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Cognitive behavioural therapy: traditional and new ways of practice

Liz Rafferty
RMN BSc South of Scotland CBT Certificate
START Project Lead
Gartnavel Royal Hospital
Glasgow

Chris Williams
MB ChB BSc MMedSc MD FRCPsych
Senior Lecturer in Psychiatry
School of Psychological Medicine
Gartnavel Royal Hospital
Glasgow

Cognitive behavioural therapy (CBT) aims to help people work on problems that are relevant to them. In particular it helps them to identify unhelpful patterns of thinking and behaviour that can worsen how they feel.(1) It has become increasingly popular since its development for depression in the 1970s, but even though it has been found to be effective in a variety of mental health disorders, it is still difficult to access for many.

What is CBT?
CBT is a structured, short-term, problem-focused psychosocial intervention first developed by the American doctor, Professor Aaron Beck, for depression.(2) CBT evolved from earlier developments in behaviour therapy and other psychotherapies. What was new was its focus on the relevance of the individual's thoughts (cognitions) and behaviours and how these could influence feelings.
CBT is very focused on education - helping people work out for themselves why they feel as they do. It is also very empowering - helping people learn important new skills that they can put into practice in their own lives.(3) While CBT aims to help people work out how important/distressing events in the past have affected them - it does so by focusing more on how the past affects them here and now, so that they can rebuild confidence, learn how to tackle distressing thoughts/memories, and plan more effectively for the future.(4) This is done in close collaboration and with support from a qualified and supervised practitioner.(5)

The cognitive therapy model
Often people with low mood or anxiety can have a negative or unhelpfully distorted view of themselves, the world around them and the future (the so-called negative cognitive triad described by Beck).(2) These negative thoughts contribute to their depression and also play a part in keeping their mood at a low level. Negative thoughts automatically seem to pop into mind in all sorts of situations and cause distress. Even so, they are not always immediately noticed by the individual. The goal of therapy is to help people begin to recognise negative thoughts and then to start the process of challenging them. The clear underlying model provides a plan for treatment and builds on an effective relationship with the practitioner.

How does CBT work?
The ethos of CBT is that the therapist and the patient work together collaboratively to address problem areas. The basis of the treatment is to teach the patient how their thoughts, feelings and behaviours are impacting on them and to learn new skills of self-management. This process is facilitated by the therapist asking the right questions at the right time (Socratic questioning), which take the person on a journey of guided discovery about what factors affect how they feel. The aim of CBT is to develop some flexibility in thinking, which allows the person to adopt more adaptive behaviour, and gives the person a sense of control over their symptoms, improving self-esteem and motivation.

What conditions can be treated by CBT?
CBT has proven to be an effective and useful treatment for a range of psychological problems, such as depression, anxiety, panic attacks, phobic disorders, obsessive compulsive disorder, bulimia, schizophrenia and posttraumatic stress disorder. This approach is pragmatic, and flexible and has now also been applied successfully to a range of physical health problems, chronic fatigue and pain.

Who is suitable for CBT?
This therapy relies on the patient being an active participant in the therapy. It is therefore essential that the patient understands the model, wants to work in this particular way, and is not so ill that they will not be able to engage in the therapy at that time. The therapy may involve reading some material or keeping a diary so it is helpful if the person has basic literacy skills, although it is possible for the therapist to work flexibly, eg, verbally and using picture illustrations.

What happens during the sessions?
Initial sessions consist of a comprehensive assessment and formulation of difficulties that the patient is facing, which is shared with them. Sessions are structured by setting an agenda of agreed topics at the beginning of each session to make best use of the time together. The patient may be asked to do "homework" where they may keep a diary or carry out a specific task. The "homework" takes the therapy out with the sessions and completed "homework" tasks have been shown to positively predict outcome. Traditionally there would be approximately 10-16 sessions of about an hour with a qualified CBT therapist; however, increasingly shorter courses of four to 10 sessions are being offered where appropriate.

Are there problems of limitations with CBT?
The main problem at present relates to the accessibility of this therapy. Unfortunately there is lack of suitably trained CBT therapists available to respond to an increasing amount of people that could potentially benefit from this therapy. The leading organisation for psychotherapists in the UK, the British Association for the Behavioural and Cognitive Therapies (BABCP), has noted that there is a lack of accredited therapists with only around 1,000 currently registered with them nationally. Although CBT has been found to be helpful for many people it is not suitable for everyone. Alternative modes of evidence-based therapy should be available for those who do not choose or cannot work in this way.

What is the difference between CBT and other therapies?
The CBT model focuses on the here and now and is structured and time limited. In other therapies the model and focus may be different - with for example a far greater emphasis on childhood experience. Unlike counselling approaches the practitioner is very active and helps maintain a focus on change.

What is the evidence base for CBT?
CBT has recently been confirmed as the treatment of choice for a number of mental health disorders by the National Institute for Health and Clinical Excellence (NICE).(6)
CBT has the strongest evidence base for effectiveness of any of the psychotherapies. The best source of summaries of this evidence is the NICE website - www.nice.org.uk - where there are reviews and treatment recommendations addressing problems, such as anxiety, depression, eating disorders and post-traumatic stress disorder.

New language for CBT
One criticism that can be made of the traditional CBT approach is that the language used tends to be complex. Although the language of CBT describes very common clinical changes that occur in times of distress it can be overly technical. For example, words such as selective abstraction, magnification, negative automatic thoughts, schemas and dysfunctional assumptions, are not immediately understood by practitioners or patients. It can be very off-putting for patients when they first start CBT to find that they have to learn the language of the therapist as well as make changes in their own lives.
Related to this is a criticism that some of the original language of CBT can be seen as being critical or shaming of the patient and imply that they are depressed because of their own distorted thinking. An NHS-funded development that has taken place over the last nine years has resulted in the formation of a user-friendly, accessible form of CBT - the so-called five areas approach for depression and anxiety.(7,8) It is not a new CBT model, but rather it is a new way of communicating the CBT approach for use in a nonpsychotherapy setting.

The five areas approach
This approach helps the person identify problems they face in each of five areas of their life:

  • Life situation, relationship, practical resources and problems.
  • Altered thinking.
  • Altered emotions (mood or feelings).
  • Altered physical feelings/symptoms in the body.
  • Altered behaviour or activity levels.

An example of a completed five areas assessment model is shown in Figure 1, which summarises the case of a 60-year-old man who has problems of long-term arthritis and has been feeling significantly anxious and depressed for the last six months. Medically the extent of the arthritis cannot explain the overall impact of the symptoms. Figure 1 indicates that what a person thinks about a situation or problem may affect how they feel physically and emotionally, and also alters what they do (behaviour or activity). Each of these five areas affects each other.

[[nip33_fig1_64]]

The diagram shows that making changes in any of the areas can be helpful. This approach is also helpful to identify targets for change and intervention as well as providing a rationale for why the patient feels as he does. It is important to note that the model can summarise a range of situations and diseases in addition to mental health problems.

Recent developments leading to improving access to CBT
Where CBT is only available in one-to-one settings the result is often long waiting lists and restricted access. As part of a response to the stepped-care approach advocated in the NICE depression guidelines there has been a shift towards the development of CBT self-help materials in a variety of formats, such as books, CD Roms, DVD's or groups.(6) The self-help materials can be used independently or supported by a practitioner.
Finally, CBT is increasingly being accessed via the internet on websites, such as the www.livinglifetothefull.com. The variety of materials available allow more rapid access to evidenced-based interventions at a time that suits the patient.

Conclusion
CBT is a flexible, evolving form of psychotherapy that increasingly is offered in different ways to improve access to care. The introduction of new ways of offering CBT, including more accessible language, stepped-care approaches, such as guided self-help, group-based and computer-based CBT, offer patients and practitioners more choices for delivery. This offers the prospect of developing exciting new ways of providing rapid local access to this evidence-based therapy. Supported self-help appears to be the most effective.