Overview
Cognitive and behavioural psychotherapies are a range of therapies
based on concepts and principles derived from psychological models of
human emotion and behaviour. They include a wide range of treatment approaches
for emotional disorders, along a continuum from structured individual
psychotherapy to self-help material.
Theoretical Perspective and Terminology
Cognitive
Behaviour Therapy (CBT) is one of the major orientations of psychotherapy
(Roth & Fonagy, 2005) and represents
a unique category
of psychological intervention because it derives
from cognitive and behavioural psychological models of human behaviour
that include for instance, theories of normal and abnormal development,
and theories of emotion and psychopathology.
Behaviour therapy, the
earliest of the cognitive and behavioural psychotherapies, is based
on the clinical application of extensively researched theories of
behaviour, such as learning theory (in which the role of classical
and operant conditioning are seen as primary). Early behavioural
approaches did not directly investigate the role of cognition and
cognitive processes in the development or maintenance of emotional
disorders.Cognitive therapy is based on the clinical application
of the more recent, but now also extensive research into the prominent
role of cognitions in the development of emotional disorders.
The
term ‘Cognitive-Behavioural Therapy’ (CBT)
is variously used to refer to behaviour therapy, cognitive therapy,
and to therapy based on the pragmatic combination of principles
of behavioural and cognitive theories.
New CBT interventions are
keeping pace with developments in the academic discipline of psychology
in areas such as attention, perception, reasoning, decision making
etc.
What
is CBT?
Cognitive
and/or behavioural psychotherapies (CBP) are psychological approaches
based on scientific principles and which research has shown to be
effective for a wide range of problems. Clients and therapists work
together, once a therapeutic alliance has been formed, to identify
and understand problems in terms of the relationship between thoughts,
feelings and behaviour. The approach usually focuses on difficulties
in the here and now, and relies on the therapist and client developing
a shared view of the individual’s problem. This then leads to identification
of personalised, usually time-limited therapy goals and strategies which
are continually monitored and evaluated. The treatments are inherently
empowering in nature, the outcome being to focus on specific psychological
and practical skills (e.g. in reflecting on and exploring the meaning
attributed to events and situations and re-evaluation of those meanings)
aimed at enabling the client to tackle their problems by harnessing their
own resources. The acquisition and utilisation of such skills is seen
as the main goal, and the active component in promoting change with an
emphasis on putting what has been learned into practice between sessions
(“homework”). Thus the overall aim is for the individual
to attribute improvement in their problems to their own efforts, in collaboration
with the psychotherapist.
Cognitive and/or behavioural psychotherapists
work with individuals, families and groups. The approaches can
be used to help anyone irrespective of ability, culture, race, gender
or sexual preference. Cognitive and/or behavioural psychotherapies can
be used on their own or in conjunction with medication, depending on
the severity or nature of each client’s
problem.
Titles and Levels of Practice
Cognitive and/or Behavioural
Psychotherapists are usually health professionals such as specialist
mental health nurses, psychologists, psychiatrists, general practitioners,
social workers, counsellors or occupational therapists who have received
additional cognitive and/or behavioural therapy training and supervision
(see Appendix 1 for an outline of the skills required by a CBT therapist).
Whilst all cognitive and behavioural psychotherapists share the
above principles, individual therapists may call themselves by different
titles. The title used may reflect the theoretical underpinnings
of the specific therapy delivered (e.g “behaviour therapist” if
therapy is based on the principles of learning theory, “cognitive
therapist”, if therapy is based on the principles of a cognitive
model of emotional disorders), but more often the term “cognitive
behaviour therapist” is used by practitioners, referring to therapy
based on either cognitive or behavioural principles, or a combination
of these. The terms “psychotherapist” and “therapist” or “psychotherapy” and “therapy” are
used synonymously. Whatever title they use, the approach is commonly
referred to as CBT.
There are different levels of the practice of
CBT, which require very different skill levels on the part of the
person talking to the “client”.
- Formulation driven CBT
(individual or group CBT for a range of people and
problem areas) – This
is a form of psychotherapy, the clients are not able
to help themselves and have sought help from a trained
professional and require expert interventions from an appropriately
trained and supervised CBT psychotherapist. The relationship between
the therapist and the client is paramount and expert
skills are required to engage the client in a therapeutic alliance.
Once this is established therapy can proceed collaboratively
through assessment, formulation and intervention. The
therapist using various cognitive and/or behavioural techniques as
appropriate. They would evaluate the efficacy of any
intervention and change tack if necessary.
- CBT approaches - Specific CBT interventions for specific problem
areas (e.g. concordance training; relapse prevention
work in people with a diagnosis of Schizophrenia; identification of
symptoms and specific CBT intervention in post-partum depression; anger
management groups, anxiety management groups, pain management etc).
This is not a
form of psychotherapy as the health workers are implementing
a technical intervention, they are not required to formulate and adapt
the treatment. The health workers will have received training in specified
CBT interventions for particular problem areas, and should be receiving
supervision from a CBT psychotherapist.
- Assisted self-help (computerized
CBT, self-help material presented to a support group
or individuals by a health worker, such as a graduate mental health
worker or assistant psychologist) – This
is not a
form of Psychotherapy and only limited, if any, formal
CBT skills or training are required by the individual
introducing the approach, such individuals should not
be claiming that they are ‘doing’ CBT.
- Self-help (books, bibliotherapy) – This
is not a
form of psychotherapy and no CBT skills or training are
required by the individual reading the self-help material.
Although there is some evidence for the efficacy
of CBT approaches at many different levels, from now on for the purposes
of this document, when the term “CBT” is used, we are
referring to CBT psychotherapy outlined
in level 1 above.
The Evidence Base for CBT
Treatment
interventions are predicated on a robust evidence base derived from
studies utilising randomised controlled and single-case methodologies
that have demonstrated the efficacy and effectiveness of cognitive
and behavioural psychotherapies in the treatment of common mental health
problems, including the anxiety disorders, generalised anxiety, panic,
phobias, obsessive-compulsive disorder, posttraumatic stress disorder,
bulimia and depression as identified by a host of recent reviews by
NICE, SIGN and other review bodies. CBT models have also been developed
for use in an increasing range of mental health and health difficulties
including severe and enduring mental health problems, such as psychosis,
schizophrenia, bi-polar disorder, anger control, pain, adjustment to
physical health problems, insomnia and organic syndromes, such as early
stage dementia. There is an extensive research base around behavioural
approaches in working with children and people with learning disabilities,
severe and enduring mental health problems and “challenging behaviour” generally.
More recently CT and CBT have become the treatments of choice for adolescent
depression, and for use with children and in intellectual disability
(learning disability). Research into the contribution of psychological
factors to physical health problems (such as low back pain, chronic
fatigue, recovery from surgery for example) is growing and has led
to the development of CB approaches in these areas.
Developments in
cognitive therapy, cognitive-behavioural therapy and/or behaviour therapy
research, theory and practice (particularly in the development, or
refinement, of clinical techniques/methods) are occurring rapidly.
So are developments in cognitive and behavioural psychological perspectives
of normal and abnormal psychological processes such as human development
and emotion. The application of cognitive, behavioural and cognitive-behavioural
theory and approaches is happening in many fields other than mental
health, eg. Education and training, public health, organisational psychology,
forensic psychology, management consultancy, sports psychology for
instance.
Key Concepts
in Cognitive-Behavioural Therapy (CBT)
The cognitive component
in the cognitive-behavioural psychotherapies refers to how people
think about and create meaning about situations, symptoms and events
in their lives and develop beliefs about themselves, others and the
world. Cognitive therapy uses techniques to help people become more
aware of how they reason, and the kinds of automatic thought that
spring to mind and give meaning to things.
Cognitive interventions
use a style of questioning to probe for peoples’ meanings
and use this to stimulate alternative viewpoints or ideas. This is called ‘guided
discovery’, and involves exploring and reflecting on the style
of reasoning and thinking, and possibilities to think differently and
more helpfully. On the basis of these alternatives people carry out
behavioural experiments to test out the accuracy of these alternatives,
and thus adopt new ways of perceiving and acting. Overall the intention
is to move away from more extreme and unhelpful ways of seeing things
to more helpful and balanced conclusions.
The behavioural component
in the cognitive-behavioural psychotherapies refers to the way in
which people respond when distressed. Responses such as avoidance, reduced
activity and unhelpful behaviours can act to keep the problems going
or worsen how the person feels. CBT practitioners aim to help the
person feel safe enough to gradually test out their assumptions and fears
and change their behaviours. For example this might include helping
people to gradually face feared or avoided situations as a means
to reducing anxiety and learning new behavioural skills to tackle problems.
Importantly the cognitive and behavioural psychotherapies
aim to directly target distressing symptoms, reduce distress, re-evaluate
thinking and promote helpful behavioural responses by offering problem-focussed
skills-based treatment interventions.
Key Factors Influencing the Effective Delivery CBT