What Is Cognitive Behavioural Therapy?

Introduction

Cognitive behavioural therapy (CBT) is a type of psychotherapy that helps you to understand how your thoughts and feelings (‘cognitive’) and actions (‘behavioural’) work together to control how you think and behave. Changing these patterns can help you to manage both mental and physical health problems.¹ 

In this article, we will explain the theory behind CBT techniques and examples of when CBT may be used. 

History of CBT

The theory of irrational thinking (‘common irrational assumptions’)

In the 1950s, Albert Ellis first developed the idea of ‘rational emotive behaviour therapy’. This involved patients recognising their irrational thoughts and being encouraged to challenge these thoughts so that more rational ones could be made. 

The theory of cognitive distortions (‘cognitive triad’)

This subsequently led to the practice of CBT in the 1960s by Aaron Beck. He identified similar cases of negative thoughts in patients with depression and decided to group these automatic negative thoughts into three categories, known as the ‘cognitive triad’.²

Theoretical foundations of CBT

Cognitive model

To understand the cognitive model of CBT, let’s further consider the ideas proposed by Aaron Beck. The primary aim of the cognitive model is to appreciate the thoughts related to the mental or physical problem.

Core beliefs

Also referred to as ‘schemas’, these are beliefs that patients may have about themselves, others or the world (Figure 1). They tend to be acquired in the first few years of life and can also be affected by childhood events. 

Cognitive distortions

Sometimes known as ‘dysfunctional assumptions’, these are strict ‘rules’ that you may feel necessary to follow (i.e. “It’s better not to try than to risk failing”). Examples include:

• Selective abstraction – only focusing on negative aspects of something while disregarding those that are positive
• Fortune telling – predicting the consequences of something before they actually occur
• Catastrophising – concentrating on the worst possible outcome even if it is almost impossible to occur

Automatic thoughts

These are described as immediate, mistaken, and exaggerated feelings that are experienced in certain situations and often focus on negativity, low self-esteem, and uselessness. For instance, in anxiety, these thoughts may centre around overestimating risk and underestimating the ability to manage the situation.

Behavioural model

After establishing your thoughts, you are taught techniques to help change these patterns. These techniques help to bring about more positive behavioural outcomes.

Learning theory principles

These principles form the basis of functional analysis, a part of CBT which sheds light on the thoughts, feelings, and environmental factors that contribute to certain behaviours. This helps you to develop skills for controlling these behaviours:^3,4 

• Operant conditioning – behaviour is modified when a reinforcement and/or punishment is added and/or removed
• Classical conditioning – two stimuli are linked together, resulting in a new learned response
• Social learning – happens through observation and imitation of others

CBT techniques

Collaborative empiricism

Working with the therapist, you aim to identify the present cognitive and behavioural patterns and implement necessary changes to allow you to manage the problem. A good patient-therapist relationship is essential to enable the therapist to fully appreciate your concerns and establish common goals in treatment. These goals can be prioritised and tackled individually to provide the best possible chance for symptom improvement.³

Cognitive restructuring

This CBT technique allows thought patterns to be analysed further. Cognitive restructuring involves trying to replace a core belief with one that is more adaptive. This allows you to adopt new ways to deal with previously challenging situations.

It can be useful to record negative automatic thoughts so that underlying patterns can be revealed and you can distinguish between facts and opinions. Then, suitable alternative thoughts can be encouraged with the desired result of replacing negative thoughts with positive ones.²

Socratic questioning

Therapists can encourage you to reconsider your beliefs by asking questions such as “What do you think causes…?” or “What are the alternative ways of looking at this?” The technique originates from the teaching methods of Socrates; he helped his students conclude without actually revealing that conclusion to them.³

Behavioural activation

This helps you to engage in healthy behaviours whilst dissuading negative behaviours that could maintain or worsen symptoms. The model was proposed in 1996 and highlighted the significance of patients being able to access pleasant events. Examples of healthy behaviours that you may adopt include⁵

• Regularly monitoring your mood
• Scheduling activities to prioritise tasks and prevent repetitive decision-making
• Discouraging engagement in negative avoidance behaviours

Graded tasks

This is a sequential process that allows you to overcome overwhelming or anxiety-provoking situations:

1. Establish a baseline of daily/weekly activities
2. Rank activities according to the amount of positivity they offer
3. Design changes that will give you the greatest amount of this positivity
4. Incorporate these activities into your routine to increase your satisfaction³

Exposure therapy

Exposure therapy involves activating a fear and then providing you with new information that contradicts the unrealistic associations, with the ultimate goal of reducing the fear. This is particularly useful for disorders associated with phobia and obsessive behaviour as it serves to challenge the ‘fear structure’, a disproportionate relationship between stimuli and response.

There are three types of exposure therapy:

• Systematic desensitisation – replicating the physical sensations felt during a panic attack for example, and exposing you to this so that you can learn new behavioural patterns to help eliminate the fear
• In vivo exposure – real-life exposure to the situation that you may deem problematic and have previously avoided, even though this situation is safe
• Imaginal exposure – picturing the anxiety-provoking situation without ignoring the anxiety that this imagining may produce⁶

Clinical applications of CBT

CBT is used in medical practice for the treatment of both mental and physical health problems.

The following list is not exhaustive but gives examples of the indications for which CBT can be used:

• Mood disorders – major depressive disorder (MDD), bipolar disorder, alcohol and substance use disorder
• Anxiety disorders – generalised anxiety disorder (GAD), panic disorder, social anxiety disorder
• Eating disorders
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
• Physical health problems – chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), fibromyalgia, irritable bowel syndrome (IBS)

Research findings highlight the effectiveness of CBT

Many clinical trials and meta-analyses have been conducted to test how effective CBT really is.

Comparison with other therapeutic modalities

Is CBT the ‘gold-standard’ treatment option?

A review published in 2010 proved that CBT is indeed better at improving symptoms up to one year after treatment in patients with mood and anxiety disorders compared to psychodynamic therapy.¹¹

Cultural considerations

Although research findings emphasise CBT’s effectiveness, it is important to consider the following questions:

• Can CBT be generalised to culturally diverse populations?
• Does treatment need to be tailored for culturally diverse populations?

CBT generally follows Western cultural models so it could be argued that the treatment does not apply to the practice of ethnic minority groups. 

To overcome these cultural barriers, different approaches can be adopted:

• Understand the patient’s culture and factor this into therapy sessions
• Appreciate the patient’s circumstances
• Acknowledge that there are differences between cultures¹²

Limitations of CBT

CBT courses often run over many weeks and can include additional requirements (i.e. keeping a record of cognitive and behavioural patterns). Patients need to be committed to get maximum benefit from the sessions.

CBT may not be suitable for patients with complex mental health difficulties or those who have comorbidities too. They may find treatment in specialist mental health facilities more beneficial.

Unlike psychodynamic therapy, CBT focuses on present issues. Without looking at underlying causes in the past, the patient may struggle to understand why they feel the way they do and may find it hard to come to terms with their symptoms.

Finally, there is the possibility of relapse, especially if treatment is not adhered to or is withdrawn.²

Future directions

Integration with technology

Emerging evidence suggests that internet-based CBT is an effective tool, both clinically and economically. It could be useful for patients in rural areas where access to health facilities is limited. Internet-CBT can be delivered in various languages, which overcomes the cultural problems of CBT.¹³

Transdiagnostic approaches

This focuses on targeting several disorders simultaneously to treat comorbidities. For example, patients with a physical health problem, such as CFS/ME, often tend to experience mental health symptoms too. Therefore, combined treatments that are primarily based on individual conditions can provide both a clinical and cost-effective treatment method for the patient.¹⁴

Summary

• CBT is a talking therapy that helps you to change your thoughts and behaviour; it is commonly used to treat mood and anxiety disorders
• Cognitive and behavioural models form the theoretical framework of CBT
• Techniques include setting goals with therapists, restructuring thought patterns, and grading tasks
• Future directions for CBT should centre on overcoming cultural barriers and developing additional ways in which the treatment can be delivered