Cognitive behavioural therapy

Abstract

Cognitive behavioural therapy (CBT) is a psychotherapeutic approach that addresses unhelpful cognitions and behaviours that result in distress. It has been shown to be effective in the management of anxiety disorders, depression, eating disorders, chronic pain syndromes and personality disorders. Although there is a clear need for CBT services, access to them remains limited. GPs cannot be expected to fill this gap, but specific CBT techniques can help in the management of common conditions. In this paper, we will discuss several CBT techniques that a clinician can apply in 10-minute consultations with a case study to espouse how the techniques can be implemented in clinical practice.

The RCGP curriculum and cognitive behavioural therapy

Clinical module 3.10: Care of people with mental health problems requires GPs to:

Understand the roles and the power of emotions and their relevance in well-being and mental illness

Understand and empathise with people who are distressed and fully assess them (including risk) and offer appropriate support and management

Use communication skills that enable your patients who are distressed to feel comfortable enough to disclose their concerns

Professional module 2.01: The GP consultation in practice requires GPs to:

Use the skills typically associated with good doctor–patient communication

Nearly 15% of the UK population has some form of a diagnosable mental disorder, and a large number of these patients see their GP on a regular basis (Craig & Boardman, 1997). The role of GPs in the management of these patients has traditionally involved risk assessment, supportive counselling, use of pharmacological agents, and referral to counselling or the local psychiatry service. GPs generally have a strong therapeutic alliance with their patients, which is vital for effective cognitive behaviour therapy (CBT). Patients may be referred for formal CBT or other psychological therapy, however, some CBT principles can applied in routine consultations for conditions such as anxiety, depression, chronic pain syndromes and phobias

Evidence

Numerous studies have shown the efficacy of CBT in treating mental disorders. In a randomised controlled trial by Barlow, Gorman, Shear, and Woods (2000), CBT showed a significantly smaller relapse rate when compared with medication in panic disorder patients (CBT group 4% compared with imipramine 25%). In another randomised controlled trial comparing CBT and clinical monitoring in patients with Parkinson’s disease and depression, the CBT group reported greater mood improvements and lower levels of motor decline (Dobkin, Menza, & Friedman, 2011). The National Institute for Health and Care Excellence (NICE) recommends the use of CBT to treat various psychological disorders, either as a primary therapy or in conjunction with other treatment modalities (see Box 1).
Box 1.
Recommendations for CBT in NICE guidelines.

• Panic disorder or generalised anxiety: CBT or CBT-based self-help ± selective serotonin reuptake inhibitor (SSRI)

• Mild-to-moderate depression: CBT ± structured group activity ± SSRI

• Moderate or severe depression: Combination of anti-depressants and CBT

• Mild obsessive compulsive disorder (OCD): Brief or group CBT + exposure and response prevention + SSRI

• Moderate OCD: SSRI or CBT

Source: NICE (2009) .

The CBT principle

The CBT principle is outlined in Fig. 1. CBT is a collaborative approach that aims to help patients identify dysfunctional thinking and behavioural patterns and replace them with more adaptive ones. CBT advocates that early life experiences shape the beliefs we hold about ourselves, the world and the future. These core beliefs tend to be inflexible and determine our perception of events. They can be positive (e.g. ‘I am loveable’) or negative (e.g. ‘I am worthless’).
Figure 1.
The CBT principle.

Core beliefs can be identified by observing our interpretations of events. These interpretations may stem from cognitive distortions (see Box 2) and negative automatic thoughts (NATs) intruding into our consciousness in a verbal or image format. CBT aims to replace NATs with more adaptive and realistic thoughts, by looking at factual evidence for and against NATs.
Box 2.
Examples of cognitive distortions.

• All-or-none thinking: I am completely useless

• Catastrophising: If I fail my exam, my life will be over

• Discounting the positive: That paper was easy so anyone could have done well

• Labelling: I am useless

• Jumping to conclusions: I have got palpitations, I must be having a heart attack

• Mind reading: He is looking at me, there is something wrong with my dress

• (Mis)fortune telling: I will not get that job

• Overgeneralising: I seem to fail at everything

• Personalising: My marriage ended because it was my fault

• Should and must: Only patients with genuine problems should see their GP

Implementation of CBT principles

The initial step in CBT is to develop an accurate understanding of the patient’s cognitive distortions and NATs that maintain the problem. This can be achieved through active listening, probing, clarification, reflecting back and summarising. Case study 1 shows how effective implementation of these techniques can uncover cognitive distortions and core beliefs.

Case study 1

John: I just do not feel like trying any more.

Dr: Tell me more about what you mean. (probing)

John: I just feel like giving up.

Dr: Do you mean … giving up on life? (clarifying)

John: I am not referring to suicide, if that is what you mean, but I am feeling really depressed.

Dr: I can see a letter from A&E that you took an overdose a week ago?

John: That was out of frustration, I did not mean to do it.

Dr: I see. What made you feel so frustrated John?

Patient: I seem to fail at everything (overgeneralising). I needed that job to get my life started. Now it is all over (catastrophising). I should not have tried in the first place (indication of a potential avoidance pattern). I am useless (labelling, core belief uncovered).

In addition, a home task may be assigned to the patient to identify his/her cognitive distortions and what has led to them. Identification can be made easier by printing out a list of the common cognitive distortions for the patient to go through at home (see Box 2). Life-mapping is a technique used in formal CBT to identify the reasons leading to a patient’s core beliefs. Life-mapping involves the patient making a list of important and emotive events in his or her life starting from earliest memories. Such an exercise is better facilitated by an appropriately trained psychological therapist, as it can be time-consuming, requires motivation and careful support. It can unlock suppressed negative memories and feelings, e.g. those related to abuse, inconsistent discipline, bullying etc. Case study 2 and Table 1 show how our inner beliefs affect our thoughts, feelings and behaviour.
Table 1.
Explaining CBT principles using an example.

Event Your friend is late for dinner

Cognitive distortion Generalisation Self-blame Catastrophising Neutral

Core belief ‘People are irresponsible’ ‘I am unlikable’ ‘What if …’ ‘We all can get late sometimes’

Thoughts ‘How dare she do this to me! She's so rude!’ ‘She probably did not want to come because she does not like me’ ‘What if she has had an accident? She could be hurt!’ ‘She might be stuck in traffic, I will ring her up in a few minutes’

Feelings Anger Shame Anxiety Neutral

Behaviour To tell her off when she arrives Stop going out for dinner again Phone her, her friends, local hospitals Order a drink and message her

Physiology Tachycardia, hyperpnoea Tiredness, insomnia Hyperventilation, palpitations, panic attack No change

Adapted from Lee (2013) .

Case Study 2

John, a 28-year-old mathematics graduate, initially presented to the surgery for follow-up after a paracetamol overdose. After the GP had risk assessed him and offered him a range of treatment options he decided to see a psychological therapist. He was given two tasks:
To identify his cognitive distortions using a list (Box 2)

To start life-mapping

At his next appointment, John identified cognitive distortions of self-blame, catastrophising and generalising. He was also able to recall a couple of interviews where he felt he had performed badly and therefore did not get the job. He had formed the core belief, ‘I am bad at interviews’, which, coupled with his cognitive distortions, led to the following NAT cascade: I am bad at interviews → I will never get a good job → I will never have a good career, family or financial security → I am a failure. John took an overdose after he missed an interview due to anxiety and fear of failure.

Once the patient is aware of such unhelpful maintenance patterns (core beliefs, cognitive distortions and NATs), it is appropriate to implement modifying techniques. There is considerable overlap of these techniques in the treatment of anxiety, depression and phobias. Some of the commonly used CBT techniques will be discussed in the rest of this article. Some of these techniques can form part of a GP consultation without the GP being aware that they are using CBT techniques. However, some techniques require appropriate training and require more than a 10-minute GP consultation. The techniques include: cognitive restructuring; behavioural activation; exposure therapy; imagery; positive data log; and humour.

Cognitive restructuring

Cognitive restructuring refers to a set of processes used to identify, challenge and replace NATs and cognitive distortions with more balanced thoughts. A popular cognitive restructuring process involves the completion of thought diaries and asking Socratic questions (Beck, 1995) (Box 3) to help uncover underlying meaning behind patients’ perceptions. Socratic questioning is a powerful technique that challenges the accuracy and completeness of thinking in a way that acts to move people towards their ultimate goal. Sequential questioning, as exemplified in Box 3, can unveil the evidence for and against negative perceptions and can help patients develop a more balanced perspective.
Box 3.
Examples of Socratic questions.

• What is going through your mind as you are feeling this emotion?

• What are you afraid might happen?

• If this thought is true, what does this say about you as a person?

• What is the worst that could happen if it were true?

• What is the evidence that supports or contradicts this thought?

• Is there an alternative explanation?

• Could you be overestimating the probability of the negative event occurring? What is most realistic?

• How shall we use this new learning (balanced perspective)? Is there anything we could do to test it?

Behavioural activation

Behavioural activation (BA) is used in the treatment of depression. It is based on the theory that inadequate reinforcement and increased punishment contribute to depression (Addis, Jacobson, & Martell, 2001). These processes can be reversed by engaging in rewarding activity. Once the contributing behaviour patterns are identified, scheduling of activities that offer a sense of pleasure or achievement is commenced (Veale, 2008). For example, someone who presents with inactivity and over-sleeping secondary to depression could consider getting up earlier and engage in a rewarding activity during that time. BA can be achieved through the use of ACTION, i.e. Assess mood and behaviour, Choose alternative behaviours, Try out alternatives, Integrate these changes into life, Observe the results and Now evaluate (Addis et al., 2001).

Exposure therapy

Exposure therapy is primarily used for anxiety disorders. It is a popular CBT intervention that is usually supported by a psychological therapist and involves developing a hierarchy of anxiety-evoking situations, followed by graded exposure to these situations.

For example, a fear of flying can be treated with the client looking at videos of planes taking off, imagining being on a short plane trip, spending time in airports, watching planes take off and land in vivo, and then finally boarding an aeroplane. The overall purpose of exposure therapy is for the patient to realise that the feared consequences are unrealistic and the probability of them happening is minimal or non-existent.

Positive data log

A positive data log involves keeping a record of positive information. For example, the patient engaged in BA for inactivity may record, ‘I managed to get up and have breakfast even though I felt exhausted. I felt better after eating. I felt worthwhile’. The process is used to help the patient gather data that disconfirm negative core beliefs and strengthen new positive beliefs. This can be used within a GP consultation or as part of self-help CBT resources.

Humour

The clinician may exaggerate a patient’s catastrophic scenarios to highlight the irrationality of their thoughts and generate more realistic views. This technique should be used after a strong therapeutic alliance has been established, to ensure that the patient does not feel ridiculed (Persons, 1989).

Behaving ‘as if’

The process refers to behaving as if the new belief (e.g. a new belief for someone suffering from low self-esteem could be ‘I am good enough’) is true even if the patient does not yet strongly believe it. Behaving ‘as if’ reduces stress and improves confidence, resulting in a favourable outcome. For example, a person attending a job interview behaves ‘as if’ he is good enough for the job. It is important to first practice behaving ‘as if’ in situations where the patient feels relatively safe.

Imagery

Imagery has a strong impact on both positive and negative emotions (more than verbal processing), making it a powerful psychotherapeutic tool for alleviating emotional distress (Holmes, Arntz, & Smucker, 2007). In the above example, the patient preparing for a job interview can benefit from mental imagery of answering interview questions confidently. Imagery is also useful as a part of exposure therapy.

Learning self-acceptance

Patients tend to attach global ratings to themselves (e.g. ‘I am a bad person’) when they have made a mistake or feel insecure about a decision. Self-acceptance means an understanding and approval of self as a fallible human being. Clinicians can help patients acknowledge that failing a task does not establish that they are a failure as a person, but rather that they are a capable person who happened to have failed a task (Neenan & Dryden, 2002).

CBT for anxiety and panic attack disorder

Anxiety is a state of apprehension and fear resulting from the anticipation of a threatening event or situation. CBT for generalised anxiety disorder incorporates techniques such as psychoeducation, self-monitoring, cognitive restructuring, behavioural experiments and exposure therapy. Psychoeducation involves giving information about the disorder and should be conducted in a way that provides relief, destigmatises the disorder and enhances motivation for treatment. Self-monitoring helps to identify triggers for anxiety. Questionnaires such as the Patient Health Questionnaire (PHQ-9) (Kroenke, Spitzer, & Williams, 2001), the Hospital Anxiety and Depression Scale (HADS) for patients with anxiety and depression and Social Phobia Inventory (SPIN) questionnaire for patients with social phobia are useful for diagnostic and prognostic purposes.

Psychoeducation is often performed in the GP consultation at the time of diagnosis of an anxiety disorder. If the patient accepts referral to psychological therapy or the GP has received the relevant training, the initial psychoeducation stage is followed by the cognitive restructuring process. This looks at the patient’s core beliefs, NAT cascades and cognitive distortions followed by use of Socratic questioning to correct them. An anxiety ladder is a useful method to identify situations that trigger anxiety and its severity. At an appropriate time, the patient will commence behavioural experiments, exposing themselves to anxiety-provoking situations starting from one that is less anxiety provoking and then moving up the anxiety ladder as appropriate. At each stage, the patient makes a note of anxiety levels before and after exposure to the triggering event. A sample sheet can be downloaded from http://media.psychology.tools/worksheets/english_us/behavioral_experiment_en-us.pdf.

During the implementation of the above techniques, the clinician serves to guide the patient through the processes; the majority of the work is done by the patient outside consultation times. The clinician can introduce pharmacological treatments at various steps as an adjunct to CBT.

CBT for depression

NICE recommends CBT with or without use of anti-depressants for mild and moderate depression and CBT with pharmacological intervention for severe depression. The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. Cognitive behavioural techniques useful in depression include cognitive restructuring, BA, and the positive data log described above.

Limitations

In using CBT in 10-minute consultations, there is a high demand on the patient to be psychologically minded and grasp the CBT concept at the outset. This may not always be possible. There is also the risk of uncovering emotions or beliefs that may be difficult to contain in 10 minutes. A longitudinal qualitative study looking into GPs’ experiences in using CBT in general practice concluded that tailored training programmes in CBT for GPs may contribute to more frequent use of CBT in general practice. A formal recognition of CBT in the reimbursement scheme for GPs might counter limiting factors to an increased use of CBT in general practice (Aschim, Lundevall, Martinsen, & Frich, 2011). Further research is required to determine the suitability of cases that could be managed by GPs without specialist input.

Conclusions

The demand for CBT interventions in primary care has increased dramatically in recent years. This demand highlights the need for medical practitioners in the front line to be aware of the benefit of CBT. Some techniques described in this paper can be used by clinicians as an alternative or in conjunction with medication with or without specialist psychological therapist input.

Key points

CBT aims to help patients identify dysfunctional thinking and behavioural patterns and replace them with more adaptive ones

Once the negative core beliefs, cognitive distortions and NAT cascades have been identified, appropriate CBT techniques can be implemented

NICE recommends use of CBT with or without other treatment modalities in conditions such as anxiety, depression, panic disorders and phobias

Questionnaires and exercise sheets such as HADS, PHQ-9, SPIN, anxiety ladder, behavioural experiment sheets, etc. are useful during the course of CBT and can be filled out by patients between follow-up appointments

Be aware of the possibility of uncovering deep-seated emotions or suppressed memories during therapy and pre-arrange follow-up appointments

Event	Your friend is late for dinner
Cognitive distortion	Generalisation	Self-blame	Catastrophising	Neutral
Core belief	‘People are irresponsible’	‘I am unlikable’	‘What if …’	‘We all can get late sometimes’
Thoughts	‘How dare she do this to me! She's so rude!’	‘She probably did not want to come because she does not like me’	‘What if she has had an accident? She could be hurt!’	‘She might be stuck in traffic, I will ring her up in a few minutes’
Feelings	Anger	Shame	Anxiety	Neutral
Behaviour	To tell her off when she arrives	Stop going out for dinner again	Phone her, her friends, local hospitals	Order a drink and message her
Physiology	Tachycardia, hyperpnoea	Tiredness, insomnia	Hyperventilation, palpitations, panic attack	No change

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