can involve using techniques to gather evidence for the validity of the thoughts, such as evidence for and against, surveys, or asking a trusted other.
Having done this, a client is then in a better position to evaluate the thought objectively and either create a more helpful thought, or be able to recognise the thought as unhelpful.
Socratic questioning, or guided discovery, is crucial to this as we want clients to be able to recognise unhelpful thoughts and take the appropriate action, rather than telling them how they should be thinking.
This technique focuses on clients’ behaviour. Using a Socratic or guided discovery technique, they are encouraged to examine which behaviours are helpful and which are not.
This may involve conducting behavioural experiments to test the effectiveness and helpfulness of the behaviour, and can be done by testing hypotheses in real-life situations to see whether an alternative behaviour may be more helpful. It can also involve simpler techniques, such as behavioural activation, which involves clients identifying activities they may have stopped doing, or have been avoiding since becoming unwell, and reintroducing these.
Cognitive behavioural therapists want clients to learn more about the way their mind works. CBT is not only about making specific and identified changes to thoughts and behaviours but also about making clients their own therapists. This will enable them to apply the learning developed in and between sessions to life in general.
Therapists use a number of measures to identify, test and reinforce this learning. Clients can use some of these after therapy ends. Measures include:
- Becks Depression Inventory (Beck et al, 1988; 1961);
- Patient Health Questionnaire 9 (Kroenke et al, 2001);
- Generalised Anxiety Disorder Assessment 7 (Spitzer et al, 2006).
These tools can be helpful in diagnosis and are also effective in demonstrating change.
Subjective measures, such as ratings, are also used. For example, a client with agoraphobia could be taught to use an anxiety rating before going out of the house, then a further anxiety rating either mid way through the exposure or towards the end. These subjective ratings may not change on first use but, as the client continues with the intervention, it is hoped the ratings will start to drop, reinforcing the intervention.
This also gives the therapist an opportunity to examine why the change is happening and embed the new technique, or think about an alternative intervention if the ratings do not change
CBT in practice
Cognitive behavioural therapy is a structured intervention that focuses on problems; it aims to help clients to come up with solutions to their problems and to develop problem-solving skills.
Collaboration between therapist and client is vital, and is largely gained through the therapeutic relationship. This can be analysed in the following ways:
- Through feedback, with the therapist observing the client and asking overt questions, such as: is there anything from last week that you were not happy about?;
- Through supervision, and the use of recorded therapy sessions, parts of which can be replayed to highlight a particular problem. This gives the therapist’s supervisor direct experience of the sessions without being there;
- Through active engagement of the client. It is important that the therapist highlights this from the first session so the client knows that much of the work is going to be done outside the sessions, with the analysis of the situations occurring in sessions.
CBT is a structured intervention with many models available, depending on the disorder being addressed. These models, like the measures, are validated and have been proven to work with certain population groups. However, this does not mean CBT is a rigid and fixed intervention; the models provide a framework for treatment on which the client’s particular problems and difficulties can be hung. The skill lies not in administering the model, but in adapting the model for individual clients to maximise their understanding and learning.
Most CBT sessions last between 50 minutes and an hour, and the majority of clients can be treated in up to 20 sessions. IAPT, for example, has a approximate treatment guide from six to eight sessions at low intensity to up to 20 sessions at high intensity. However, treating patients with psychosis or personality disorders can take much longer, sometimes up to two years for clients with complex needs.
Does CBT always work?
Like any intervention, CBT does not work for everyone. It relies on clients to do a significant amount of work between sessions, so they need to be motivated. It also requires a motivated therapist who is prepared to attend to the therapeutic relationship and fully engage in the supervision process.
Therapists must also be true to the CBT models; these are evidence based. Positive treatment outcomes depend on both the skill of the therapist, gained through training and experience, and adherence to treatment models and protocols.
CBT addresses current problems, not always the underlying causes, which can also be a drawback for some.
Who can provide CBT and where is it practised?
Cognitive behavioural therapists are not always psychologists. Many professions , including nurses, practise CBT in a wide range of clinical environments.
This can vary from GPs providing a CBT consultation, through to CBT practitioners working in areas such as chronic pain and long-term conditions and CBT therapists working in acute mental health teams.
Some services have strict criteria for eligibility for CBT, but many privately registered CBT practitioners are prepared to treat any problem with an underlying cognitive or behavioural aspect.
The governing body that regulates CBT is the British Association for Behavioural and Cognitive Psychotherapies (BABCP) (www.babcp.com). Therapists registering with the BABCP have to meet a number of conditions, including attending a registered CBT course and having a minimum amount of CBT case supervision by a qualified and registered CBT therapist.
Many courses give participants an introduction to CBT, allowing them to start using some of the basic techniques with their patient groups. Anyone wanting to practise CBT at any level should have access to a qualified CBT therapist for supervision.
Beck AT (1975)Cognitive Therapy and the Emotional Disorders. New York NY: International Universities Press.
Beck AT et al (1988) An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology; 56: 6, 893-897.
Beck AT et al (1961) Beck Depression Inventory (BDI). Archives of General Psychiatry; 4: 561-571.
Department of Health (2011a) No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages. London: DH.
Department of Health (2011b) Talking Therapies: A Four-Year Plan of Action. London: DH.
Ellis A (1962) Reason and Emotion in Psychotherapy. New York, NY: Lyle Stewart.
Kroenke K et al (2001) PHQ-9: validity of a brief depression severity measure.Journal of General Internal Medicine; 16: 9, 606-613.
National Institute for Health and Clinical Excellence (2009) Depression: The Treatment and Management of Depression in Adults.London: NICE.
Padeskey CA, Greenberger D (1995) Clinician’s Guide to Mind Over Mood. London: Guilford Press.
Spitzer RL et al (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine; 166: 10, 1092-1097.
Westbrook D et al (2011) An Introduction to Cognitive Behaviour Therapy. London: Sage.