Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is probably the most extensively researched approach to psychotherapy.
The first scientific study on the approach was published in 1977. More than 500 studies followed, demonstrating the effectiveness of CBT for a wide range of mental health disorders and difficulties, as well as for physical health problems with a psychological component (see Beck, 2019). These include major depressive disorders, various anxiety disorders, personality disorders, substance misuse and dependence, and eating disorders.
In a landmark meta-analysis covering an impressive 269 studies, CBT was found to be significantly more effective than other therapies and placebo treatments for anxiety and depressive disorders (see Cuijpers et al., 2016). Similar meta-analyses have examined its effectiveness for eating disorders (see Linardon et al., 2018), post-traumatic stress disorder (see Bradley et al., 2005), obsessive-compulsive disorder (see Abramowitz et al., 2013) and other conditions.
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CBT understands experience in terms of four main components: thoughts, feelings or emotions, bodily sensations and behaviour. The central idea proposed by Dr Aaron Beck, the founder of the approach, is that changing cognition, or how we think, can also change the other parts of our experience: what we feel emotionally, what we notice in our bodies and how we behave. Sustained work on how we think can therefore improve our overall emotional well-being and day-to-day functioning. CBT works at several levels of cognition and uses a range of tools to do so.
The most immediate level is that of automatic thoughts. These are brief and often hard to notice. They arise directly from how we interpret an event and can give us a distorted picture of what is happening. For example, when you need to perform in front of others or complete a task, a thought might flash through your mind: ‘I’m going to mess this up again.’ Even a fleeting thought or mental image can noticeably affect how you feel, bringing up shame or guilt, and how you act, perhaps leading you to put the task off.
At the deepest level are core beliefs. These are rigid views about ourselves, the world, other people and the future, shaped by early experiences in childhood. Examples might be ‘I’m a complete loser’, ‘Everyone is awful’ or ‘I don’t belong anywhere’. These are sweeping, all-encompassing and extreme conclusions. They rarely stand up to scrutiny, yet they can cause considerable difficulties and affect how we function in everyday life.
Between the two is an intermediate level made up of rules and assumptions. A rule can serve as a kind of defence, a way of thinking that protects us from a painful core belief. In the context of alcohol dependence, an example might be ‘If I drink with the group, I’ll fit in’. Another might be ‘If I go out a lot and get high, I’m the fun one and I’m no loser’.
The therapist and client work together to identify these patterns. They use a range of techniques, both in sessions and in everyday life, to develop ways of thinking and responding that better reflect what the person needs and what is actually happening.
CBT uses a range of techniques to change thinking at the surface and at deeper levels.
Broadly speaking, we can tackle a problem practically, by doing something about it in the outside world, or emotionally, by working with what is happening in our own minds.
By ‘practically’, I mean coming up with concrete options for dealing with a problem and learning the skills to put them into practice. This approach is useful when the psychologist and the person seeking help agree that the difficulty is real and their thoughts and feelings fit the situation. Weighing the costs and benefits of a possible course of action is one way to work out which direction to take. In sessions, we might work on interpersonal skills or on how to plan and organise what to do.
If we discover that a thought is distorted in some way, the emotion it brings up may also be out of step with the situation. It may be a different emotion from what the situation calls for, or it may be more intense than the situation warrants. CBT offers tools for working with this, including noticing the automatic thought, identifying cognitive distortions, examining the evidence and finding an alternative thought. The psychologist initially guides the client through these tools and then teaches them to use the tools independently.
Behavioural experiments sit somewhere between the two. They can help people practise a skill, and often their main effect is to change how the person thinks about the situation. The psychologist and client choose experiments that fit the problem, consider what might get in the way before trying them, and afterwards look at any difficulties they encountered and what they learnt from the results.
CBT uses many other tools, including variations on the ones described here. It can also draw on techniques from approaches such as schema therapy, including techniques that work directly with emotions or involve re-enacting situations.
Cognitive behavioural therapy is structured.
CBT moves at a pace that suits each person and adapts to their particular difficulties or goals. At the same time, it provides a clear structure for making sense of the problem, planning the course of therapy and organising individual sessions. In practice, we use this structure flexibly. It gives the work a clear direction and purpose and helps keep sessions from getting bogged down in discussions about day-to-day events.
Generally, we start with the most intense emotions and pressing difficulties. From there, we may gradually build towards other goals for personal growth, if the client has any. The therapist guides the work at first. Over time, the client becomes more independent in understanding and managing their own thoughts and emotions. A successful course of therapy ends with work on how to prevent a relapse.
When working with thoughts, we move from the more immediate ones towards deeper beliefs. We often identify a core belief by noticing how frequently it comes up and how widely it affects the person’s life. We usually work with automatic thoughts using cognitive techniques. At a deeper level, it can be useful to combine these with techniques that work directly with emotions.
Despite its strong scientific foundations and evidence of effectiveness, CBT has drawn some criticism.
One common criticism is that CBT stays on the surface. That can be true early in therapy, when the focus is on immediate difficulties. As the work progresses, it can move towards deeper patterns of thinking, including core beliefs. The therapist can also bring in techniques that work directly with emotions and help the client explore these patterns in greater depth.
Dr Jeffrey Young built on CBT to work more directly with emotions and deeply rooted patterns. His work gradually developed into a distinct approach called schema therapy. It addresses entrenched ways of seeing ourselves and patterns of behaviour learnt in childhood, often in restrictive or even traumatic circumstances. In one of his foundational texts for therapists, Young describes a process that begins with recognising the schemas, modes and beliefs that have been activated, then moves into working with them emotionally.
Another challenge is that clients sometimes resist parts of the approach. CBT involves working independently between sessions, for example by writing down thoughts and the evidence for or against them, or by practising new behaviours. This can do a great deal to help clients become more independent, yet it often meets with resistance. Part of the art of therapy is for the client and therapist to decide together what is realistic to practise, and how often, given the person’s circumstances. They can then work together on any reluctance and on practical barriers that get in the way.
In conclusion.
CBT is a well-researched approach with strong evidence of effectiveness. It combines a clear structure with the flexibility to adapt to the person. It offers techniques for working at different levels of thinking and leaves room to bring in methods that work more directly with emotions.
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