CBT or Cognitive Behavioural Therapy seems straightforward. ‘Cognitive’ referring to our cognitions or thoughts and behaviours that are all learned. If we, for example, learned that other people are ‘dangerous’, then we will experience the ‘emotion’ of anxiety when we are in their company. We might then use behaviour, such as avoiding certain people’s company and notice that our anxiety seems to go. Because this behaviour leads to less anxiety, it seems to prove that the thought- that ‘people are dangerous’ must be true. In a situation such as this, CBT would look at changing our thinking and our behaviour to manage our anxiety more effectively.

CBT therapists start with a formulation which is a diagram that links the past, where thoughts and behaviour were learned to the present day. It depicts how thoughts, emotions, behaviours, and physical sensations act in ways that reinforce each other leading to a vicious circle. Someone who uses avoidance to keep managing their anxiety may just keep repeating the same coping pattern. The formulation is used as the start of therapy for both depression and anxiety.

The approach used for depression is based on the work of Aaron Beck, who is the closest there can be to a father of CBT. His formulation looks at how someone’s background history produces ‘core beliefs’. These beliefs are the underlying negative presuppositions at the heart of depression.

The outward expression of internal narratives

Someone who grows up in an atmosphere where they are constantly criticised may have a core belief of being a failure. Someone who grows up in an environment where they are abused may have a core belief about being a bad person. How someone deals with their core beliefs forms the second layer of Beck’s formulation. These thoughts about coping referred to as ‘rules for living’. Someone who believes they are a failure may try to be over-successful at their work.

"If I work hard, then I can prove to others that I am not a failure."

These rules will then be enacted by behaviours such as working extra hard. The rules and behaviours can give the semblance of ‘control’ and mask the depression for many years until there is a trigger event. The event takes away the perception of control, bringing the person face to face with their core beliefs. A trigger event can be as simple as redundancy.

David had believed that he was a failure for much of his life. He could get by working hard until one day the company lost money, and they had to make him redundant.

The third level of thinking in depression is seen in negative automatic thoughts, sometimes referred to as thinking errors. The keyword here is ‘automatic’. Thoughts appear automatically. They can include catastrophic thinking, jumping to conclusions and mind reading. They are errors because there is no evidence to support them.

The day-to-day work of CBT in depression involves challenging these thoughts and working out alternatives that might be more accurate and helpful. Ultimately CBT for depression is about ‘thinking’. CBT for anxiety, on the other hand, focusses more, although not exclusively, on behaviour.

Anxiety problems are numerous and range from Obsessional Compulsive Disorder (OCD) to Post Traumatic Stress Disorder (PTSD). CBT here begins by educating people on the physical nature of anxiety identifying the changes that happen in the body. These changes are programmed within us at a deep level to help us run away from danger. However, in anxiety conditions such as OCD, the threats are the thoughts we are having. We cannot run away from our thinking.

The education on anxiety tells us that these physical changes are temporary and fade after one to two hours. This is important because ways of coping with anxiety, such as excessive washing, in some forms of OCD will bring down the level of anxiety in a temporary way. However, the fact that it lowers anxiety and the original belief about contamination was correct ensures the behaviour continues. In order to get rid of this behaviour, we need to be able to tolerate anxiety. The approach used in CBT is called
Exposure Response Prevention or ERP.

ERP exposes someone to anxiety by asking them to ‘prevent themselves’ from using the usual coping behaviour. If it was agoraphobia, this might involve not avoiding using the local park. If they then went to that park, their anxiety would then not surprisingly rise. The therapist would then be asked to rate how anxious they feel using a simple rating scale such as a percentage where 100% was extremely high anxiety. They will then be asked to re-rate it at different time intervals, usually over an hour.

The time period allows them to experience the natural drop in the physical feelings of anxiety which can then help in the reappraisal of the perception of threat. This will hopefully lead to a recognition that anxiety can be tolerated. The therapy would be arranged hierarchically so that responses that are stopped begin with the least threatening situations such as the local part to high threat situations such as a supermarket.

The three waves of CBT: behavioural, automatic thoughts, and finding life goals

When we speak about CBT, we need to think of a family of different therapies, sometimes grouped into three waves. The focus we have taken so far is with second wave CBT. First wave CBT is a behavioural therapy that is used for specific single-issue problems such as spider phobia. Third wave CBT covers a range of different treatments, which are there to deal with some of the limitations of second wave CBT.

These limitations are based around the notion that simply recognising a thought and changing it is straightforward. This is, however, too simplistic. Recognising what a thought is, is not easy. They are not just ‘what’ we think but also the ‘way’ we think. There are two problem ways of thinking which are rumination and worry. Worry is the way of thinking involved in anxiety and is focussed on what might happen in the future. Rumination is a way of thinking which is part of depression and is concentrated on what has happened in the past. In both cases, we end up paying attention to our thinking and disconnecting ourselves from what is happening outside of ourselves.

When we change the focus of attention to what is happening ‘outside of our heads’, we are more likely to be living in the ‘present’ rather than focussing on the past or the future. Second wave CBT is less effective at dealing with ‘ways of thinking’. Mindfulness-Based Cognitive Therapy or MBCT is one third-wave approach that uses meditation as a means of coping with rumination.

Another third wave approach, such as Behavioural Activation, recognises that changing behaviour rather than thinking, is often easier to accomplish. CBT also fails to answer some of the more existential questions within depression about what is of ‘value’ in life. Acceptance and Commitment Therapy, or ACT, with its focus on values and goals, is another welcome addition to the number of third-wave CBT approaches.

CBT can be accessed privately and in the NHS. A stepped care approach is used in the NHS, which delineates the degree of difficulty of a mental health problem. Less complex problems are seen in primary care through the Increasing Access to Psychological Therapies of IAPT services, where there is often a self-referral process. Here, there is a time-limited number of sessions provided. Secondary care CBT services that deal with more complex problems exist within Community Mental Health services and will generally offer more sessions.