This information is for anyone who wants to know more about Cognitive Behavioural Therapy (CBT).
It discusses how it works, why it is used, its effects, its side-effects, and alternative treatments.
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© April 2020 Royal College of Psychiatrists
This information reflects the best available evidence at the time of writing. We aim to review our mental health information every three years, and update critical changes more regularly.
It 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 to 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.
CBT has been shown to help with many different types of problems. These include: anxiety, depression, panic, phobias (including agoraphobia and social phobia), stress, bulimia, obsessive compulsive disorder, post-traumatic stress disorder, 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.
BT 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 - a problem, event or difficult situation. From this 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.
All these areas of life can connect like this:
What happens in one of these areas can affect all the others.
There are helpful and unhelpful ways of reacting to most situations, depending on how you think about it. The way you think can be helpful - or unhelpful.
An example: The Situation
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. This starts a cascade of:
|Thoughts:||He/she ignored me - they don't like me||He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?|
|Low, sad and rejected||Concerned for the other person, positive|
|Physical:||Stomach cramps, low energy, feel sick||None - feel comfortable|
|Action:||Go home and avoid them||Get in touch to make sure they're 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 example in the left hand column, you've jumped to a conclusion without very much evidence for it - and this matters, because it's led to:
having a number of uncomfortable feelings
behaving in a way that makes you feel worse.
If you go home feeling depressed, you'll probably brood on what has happened and feel worse. If you get in touch with the other person, there's a good chance you'll feel better about yourself.
If you avoid the other person, you won't be able to correct any misunderstandings about what they think of you - and you will probably feel worse.
This 'vicious circle' can make you feel worse. It 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 to 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.
You can do CBT individually or with a group of people, or even a self-help book or computer programme.
In England and Wales, two computer-based programmes have been approved for use by the NHS. Fear Fighter is for people with phobias or panic attacks; Beating the Blues is for people with mild to moderate depression.
If you have individual therapy:
- You will usually meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes.
- In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and you will check that 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 the 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 to 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
- 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, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend 'homework' - you practise these changes in your everyday life. Depending on the situation, you might start to:
- question a self-critical or upsetting thought and replace it with a more helpful (and more realistic) one that you have developed in CBT
- recognise that you are about to do something that will make you feel worse and, instead, 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 will not 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.
- It is one of the most effective treatments for conditions where anxiety or depression is the main problem.
- It is the most effective psychological treatment for moderate and severe depression.
- It is as effective as antidepressants for many types of depression.
CBT is used in many conditions, so it isn't possible to list them all here. We will look at alternatives to the most common problems - anxiety and depression.
- CBT isn't for everyone. Another type of talking treatment may work better for you.
- CBT works as well as antidepressants for many forms of depression. It may be slightly better than antidepressants in helping anxiety.
- For severe depression, CBT should be used with antidepressant medication. When you are very low, you may find it hard to change the way you think until the 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.
- CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages - but cannot 'do' it for you.
- If you are 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.
A course may be from 6 weeks to 6 months. It will depend on the type of problem and how it is working for you. The availability of CBT varies between different areas and there may be a waiting list for treatment.
There is 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 is important to keep practising your CBT skills, even after you are feeling better. There is some research that suggests CBT may be better than antidepressants at preventing depression coming back. If necessary, you can have a "refresher" course.
Depression and anxiety are unpleasant. They can seriously affect your ability to work and enjoy life. CBT can help you to control the symptoms. It is unlikely to have a negative effect on your life, apart from the time you need to give up to do it.
- Speak to your GP. They may refer you to someone trained in CBT - for example, a psychologist, nurse, social worker or psychiatrist.
- The British Association for Behavioural and Cognitive Psychotherapies keeps a register of accredited therapists.
- 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.
It depends very much on the problem. You could:
- Wait to see if you get better anyway - you can always ask for CBT later if you change your mind.
- Talk over some alternatives with your doctor.
- Read more about CBT and its alternatives. (see below).
- If you want to "try before you buy", get hold of a self-help book or CD-Rom and see if it makes sense to you.
- Change: your thoughts and actions
- Homework: practice makes perfect
- Action: don't just talk, do!
- Need: pinpoint the problem
- Goals: move towards them
- Evidence: shows CBT can work
- View: events from another angle
- I can do it: self-help approach
- Experience: test out your beliefs
- Write it down: to remember progress
Useful CBT web links
Helpline: 0845 123 23 20; firstname.lastname@example.org
Information, support and understanding for people who suffer with depression, and for relatives who want to help. Self-help groups, information, and raising awareness for depression.
Further readingReading Well Agency: Books on Prescription
Self-help books which use the theories and concepts of CBT to help people overcome many common problems. Titles include: overcoming social anxiety and shyness, overcoming depression and overcoming low self-esteem.
Free online CBT resources
- Living Life to the Full: Free online life skills course for people feeling distressed and their carers. Helps you understand why you feel as you do and make changes in your thinking, activities, sleep and relationships.
- FearFighter: free access can only be prescribed by your doctor in England and Wales.
Williams CJ (2009) Overcoming depression and low mood: a five areas approach. 3rd edition Hodder: London
- NICE (2011) CG113 : Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care
- NICE (2009) CG90 : Depression in adults: The treatment and management of depression in adults
- NICE (2011): CG123: Common mental health disorders: Identification and pathways to care.
- NICE (2006) CG38: Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care
- NICE (2005) CG31: Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder
- NICE (2014) CG178: Psychosis and schizophrenia in adults: treatment and management
- NICE technology appraisal TA 97 (2006): Computerised Cognitive Behaviour Therapy for depression and anxiety: Review of Technology Appraisal 51.
Produced by the RCPsych Public Education Editorial Board.
Editor: Dr Philip Timms.
Main author: Dr Paul Blenkiron
This page reflects the best available evidence at the time of writing.