Cognitive behavioral therapy

The core idea

1. Interpretation, not event1

   Emotions are seen as caused mainly by how people perceive events, and events, thoughts, feelings, behaviour and body reactions all affect each other.

2. Automatic thoughts4

   Beck noticed streams of negative thoughts that seemed to arise on their own and called them automatic thoughts.

3. The cognitive triad4

   In depression these thoughts fall into negative views of oneself, the world and the future.

4. Core beliefs4

   Frequent negative automatic thoughts reveal core beliefs, formed over lifelong experience and felt to be true.

5. Example thoughts5

   A questionnaire of automatic thoughts includes "I'm worthless", "I've let people down" and "My future is bleak".

A thought record, filled in

1. Situation7

   A real entry from a 2021 study: "while walking down the street I see someone I know, wave at them and they don't acknowledge my wave."

2. Emotion, rated7

   One word and a strength: disappointment, 45 out of 100, which the person files under sadness.

3. Automatic thought7

   "They don't like me enough to wave back."

4. Going down the arrow7

   Asked what it would mean if that were true: "I may be unlikeable", then "If I am unlikeable then I won't have friends and will be alone all my life." The downward arrow aims to reach the deeper belief behind the thought.

5. Evidence and a balanced thought8

   Illustration: the fuller record adds evidence for the thought, evidence against it, a balanced thought, then re-rates the emotion. Here: for, "they didn't wave"; against, "they may not have seen me, and people I know do greet me"; balanced, "I don't know why they didn't wave".

6. A new rule8

   When the deeper rule is perfectionism, the alternative written out might be: "It is good to do things well, but I am only human-sometimes I make mistakes."

Thinking traps, one example each

1. All-or-nothing thinking6

   A woman on a diet eats a spoonful of ice cream, decides she is a complete failure, and ends up eating the whole quart.

2. Mind reading6

   Someone sitting alone at lunch assumes everyone else must think they are a loser.

3. Fortune-telling6

   A depressed person tells themselves they will never improve and will be depressed for the rest of their life.

4. Emotional reasoning6

   "I feel stupid, therefore I must be stupid"; or feeling afraid of flying and concluding that planes are dangerous.

5. Should statements6

   After a performance, a concert pianist believes they should not have made so many mistakes.

6. Overgeneralisation6

   Asked on a first date but not a second: "This always happens to me! I'll never find love!"

7. Labelling6

   After one bad event, a sweeping verdict: "I am a failure."

8. Personalisation8

   "The watchman didn't smile at me because I did something wrong."

9. Mental filter6

   After a presentation that drew mostly praise and one small criticism, someone dwells for days on the criticism and forgets the praise.

10. Disqualifying the positive6

    "They are just congratulating me to be nice."

How a session works

1. Structured and time-limited3

   Sessions are structured, time sensitive and start from present problems.

2. Socratic questioning1

   The therapist asks questions that help you test how realistic a distressing thought is, rather than telling you what to think.

3. Homework1

   Between sessions you practise, for example going to a social event when depressed or talking to a stranger when anxious.

4. Facing fear1

   In anxiety you re-evaluate the feared thing as less dangerous and approach it instead of avoiding it.

What the research says

1. A large evidence base2

   A 2012 review of 106 meta-analyses called CBT's evidence base very strong, while noting gaps for minorities and low-income groups.

2. Not clearly better than others1

   Re-analyses have found no evidence that CBT is superior to other bona fide therapies for some conditions.

3. Unblinded trials1

   Patients and therapists always know which therapy is given; one meta-analysis with placebo controls found small effects for depression.

4. Declining effects1

   A 2015 meta-analysis found CBT's effects on depression have been shrinking since 1977.

5. Drop-out1

   One meta-analysis found drop-out rates 17% higher than for other therapies.

Where to start reading

The line under a date fills as it gets older: empty when new, full at 2 years.

1. 1979 · 47 years ago

   Cognitive Therapy of Depression4

   Beck, Rush, Shaw and Emery; the first treatment manual.

2. 2012 · 14 years ago

   The Anxiety and Worry Workbook4

   Clark and Beck; a self-help CBT workbook for anxiety.

3. Understanding CBT (Beck Institute) (opens beckinstitute.org)3

   Short plain-language overview of the cognitive model and CBT's principles.