Mental health

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Cognitive behavioural therapy (CBT) – how does it work?

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) can help you make sense of overwhelming problems by breaking them down into smaller parts.

In CBT, problems are broken down into five main areas:

situations

thoughts

emotions

physical feelings

actions

CBT is based on the concept of these five areas being interconnected and affecting each other. For example, your thoughts about a certain situation can often affect how you feel both physically and emotionally, as well as how you act in response.

How CBT is different

CBT differs from many other psychotherapies because it’s:

pragmatic – it helps identify specific problems and tries to solve them

highly structured – rather than talking freely about your life, you and your therapist discuss specific problems and set goals for you to achieve

focused on current problems – it’s mainly concerned with how you think and act now rather than attempting to resolve past issues

collaborative – your therapist won’t tell you what to do; they’ll work with you to find solutions to your current difficulties

Stopping negative thought cycles

There are helpful and unhelpful ways of reacting to a situation, often determined by how you think about them.

For example, if your marriage has ended in divorce, you might think you’ve failed and that you’re not capable of having another meaningful relationship.

This could lead to you feeling hopeless, lonely, depressed and tired, so you stop going out and meeting new people. You become trapped in a negative cycle, sitting at home alone and feeling bad about yourself.

But rather than accepting this way of thinking you could accept that many marriages end, learn from your mistakes and move on, and feel optimistic about the future.

This optimism could result in you becoming more socially active and you may start evening classes and develop a new circle of friends.

This is a simplified example, but it illustrates how certain thoughts, feelings, physical sensations and actions can trap you in a negative cycle and even create new situations that make you feel worse about yourself.

CBT aims to stop negative cycles such as these by breaking down things that make you feel bad, anxious or scared. By making your problems more manageable, CBT can help you change your negative thought patterns and improve the way you feel.

CBT can help you get to a point where you can achieve this on your own and tackle problems without the help of a therapist.

Exposure therapy

Exposure therapy is a form of CBT particularly useful for people with phobias or obsessive compulsive disorder (OCD).

In such cases, talking about the situation isn’t as helpful and you may need to learn to face your fears in a methodical and structured way through exposure therapy.

Exposure therapy involves starting with items and situations that cause anxiety, but anxiety that you feel able to tolerate. You need to stay in this situation for one to two hours or until the anxiety reduces for a prolonged period by a half.

Your therapist will ask you to repeat this exposure exercise three times a day. After the first few times, you’ll find your anxiety doesn’t climb as high and doesn’t last as long.

You’ll then be ready to move to a more difficult situation. This process should be continued until you have tackled all the items and situations you want to conquer.

Exposure therapy may involve spending six to 15 hours with the therapist, or can be carried out using self-help books or computer programs. You’ll need to regularly practice the exercises as prescribed to overcome your problems.

CBT sessions

CBT can be carried out with a therapist in one-to-one sessions or in groups with other people in a similar situation to you.

If you have CBT on an individual basis, you’ll usually meet with a CBT therapist for between five and 20 weekly or fortnightly sessions, with each session lasting 30-60 minutes.

Exposure therapy sessions usually last longer to ensure your anxiety reduces during the session. The therapy may take place:

in a clinic

outside – if you have specific fears there

in your own home – particularly if you have agoraphobia or OCD involving a specific fear of items at home

Your CBT therapist can be any healthcare professional who has been specially trained in CBT, such as a psychiatrist, psychologist, mental health nurse or GP.

First sessions

The first few sessions will be spent making sure CBT is the right therapy for you, and that you’re comfortable with the process. The therapist will ask questions about your life and background.

If you’re anxious or depressed, the therapist will ask whether it interferes with your family, work and social life. They’ll also ask about events that may be related to your problems, treatments you’ve had, and what you would like to achieve through therapy.

If CBT seems appropriate, the therapist will let you know what to expect from a course of treatment. If it’s not appropriate, or you don’t feel comfortable with it, they can recommend alternative treatments.

Further sessions

After the initial assessment period, you’ll start working with your therapist to break down problems into their separate parts. To help with this, your therapist may ask you to keep a diary or write down your thought and behaviour patterns.

You and your therapist will analyse your thoughts, feelings and behaviours to work out if they’re unrealistic or unhelpful and to determine the effect they have on each other and on you. Your therapist will be able to help you work out how to change unhelpful thoughts and behaviours.

After working out what you can change, your therapist will ask you to practise these changes in your daily life. This may involve:

questioning upsetting thoughts and replacing them with more helpful ones

recognising when you’re going to do something that will make you feel worse and instead doing something more helpful

You may be asked to do some “homework” between sessions to help with this process.

At each session, you’ll discuss with your therapist how you’ve got on with putting the changes into practice and what it felt like. Your therapist will be able to make other suggestions to help you.

Confronting fears and anxieties can be very difficult. Your therapist won’t ask you to do things you don’t want to do and will only work at a pace you’re comfortable with. During your sessions, your therapist will check you’re comfortable with the progress you’re making.

One of the biggest benefits of CBT is that after your course has finished, you can continue to apply the principles learned to your daily life. This should make it less likely that your symptoms will return.

Computerised CBT

A number of interactive software programs are now available that allow you to benefit from CBT with minimal or no contact with a therapist.

The main program currently approved for use by the NHS is Beating the Blues, which is approved for treating mild to moderate depression.

However, there are many similar computerised CBT (CCBT) packages that may also be effective.

Some people prefer using a computer rather than talking to a therapist about their private feelings. However, you may still benefit from occasional meetings or phone calls with a therapist to guide you and monitor your progress.

Read more about self-help therapies.

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Depression – living with depression!

Is enough being done to help people with mental health conditions (such as depression, anxiety and bipolar) in your opinion?

Is enough being done to help people with mental health conditions (such as depression, anxiety and bipolar) in your opinion?

Talking about it

Sharing a problem with someone else or with a group can give you support and an insight into your own depression. Research shows that talking can help people recover from depression and cope better with stress.

You may not feel comfortable about discussing your mental health and sharing your distress with others. If this is the case, writing about how you feel or expressing your emotions through poetry or art are other ways to help your mood.

Here’s a list of depression support groups and information about how to access them.

Smoking, drugs and alcohol

If you have depression it may be tempting to smoke or drink to make you feel better. Cigarettes and alcohol may seem to help at first, but they make things worse in the long run.

 

You may also find the following pages useful:

stop smoking

getting help for drug addiction

alcohol support

Work and finances

If your depression is caused by working too much or if it’s affecting your ability to do your job, you may need time off to recover.

However, there’s evidence to suggest that taking prolonged time off work can make depression worse. There’s also quite a bit of evidence to support that going back to work can help you recover from depression.

Read more about returning to work after having mental health issues.

It’s important to avoid too much stress, and this includes work-related stress. If you’re employed, you may be able to work shorter hours or work in a more flexible way, particularly if job pressures seem to trigger your symptoms.

Under the Equality Act (2010), all employers must make reasonable adjustments to make the employment of people with disabilities possible. This can include people who’ve been diagnosed with a mental illness.

Read more about how to beat stress at work.

 

Looking after someone with depression

It’s not just the person with depression who’s affected by their illness. The people close to them are also affected.

If you’re caring for someone with depression, your relationship with them and family life in general can become strained. You may feel at a loss as to what to do. Finding a support group and talking to others in a similar situation might help.

If you’re having relationship or marriage difficulties, it might help to contact a relationship counsellor who can talk things through with you and your partner.

In this video called ‘Help with your relationship: couples therapy’, a relationship counsellor explains what couples therapy involves and who it can help.

Men are less likely to ask for help than women and are also more likely to turn to alcohol or drugs when depressed.

Read more about care and support.

Coping with bereavement

Losing someone close to you can be a trigger for depression.

When someone you love dies, the sense of loss can be so powerful that you feel it’s impossible to recover. However, with time and the right help and support, it’s possible to start living your life again.

Find out more with these videos and articles all about coping with bereavement.

Depression and suicide

The majority of suicide cases are linked with mental disorders, and most of them are triggered by severe depression.

Warning signs that someone with depression may be considering suicide include:

making final arrangements, such as giving away possessions, making a will or saying goodbye to friends

talking about death or suicide – this may be a direct statement, such as “I wish I was dead”, but often depressed people will talk about the subject indirectly, using phrases like “I think dead people must be happier than us” or “Wouldn’t it be nice to go to sleep and never wake up”

self-harm, such as cutting their arms or legs, or burning themselves with cigarettes

a sudden lifting of mood, which could mean that a person has decided to attempt suicide and feels better because of this decision

Contact your GP as soon as possible if you’re feeling suicidal or are in the crisis of depression. They’ll be able to help you.

If you can’t or don’t want to contact your GP, call the Samaritans on 116 123 (the helpline is open 24 hours a day, 365 days a year). You can also email jo@samaritans.org.

Helping a suicidal friend or relative

If you see any of the above warning signs in a friend or relative:

get professional help for them

let them know they aren’t alone and you care about them

offer support in finding other solutions to their problems

If you feel there’s an immediate danger, stay with the person or have someone else stay with them, and remove all available means of committing suicide, such as medication.

Over-the-counter medication, such as painkillers, can be just as dangerous as prescription medication. Also, remove sharp objects and poisonous household chemicals such as bleach.

Read more about how supporting someone who’s suicidal.

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Depression – what are the signs and symptoms of depression?

Guts and depression

Guts and depression

The symptoms of depression can be complex and vary widely between people. But as a general rule, if you’re depressed, you feel sad, hopeless and lose interest in things you used to enjoy.

The symptoms persist for weeks or months and are bad enough to interfere with your work, social life and family life.

There are many other symptoms of depression and you’re unlikely to have all of those listed below.

Psychological symptoms

The psychological symptoms of depression include:

continuous low mood or sadness

feeling hopeless and helpless

having low self-esteem

feeling tearful

feeling guilt-ridden

feeling irritable and intolerant of others

having no motivation or interest in things

finding it difficult to make decisions

not getting any enjoyment out of life

feeling anxious or worried

having suicidal thoughts or thoughts of harming yourself

Physical symptoms

The physical symptoms of depression include:

moving or speaking more slowly than usual

changes in appetite or weight (usually decreased, but sometimes increased)

constipation

unexplained aches and pains

lack of energy

low sex drive (loss of libido)

changes to your menstrual cycle

disturbed sleep – for example, finding it difficult to fall asleep at night or waking up very early in the morning

Social symptoms

The social symptoms of depression include:

not doing well at work

avoiding contact with friends and taking part in fewer social activities

neglecting your hobbies and interests

having difficulties in your home and family life

Severities of depression

Depression can often come on gradually, so it can be difficult to notice something is wrong. Many people try to cope with their symptoms without realising they’re unwell. It can sometimes take a friend or family member to suggest something is wrong.

Doctors describe depression by how serious it is:

mild depression – has some impact on your daily life

moderate depression – has a significant impact on your daily life

severe depression –  makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms

Grief and depression

It can be difficult to distinguish between grief and depression. They share many of the same characteristics, but there are important differences between them.

Grief is an entirely natural response to a loss, while depression is an illness.

People who are grieving find their feelings of sadness and loss come and go, but they’re still able to enjoy things and look forward to the future.

In contrast, people who are depressed constantly feel sad. They don’t enjoy anything and find it difficult to be positive about the future.

Read more about coping with grief and bereavement.

Other types of depression

There are different types of depression, and some conditions where depression may be one of the symptoms. These include:

postnatal depression – some women develop depression after they have a baby; this is known as postnatal depression and it’s treated in a similar way to other types of depression, with talking therapies and antidepressant medicines

bipolar disorder – also known as “manic depression”, in bipolar disorder there are spells of both depression and excessively high mood (mania); the depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour, such as gambling, going on spending sprees and having unsafe sex

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10 stress busters

National Stress Awareness Day

National Stress Awareness Day

 

Original on the NHS site here

 

If you’re stressed, whether by your job or by something more personal, the first step to feeling better is to identify the cause.

The most unhelpful thing you can do is turn to something unhealthy to help you cope, such as smoking or drinking.

“In life, there’s always a solution to a problem,” says Professor Cary Cooper, an occupational health expert at the University of Lancaster. “Not taking control of the situation and doing nothing will only make your problems worse.”

He says the keys to good stress management are building emotional strength, being in control of your situation, having a good social network and adopting a positive outlook.

Check out our selection of stress-busting apps in the Digital Apps Library.

What you can do to address stress

These are Professor Cooper’s top ten stress-busting suggestions:

Be active

Exercise won’t make your stress disappear, but it will reduce some of the emotional intensity that you’re feeling, clearing your thoughts and letting you to deal with your problems more calmly.

For more advice, read how being active helps mental wellbeing.

Get started with exercise.

Take control

There’s a solution to any problem. “If you remain passive, thinking, ‘I can’t do anything about my problem’, your stress will get worse,” says Professor Cooper. “That feeling of loss of control is one of the main causes of stress and lack of wellbeing.”

The act of taking control is in itself empowering, and it’s a crucial part of finding a solution that satisfies you and not someone else.

Read tips on how to manage your time.

Connect with people

A good support network of colleagues, friends and family can ease your work troubles and help you see things in a different way.

“If you don’t connect with people, you won’t have support to turn to when you need help,” says Professor Cooper.

The activities we do with friends help us relax. We often have a good laugh with them, which is an excellent stress reliever.

“Talking things through with a friend will also help you find solutions to your problems,” says Professor Cooper.

Read about some other ways relationships help our wellbeing.

Have some ‘me time’

Here in the UK, we work the longest hours in Europe, meaning we often don’t spend enough time doing things we really enjoy.

“We all need to take some time for socialising, relaxation or exercise,” says Professor Cooper.

He recommends setting aside a couple of nights a week for some quality “me time” away from work. “By earmarking those two days, it means you won’t be tempted to work overtime,” he says.

Challenge yourself

Setting yourself goals and challenges, whether at work or outside, such as learning a new language or a new sport, helps to build confidence. This will help you deal with stress.

“By continuing to learn, you become more emotionally resilient as a person,” says Professor Cooper. “It arms you with knowledge and makes you want to do things rather than be passive, such as watching TV all the time.”

Avoid unhealthy habits

Don’t rely on alcohol, smoking and caffeine as your ways of coping. “Men more than women are likely to do this. We call this avoidance behaviour,” says Professor Cooper. “Women are better at seeking support from their social circle.”

Over the long term, these crutches won’t solve your problems. They’ll just create new ones. “It’s like putting your head in the sand,” says Professor Cooper. “It might provide temporary relief, but it won’t make the problems disappear. You need to tackle the cause of your stress.”

Help other people

Professor Cooper says evidence shows that people who help others, through activities such as volunteering or community work, become more resilient.

“Helping people who are often in situations worse than yours will help you put your problems into perspective,” says Professor Cooper. “The more you give, the more resilient and happy you feel.”

If you don’t have time to volunteer, try to do someone a favour every day. It can be something as small as helping someone to cross the road or going on a coffee run for colleagues.

See more on giving for mental wellbeing.

Work smarter, not harder

Working smarter means prioritising your work, concentrating on the tasks that will make a real difference. “Leave the least important tasks to last,” says Cooper. “Accept that your in-tray will always be full. Don’t expect it to be empty at the end of the day.”

Read some tips on how to manage your time better.

Try to be positive

Look for the positives in life, and things for which you’re grateful.

“People don’t always appreciate what they have,” says Professor Cooper. “Try to be glass half full instead of glass half empty,” he says.

Try writing down three things that went well, or for which you’re grateful, at the end of every day.

Listen to an audio guide on beating unhelpful thinking.

Accept the things you can’t change

Changing a difficult situation isn’t always possible. Try to concentrate on the things you do have control over.

“If your company is going under and is making redundancies, for example, there’s nothing you can do about it,” says Professor Cooper.

“In a situation like that, you need to focus on the things that you can control, such as looking for a new job.”