Cognitive behavioural therapy (CBT)

This information is for anyone who wants to know more about cognitive behavioural therapy (CBT).

It looks at how CBT works, why it's used, its effects, its side-effects, and alternative treatments.

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CBT is a talking therapy. Talking therapies are also known as psychotherapies. You can find out more about these on our information page on psychotherapies and psychological treatments.

CBT helps you to learn more helpful ways of thinking and reacting in everyday situations. Changing the way you think, and what you do, can help you to feel better.

Unlike some other talking therapies, CBT focuses on your current challenges rather than on your past experiences. It aims to improve your state of mind by teaching you to spot the links between your thoughts, actions and feelings.

When doing CBT, you will work with your therapist to find new ways of dealing with problems, and set goals for what you want to change. When CBT is successful it can help you to feel more in control of your life.

CBT has been shown to help with many different mental health conditions. These include:

CBT can also help with other problems, including:

  • sleep difficulties
  • stress
  • anger
  • low self-esteem, and
  • physical health problems, like pain and extreme tiredness.

CBT can work for people of any age, including children.

You can take medication for your mental health at the same time as having CBT. This will depend on the problem, what your doctor advises and personal choice.

If you have alcohol or drug dependency issues, it is best to get help to deal with these before starting CBT for another problem. This is because using high levels of alcohol or drugs can make it difficult to learn and remember more helpful ways of managing your mental health.

CBT has not been shown to be effective in people with severe memory problems, including dementia. Learning new skills is an important part of CBT and this is likely to be difficult if you cannot remember or practice new ways of coping.

C stands for ‘cognitive’ (what you think) – In CBT, you learn to notice when you are thinking negatively. You work to challenge negative or unhelpful thoughts, for example:

  • ‘I’m useless’ or
  • ‘It’s all going to go wrong’.

Instead, you work to develop more useful, realistic thoughts, for example:

  • ‘What’s the evidence this is true?’
  • ‘What’s another way to think about this?’ or
  • ‘What advice would I give a friend in my situation?’

B stands for ‘behaviour’ (what you do) – Your behaviour is what you do and how you act. CBT can help you to deal with things you have been avoiding or have fears around. When doing CBT, you might keep a daily diary of activities, and set goals to try things that you are afraid of doing. Writing down your goals and actions can give you a sense of achievement and help you to mark your progress.

T stands for ‘therapy’ (what you learn) – Through CBT you learn new skills that you can then practise as ‘homework’. After you have finished receiving CBT you can continue to practise these skills, which can give you the tools to stay well in the future.

CBT in more detail

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 are connected and how they affect you. These parts are:

  • A situation – for example, an activity, or something that happens to you that you find difficult

From this can follow:

  • Thoughts
  • Emotions
  • Physical feelings
  • Actions

This diagram shows how the way we think about and react to situations can affect our behaviour and emotions:

CBT - how we think and react diagram

Here is an example of how the way you think in a situation can have an impact on your emotions, feelings and actions.

Example:

The situation

You've had a bad day and feel fed up, so you go out shopping. As you walk down the road, someone you know walks by and seems to ignore you. You can react to this situation with helpful or unhelpful thoughts. Depending on how you react, the following things might happen:

 UnhelpfulHelpful
Thoughts:
They ignored me - they don't like me

They look preoccupied - I wonder if there's something wrong?

Emotional feelings:
Low, sad and rejectedConcern for the other person, positive
Physical feelings:
Stomach cramps, low energy, feel sickNone - feel comfortable
Actions:
Go home and avoid themGet in touch to make sure they're OK

 

In this example, the same situation has led to two very different results.

When we are feeling sad or distressed, we might be more likely to interpret things in extreme and unhelpful ways.

CBT helps you to understand the ways your thoughts, feelings and actions work together. This can help you learn to:

  • let go of unhelpful thinking habits (jumping to conclusions)
  • let go of unhelpful actions (avoiding situations)
  • adopt helpful thinking habits (seeing the potential for something positive) and
  • adopt helpful actions (in this example, reaching out to a friend). 

A course of CBT can last from 6 weeks to 6 months. It will depend on the problem and how CBT is working for you.

You will usually meet with a therapist for between 6 and 20 sessions. These will take place weekly or fortnightly. Each session normally lasts between 30 and 60 minutes.

In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and that you feel comfortable with it. While CBT doesn’t focus on the past, the therapist will still need to ask some questions about your life and background. At times it’s important to talk about the past to understand how it is affecting you now.

In each session, you and the therapist will start by agreeing what to discuss that day. This may include how you have got on since the last session, looking at homework and talking through any problems.

At the end of a CBT course you will create a personal ‘staying well’ plan. This will include the skills you have learned, and how you can use them to deal with difficulties in the future. You will be encouraged to continue to practice these skills after your CBT has ended.

In CBT you will work with your therapist to break each problem down into its separate parts, as in the example above. Together you will look at your thoughts, feelings and behaviours to work out:

  • if they are unrealistic or unhelpful
  • how they affect each other, and you.

You will be asked to complete some questionnaires or worksheets during treatment. Your therapist might also ask you to keep a diary. This will allow you to record how you think, feel and act in different situations day to day. Your therapist will then help you to work out how to change upsetting thoughts and unhelpful behaviours.

CBT is more effective if you put these changes into practice. Your therapist will recommend regular 'homework'. This will involve practising new skills in your everyday life. You might start to practise:

  • Questioning thoughts – Such as being self-critical, ignoring positives or taking things personally. You will learn to change unhelpful thinking habits and develop more helpful and realistic thoughts.
  • Challenging actions – Recognising that you are about to do something that may help for a short time but will make you feel worse in the long term. For example, avoiding a situation, checking things over and over or repeatedly asking for reassurance. Instead, you will learn to start doing things that are more helpful.
  • Testing beliefs – Testing out things you believe to find out if they are true or not. For example, if you are very tired and depressed you may fear that that going for a walk for 20 minutes each day will make you feel worse. You agree to try this out for a week, keep a written record and check whether your prediction was true.

You might also use problem solving for practical or realistic problems, such as debts.

This ‘homework’ is important, because CBT aims to get you to a point where you can 'do it yourself', and work out your own ways of tackling problems.

    The National Institute for Health and Care Excellence (NICE) recommends CBT as a first choice for a range of problems.

    • Anxiety and depression - CBT is one of the most effective treatments for conditions where the main problem is anxiety (eg. generalised anxiety disorder or panic disorder) or depression.
    • Phobias and OCD - CBT is the most effective psychological treatment for phobias and OCD.

    About one in four people drop out of CBT. This is more likely to happen early on in treatment, if you are depressed, or if CBT is not delivered face to face with a therapist.

    CBT works as well as antidepressants for treating many forms of depression. It may work slightly better than antidepressants in treating anxiety. CBT has longer lasting effects than medication, helping you to stay well in the future.

    If your mental health problem is severe, adding CBT to medication may be more effective than medication on its own, or CBT on its own.

    CBT is delivered by a trained therapist. You can get CBT in different ways:

    Face-to-face CBT

    This can take place as individual sessions or in a group. Face-to-face is usually the most effective method of receiving CBT.

    Digital CBT (online or ‘e-CBT’)

    This can take place on a computer, laptop, tablet or smart phone through video or text-based chat. Digital CBT can be useful if:

    • you cannot meet in person, for example due to health problems
    • you have caring responsibilities that make it difficult to go to appointments on your own or
    • you live far away from somewhere that offers face-to-face CBT.

    Digital CBT can be as effective as face-to-face CBT, but this will depend on the individual.

    Self-help CBT

    For self-help CBT you will use a book, online programme or app. Doing it yourself means you need motivation to do homework and finish the course. Self-help CBT is more likely to work if you also get support from a professional. This is called ‘guided self-help’, and can be delivered by phone, email or online.

    See the further information section below for different recommendations on how to access CBT.

    CBT is the name for a group of talking therapies, rather than a single therapy. The best approach often depends on who you are and what challenges you are facing. For example, some types of CBT help you to drop old behaviours. Others teach you to change how you react to your thoughts, rather than changing the thoughts themselves.

    Here are some types of CBT have been shown to be effective:

    Type of CBTWhat do you do in this treatment?What can it help to treat?
    Cognitive therapy
     
    Spot unhelpful thoughts and beliefs. Keep a record and try out more useful and realistic ways of thinking and reacting. Many mental  health problems (eg depression, anxiety)
     
    Behaviour therapy (eg graded exposure) Change unhelpful behaviours, like avoiding, checking or getting reassurance. Gradually face situations, thoughts or memories you’ve been avoiding. Phobias, anxiety, OCD, PTSD
    Behavioural activation
     
    Get more active and involved in life by doing things that give a sense of pleasure or achievement. Keep a diary and schedule in positive activities.
     
    Depression, low mood
    Problem solving therapyIdentify the problem, come up with ways of solving it, pick one solution and put it into practice.
     
    Practical difficulties (eg job, money)
    Motivational interviewing Look at the pros and cons of a habit. Set goals for change.
     
    Alcohol use
    Mindfulness Pay attention to your thoughts and surroundings in the here and now without reacting to them.
     
    Recurrent depression, stress, anxiety
    Compassionate mind therapy Be kinder and less critical of yourself and others, helping you to feel safer and more content. Shame, anger, depression, low self-esteem, trauma
     
    Acceptance and commitment therapy (ACT, pronounced ‘act’) Accept unpleasant thoughts and feelings rather than fight them or get upset.
     
    Physical illness, pain, anxiety, depression
     
    Dialectical behaviour therapy (DBT) Manage strong feelings and sudden mood changes to overcome relationship difficulties. Combines one-to-one CBT with group therapy Emotionally unstable or borderline personality disorder, repeat self-harm
     
    Cognitive analytic therapy
     
    Understand past causes for current difficulties and find new ways of coping. Combines CBT with analytic therapy.
     
    Anorexia nervosa, borderline personality

    CBT is not a quick fix, and won’t necessarily work for everyone. It may seem difficult to put in the time and effort if you are experiencing poor mental health.

    Speak to your therapist if any of the tasks seem too hard or don't seem to be helping. They will not ask you to do things you don't want to do. A good therapist will pace your sessions and work with you to decide what to do in your sessions, allowing you to be in control.

    Support from your family or carers can be very helpful. For example, they can help you to face your fears, develop a structure to your day or go out more often.

    CBT isn't for everyone, and other types of treatments or medications may work instead of or alongside CBT. These include other types of talking treatments, or medications like antidepressants. For severe depression, CBT should be used with antidepressants. When you are very low, you may find it hard to change the way you think until medication has started to make you feel better.

    Remember, you can always try CBT in the future if you don’t want to do it now. You could also read about CBT before deciding to do it, or access it on your own (see the further information section below).

    Depression and anxiety are unpleasant. They can seriously affect your ability to work and enjoy life. After a course of CBT, your symptoms and your quality of life are likely to improve. This can help you to feel better and improve your ability to function at home and at work.

    A benefit of CBT is that you can continue to practice and develop your skills after the sessions have finished. This makes it less likely that your symptoms or problems will return. If they do, the skills you learnt in CBT should make it easier for you to control them. If necessary, you can have a ‘refresher’ course of CBT.

    CBT is available on the NHS. Your GP might refer you to someone trained in CBT if:

    • you are experiencing challenges with your mental health, or
    • have been diagnosed with a mental illness that might benefit from CBT.

    This could be a CBT practitioner, psychologist, mental health nurse or psychiatrist.

    If you think you would benefit from CBT, you can also refer yourself to an NHS psychological therapies service. You can do this without a GP referral through the Improving Access to Psychological Therapies programme (IAPT).

    If you would like to and can afford to do so, you can pay to receive CBT privately. Costs vary, but are often between £40 and £100 per session. Some private therapy services offer reduced rates to people who are on a lower income.

    Here are some useful websites to support you with finding a CBT therapist:

    There are a few misconceptions about CBT and how it works. Below are some myths and facts about CBT:

    MythFact
    CBT is just positive thinking Learning more helpful, realistic ways of thinking can have a positive impact on how you live your life.
     
    CBT does not deal with the ‘real’ problem Life will always have problems or challenges, and some of them will be out of our control. CBT can give you the tools to deal with problems more effectively.
     
    CBT is quick and easy to do You need time and practice to change old habits, but once you learn them they can stay with you for a long time.
     
    CBT uses techniques but ignores the person
     
    You are centre stage and in control, and CBT will be focused around the things that you need help with.
     
    CBT cannot work for me You are more likely to see the benefits of CBT if you commit to it and believe it can work for you.
     
    CBT is a short-term fix CBT can help to change how you live your life in the long term.
     


    Get Self HelpFree CBT self-help information, resources and therapy worksheets.

    NHS mental health information - Free information and an A to Z on mental and physical health conditions, NHS services and who to contact in crisis.

    Organisations

    British Association for Behavioural and Cognitive Psychotherapies - Provides information on CBT and a list of accredited CBT therapists.

    Anxiety UK - Provides information and support to people in the UK who are dealing with an anxiety condition, including stress & panic.
    Tel: 03444 775 774
    Email: support@anxietyuk.org.uk 

    Depression UK - Offers friendship, support and information for people with depression. Includes self-help groups, Facebook and e-penfriend links.

    Further reading

    Reading Well (Books on Prescription) Scheme – This scheme, endorsed by professionals, helps you to manage your well-being using self-help reading. The books are all chosen and recommended by health experts and people living with the conditions covered. They are described online, and available free in public libraries. There are five book lists: adult mental health, children, young people, long term (physical) conditions and dementia.

    Online CBT resources

    Beating the Blues – Self-help CBT course for depression and anxiety. Free access can be prescribed by your doctor.

    Living Life to the Full – Free online life skills course for people who are feeling distressed, depressed or anxious.

    NHS Apps Library – Online apps and tools to manage your wellbeing and mental health. Research by NHS X is planned to look into the effectiveness of these apps.

    Headspace – Mindfulness App with free introductory exercises.

    This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

    Expert author: Dr Paul Blenkiron

    Full references for this resource are available on request.

    © March 2022 Royal College of Psychiatrists