InnovAiT, 6(9), 579–585 DOI: 10.

1177/1755738012471029

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The key principles of

cognitive behavioural
therapy

C
ognitive behavioural therapy (CBT) explores the links between thoughts,
emotions and behaviour. It is a directive, time-limited, structured
approach used to treat a variety of mental health disorders. It aims to
alleviate distress by helping patients to develop more adaptive cognitions and
behaviours. It is the most widely researched and empirically supported
psychotherapeutic method. This strong evidence base is reflected in clinical
guidelines, which recommend it as a treatment for many common mental
health disorders.

The GP curriculum and cognitive behavioural therapy

CBT is listed as a treatment in the knowledge base of clinical example 3.10: Care of people with mental
health problems. The GP should be able to:
. Understand the range of psychological therapies available including CBT
. Understand specific interventions and guidelines for individual conditions using, where appropriate, best practice
as described in the Scottish Intercollegiate Guidelines Network or National Institute for Health and Care
Excellence (NICE) guidelines
..........................................................................................

Core beliefs, or schemas, are deeply held beliefs about

What is CBT?
........................................................... self, others and the world. Core beliefs are generally
learned early in life and are influenced by childhood
CBT is based on the cognitive model of mental illness,
experiences and seen as absolute. The cognitive triad
initially developed by Beck (1964). In its simplest form,
of negative core beliefs, as depicted in Fig. 1, captures
the cognitive model ‘hypothesises that people’s emotions
how they relate to:
and behaviours are influenced by their perceptions of 1. The self, e.g. ‘I’m useless’
events. It is not a situation in and of itself that determines 2. The world/others, e.g. ‘the world is unfair’
what people feel but rather the way in which they con- 3. The future, e.g. ‘things will never work out for me’
strue a situation’ (Beck, 1964). In other words, how people
feel is determined by the way in which they interpret situ-
ations rather than by the situations per se. For example,
depressed patients are considered to be excessively nega- Dysfunctional assumptions are rigid, conditional ‘rules for
tive in their interpretations of events (Beck, 1976). living’ that people adopt. These may be unrealistic and
therefore maladaptive. For example, one may live by the
Fundamental to the cognitive model is the way in which rule that ‘It’s better not to try than to risk failing’.
cognition (the way we think about things and the content
of these thoughts) is conceptualised. Beck (1976) out- Negative automatic thoughts (NATs) are thoughts that
lined three levels of cognition: are involuntarily activated in certain situations. In depres-
1. Core beliefs sion, NATs typically centre on themes of negativity, low
2. Dysfunctional assumptions self-esteem and uselessness. For example, when facing a
3. Negative automatic thoughts task, a NAT may be ‘I’m going to fail’. In anxiety

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Figure 1. The cognitive triad of negative core beliefs.
From Beck (1976).
Figure 2. The hot-cross bun model of CBT formulation.
From an idea attributed to Greenberger and Padesky
disorders, automatic thoughts often include overesti- (1995).
mations of risk and underestimations of ability to cope. Reproduced from Scott, A. Cognitive behavioural therapy
and young people: an introduction. Journal of Family Health
In CBT, the ‘cognitive model’ is used as a framework in Care (2009) 19(3), 80–82. With permission from Pavilion
Publishing and Media.
which to understand a person’s mental distress or pre-
senting problem. The process of placing an individual’s
idiosyncratic experiences within a cognitive behavioural grouped into those that help foster an environment of
framework is known as ‘formulation’. A formulation is ‘A collaborative empiricism and those that support the struc-
hypothesis about the causes, precipitants and maintaining tured, problem-orientated focus of CBT.
influences of a person’s problems’ (Eels, 1997). The for-
mulation is intended to make sense of the individual’s Collaborative empiricism (Wright, 2006) is based upon the
experience and aid the mutual understanding of the indi- establishment of a collaborative therapeutic relationship in
vidual’s difficulties. which the therapist and patient work together as a team to
identify maladaptive cognitions and behaviour, test their
Formulations can be developed using different formats, validity, and make revisions if needed. A principal goal of
exemplified by different ways of formulating depression. this collaborative process is to help patients effectively
Beck et al. (1979) created a longitudinal formulation of define problems and gain skills in managing these prob-
depression. Within this formulation, early experiences lems. CBT also relies on the non-specific elements of the
(e.g. rejection by parents) contribute to the development therapeutic relationship, such as rapport, genuineness,
of core beliefs, which lead to the development of dys- understanding and empathy. Initially, to aid the collabora-
functional assumptions (e.g. ‘Unless I am loved I am tive relationship, the therapist explains the rationale of the
worthless’), which are later activated following a critical cognitive behavioural model and illustrates the description
incident (e.g. loss), leading to NATs and the symptoms of using examples from the patient’s own experience.
depression. Formulations can also be cross-sectional. For
example, The ‘hot-cross bun model’ (Greenberger and The focus of CBT is problem-oriented, with an emphasis
Padesky, 1995), shown in Fig. 2, emphasises how an on the present. Unlike some of the other talking treat-
individual’s thoughts, feelings, behaviour and physical ments, it focuses on ‘here and now’ problems and diffi-
symptoms interact. culties. Instead of focusing on the causes of distress or
symptoms in the past, it looks for ways to improve a
patient’s current state of mind. CBT involves mutually
What are the key agreed goal setting. Goals should be ‘SMART’, i.e. spe-
cific, measurable, achievable, realistic and time-limited.
elements of CBT?
...........................................................
For example, a goal for a patient with obsessive compul-
sive disorder may be to reduce the time spent washing
CBT ultimately aims to teach patients to be their own their hands from 5 hours per day to 1 hour per day by
therapist, by helping them to understand their current the end of 3 weeks of therapy. The therapist helps the
ways of thinking and behaving, and by equipping them patient to prioritise goals by breaking down a problem
with the tools to change their maladaptive cognitive and and creating a hierarchy of smaller goals to achieve. CBT
behavioural patterns. The key elements of CBT may be sessions are structured to increase the efficiency of

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treatment, improve learning and focus therapeutic efforts To target dysfunctional assumptions, the patient can be
on specific problems and potential solutions. Sessions asked to provide evidence that supports/does not sup-
begin with an agenda-setting process in which the ther- port their assumptions. The mixed evidence can help
apist assists the patient in selecting items which can lead remould the rules to make them more ‘elastic’ and
to productive therapeutic work in that particular session. accurate.
Furthermore, homework assignments are used to extend
the patient’s efforts beyond the confines of the treatment Thought records are used to make a patient aware of
session and to reinforce learning of CBT concepts. their NATs, distinguish thoughts from facts, and see
how they impact upon their mood. They encourage the
CBT is a structured and time-limited treatment. For non- consideration of alternative thoughts and the resulting
comorbid anxiety or depression, a course of CBT typic- change in emotion. These are used to challenge NATs.
ally lasts 5–20 sessions. If axis II disorders are present, Filling out a seven-column thought record (Greenberger
which are personality disorders or intellectual disabilities, and Padesky, 1995) involves detailing the situation,
treatment may need to be extended due to the lifelong, mood, the NAT, evidence for this NAT, evidence against
pervasive pattern of these disorders and slower change this NAT, the development of an alternative rational
that has been observed with CBT. response, and a rerating of mood.

Behavioural techniques
Activity scheduling and graded task assignment aim to
What techniques are enhance functioning and systematically increase pleasur-
able or productive experiences. Activity scheduling is used
used in CBT?
........................................................... to plan each day in advance. The therapist and patient
work to reduce the mass of tasks to a manageable list,
CBT aims to change how a person thinks (‘cognitive’) and which removes the need for repeated decision making.
what they do (‘behaviour’). CBT therefore uses both cog- The graded task assignments create manageable steps to
nitive and behavioural techniques. The specific interven- help overcome procrastination and anxiety-provoking situ-
tions chosen depend on the individual’s formulation. ations. These techniques involve obtaining a baseline of
activities during a day or week, rating activities on the
degree of mastery and/or pleasure, and then collabora-
Cognitive techniques tively designing changes that will reactivate the patient,
A key cognitive concept in CBT is ‘guided discovery’ stimulate a greater sense of enjoyment in life, or change
(Padesky, 1993). This is a therapeutic stance which patterns of isolation or procrastination. These techniques
involves trying to understand the patient’s view of things help patients re-establish daily routines, increase pleasur-
and help them expand their thinking to become aware of able activities and deal with problems and difficult issues
their underlying assumptions, and discover alternative by increasing problem solving.
perspectives and solutions for themselves. An aspect of
guided discovery is Socratic questioning, which is a Behavioural experiments are mainly used with anxiety-
method of questioning based on the way in which based mental health disorders. The technique allows a
Socrates (c. 400 BC) helped his students to reach a con- person to test out their catastrophic predictions (e.g. ‘If I
clusion without directly telling them. Padesky (1993) leave the house, something terrible will happen’).
explained that Socratic questions should draw the patient’s Concurrently, behavioural experiments also help patients
attention to something outside of their current focus. to learn to tolerate anxiety. The patient makes a predic-
Therapists use questions to probe a patient’s assumptions, tion before completing a task (e.g. walking to the shop)
question the reasons and evidence for their beliefs, high- and then records whether that prediction came true.
light other perspectives and probe implications. For exam- Over time, the patient will thereby be re-evaluating
ple, ‘What else could we assume?’, ‘What do you think their catastrophic thoughts, by developing helpful evi-
causes . . .?’, ‘What alternative ways of looking at this are dence against their predictions. The therapist works
there?’ and ‘Why is . . . important?’. Guided discovery is with the client to develop hierarchical tasks, starting
central to the interventions aimed at each level of from lowest anxiety-provoking task going up to high
cognition. anxiety-provoking tasks.

To target maladaptive core beliefs, the patient can be Behavioural experiments are also used to help patients
asked to keep a positive data log (Padesky, 1994), in gather evidence against the use of ‘safety behaviours’
which the patient keeps a daily log of all observations (Salkovskis, 1996), which are avoidance and escape
that are consistent with a new, more adaptive schema behaviours. Within the cognitive model, safety behav-
(e.g. ‘I am useful to people’). Core beliefs are the least iours reinforce anxiety as they make disconfirmation of
accessible level of cognition and so are tackled later in dysfunctional assumptions and negative automatic beliefs
therapy than dysfunctional assumptions and negative impossible. For example, if a patient avoids going on
automatic thoughts. public transport because they believe something terrible

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will happen, they will believe that avoiding public trans- provide initially, the cumulative cost of continued medi-
port ‘saves’ them from this perceived threat. A behav- cations proved to be more expensive by the end of the
ioural experiment would allow the patient to gather first year of follow-up. Furthermore, mindfulness-based
evidence to discount the predictions that something CBT is a particularly cost-effective approach, because it is
terrible will happen and that the safety behaviour of delivered in a group format.
avoidance is necessary to remain safe.

Progressive relaxation training and breathing exercises

may be used to reduce levels of autonomic arousal related
When should I
to anxiety. These techniques may be used to help manage
panic attacks or other symptoms of anxiety disorders.
recommend CBT?
...........................................................
CBT is a main treatment option for common
mental health disorders. NICE (2011) recommends
Is there evidence that CBT for all depressive and anxiety disorders, as shown
CBT is effective?
...........................................................
in Box 1.

CBT has proven to be an effective treatment for many Box 1. Summary of recommendations for
psychiatric conditions. In a meta-analytic review of con- common mental health disorders.
trolled trials, Lynch et al. (2010) found CBT to be an effect-
CBT is recommended in the following cases:
ive intervention in the treatment of major depression.
Butler et al. (2006) conducted a comprehensive review Depression
of 16 meta-analyses comparing CBT to no-treatment, . Mild to moderate: individual facilitated self-help
wait list and placebo conditions. The authors found CBT based on the principles of CBT and computerised
to be an effective treatment for adult and adolescent bipo- CBT
lar disorder, generalised anxiety disorder, panic disorder . Moderate to severe: CBT in combination with
with or without agoraphobia, social phobia, post traumatic ADM
stress disorder, and childhood depressive and anxiety dis- . Relapse prevention: individual CBT and mindful-
orders. However, there is evidence from Scott et al. (2006) ness-based cognitive therapy (for those who have
that CBT for bipolar disorder may be less effective than had three or more episodes)
treatment as usual in people who have suffered more than Generalised anxiety disorder
12 episodes. CBT fulfils the criteria for a ‘well-established’ . When there is marked functional impairment
empirically supported therapy, as its efficacy has been . When there has been no response to a low-inten-
established in two or more carefully designed methodo- sity intervention
logically reliable randomised controlled trials (Meyer and Panic disorder
Scott, 2008). . For moderate to severe cases (with or without
agoraphobia)
Obsessive compulsive disorder
What are the . Mild to moderate: individual CBT with exposure
and response prevention (ERP) (using self-help
advantages of using materials or over the phone) or group CBT
. Moderate to severe functional impairment, and
CBT?
...........................................................
when there is significant co-morbidity: CBT
(including ERP)
Long-term outcome . Severe impairment: CBT combined with ADM
CBT has been shown to have an enduring positive effect Post traumatic stress disorder
for patients. In a randomised trial, Dobson et al. (2008) . All cases including mild to moderate cases:
found that depressed patients who had previously been trauma-focused CBT.
treated with anti-depressant medication (ADM) had a
Source: NICE (2011).
greater chance of relapse through 1 year follow-up than
patients who had previously received CBT. In fact, prior
CBT had an enduring effect (in terms of prevention of
relapse and recurrence during the follow-up period) that
was at least as strong as continuing patients on ADM.
Improving access to psychological
Cost-effectiveness therapies
In a randomised trial of CBT and ADM, Dobson et al. In 2007 the UK Government announced a large-scale
(2008) found that, although CBT was more expensive to initiative for Improving Access to Psychological

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Therapies (IAPT) for depression and anxiety disorders by patients. A selection of CBT resources is shown
within the English NHS. The IAPT programme supports in Box 2.
frontline NHS in the implementation of NICE guidelines
for depression and anxiety, of which CBT is a key rec-
ommendation. By March 2011, 3660 new cognitive Box 2. Online resources and books based on
behavioural therapy workers had been trained (though CBT principles.
not necessarily as clinical psychologists) to work on the
IAPT programme. High-intensity therapists are trained in Online resources
CBT to treat moderate to severe depression and anxiety. For depression
Psychological well-being practitioners are trained in cog-
nitive behavioural approaches (guided self-help; psycho- www.beatingtheblues.co.uk and www.moodgym.
educational groups) to treat mild to moderate depression anu.edu.au/welcome
and anxiety (www.iapt.nhs.uk). For panic and phobias
www.fearfighter.com (free access can only be pre-
In 2012, a total of 142 of the 151 Primary Care Trusts in scribed by a doctor in England and Wales)
England provided a service from this programme in at
least part of their area and just over 50% of the adult ‘Living life to the full’: www.llttf.com (self-help life
population had access to these services. However, skills training based on CBT)
IAPT services vary significantly across the UK. Details www.moodjuice.scot.nhs.uk/ (for a variety of emo-
of local service provision can be found at www.iapt. tional problems)
nhs.uk/services Books
Manage Your mood: How to use Behavioral
Activation Techniques to Overcome Depression. By
Can CBT be used in Veale and Wilson (2007); Published by Robinson:
London.
primary care?
........................................................... The ‘Overcoming’ series: Published by Constable and
Robinson, this is a series of self-help books which use
Most people with psychological problems are managed in
the theories and concepts of CBT to help people
primary care. There is some evidence that CBT can be
overcome many common problems. Titles include:
effectively adapted and utilised in such settings. For exam-
Overcoming Social Anxiety and Shyness,
ple, Edinger and Sampson (2003) found that a specially
Overcoming Depression and Overcoming Low Self-
abbreviated two-session course of CBT for insomnia, deliv-
Esteem.
ered by a beginner-level clinical psychologist, reduced
subjective sleep disturbance and insomnia symptoms in Manage Your Mind: The Mental Fitness Guide,
primary care patients to a greater extent than generic second edition. By Butler and Hope (2007).
sleep hygiene suggestions. Additionally, Proudfoot et al. Published by Oxford University Press.
(2004) found computer-delivered CBT (a package called
‘Beating the Blues’) to be an effective treatment for anxiety
and/or depression in general practice.

Studies have investigated how best to equip GPs with CBT

skills to use in primary care. Heatley et al. (2005) found that Key points
training and clinical supervision in CBT for panic disorders . The cognitive model hypothesises that people’s
increased GPs’ use of CBT techniques and ability to assess
emotions and behaviours are influenced by their
and manage the disorders. Nonetheless, a remaining ques-
perceptions of events
tion is how to most (time- and cost-) effectively equip
. Cognition is split into three levels: core beliefs,
already heavily burdened GPs with additional CBT skills.
dysfunctional assumptions and NATs
Given the proven effectiveness of CBT, this is a worthwhile
. Formulation is the process by which an individual’s
endeavour.
experiences are placed within a cognitive behav-
ioural framework
. CBT is time-limited, problem-oriented and
What CBT resources can collaborative
. CBT involves both cognitive techniques, such as
I recommend to guided discovery and Socratic questioning, and
behavioural techniques, such as activity schedul-
patients?
...........................................................
ing and behavioural experiments
. The effectiveness of CBT for many psychiatric con-
There are various online resources and books based ditions is supported by meta-analytic and system-
on CBT principles, which can be accessed directly atic reviews

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. Lynch, D., Laws, K., and McKenna, P. (2010).
References and further information Cognitive behavioural therapy for major psychiatric
. Beck, A. T. (1976). Cognitive Therapy and the disorder: Does it really work? A meta-analytic
Emotional Disorders. New York: Penguin review of well-controlled trials. Psychological
. Beck, A. T., Rush, J., Shaw, B., & Emery, G. (1979). Medicine, 40, 9–24. doi: 10.1017/
Cognitive Therapy of Depression. New York: S003329170900590X
Guildford Press . Linehan, M. (1993). Cognitive-Behavioral
. Beck, J. S. (1964). Cognitive Therapy: Basics and Treatment of Borderline Personality Disorder.
Beyond. New York: Guildford Press New York: Guilford Press
. British Association for Counselling and . Meyer, T., & Scott, J. (2008). Cognitive behavioural
Psychotherapies. How has IAPT evolved? therapy for mood disorders. Behavioural and
Retrieved from www.bacp.co.uk/iapt/how.php Cognitive Psychotherapy, 36, 685–693. doi:
. Butler, A., Chapman, J., Foreman, E., & Beck, A. T. 10.1017/S1352465808004761
(2006). The empirical status of cognitive-behavioral . NICE (2011). CG123: Common Mental Health
therapy: a review of meta-analyses. Clinical Disorders: Identification and Pathways to Care.
Psychology Review, 26, 17–31. doi:10.1016/ Retrieved from: www.nice.org.uk/nicemedia/live/
j.cpr.2005.07.003 13476/54520/54520.pdf
. Clark, D., Beck, A. T., & Alford, B. (1999). . Padesky, C. (1993). Socratic questioning: changing
Scientific Foundations of Cognitive Theory and minds or guiding discovery? Keynote address
Therapy of Depression. New York: John Wiley delivered at European Association for Behavioural
. Dimidjian, S., Hollon, S., Dobson, K., Schmaling, and Cognitive Psychotherapies Conference,
K., Kohlenberg, R., Addis, M., . . . Jacobson, N. London.
(2006). Randomized trial of behavioral activation, . Padesky, C. (1994). Schema change processes in
cognitive therapy, and antidepressant medication cognitive therapy. Clinical Psychology and
in the acute treatment of adults with major depres- Psychotherapy, 1, 267–278. doi: 10.1002/
sion. Journal of Consulting and Clinical Psychology, cpp.5640010502
74, 658–670. doi: 10.1037/0022-006X.74.4.658 . Proudfoot, J., Ryden, C., Everitt, B., Shapiro, D.,
. Dobson, K. (1989). A meta-analysis of the efficacy Goldberg, D., Mann, A., . . . Gray, J. (2004).
of cognitive therapy for depression. Journal of Clinical efficacy of computerised cognitive-
Consulting and Clinical Psychology, 57, 414–419. behavioural therapy for anxiety and depression in
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. Dobson, K., Hollon, S., Dimidjian, S., Schmaling, Journal of Psychiatry, 85, 46–54. doi: 10.1192/
K., Kohlenberg, R., Gallop, R., . . . Jacobson, N. bjp.185.1.46
(2008). Randomized trial of behavioral activation, . RCGP. Clinical example 3.10: Care of people with
cognitive therapy, and antidepressant medication mental health problems. Retrieved from
in the prevention of relapse and recurrence in www.rcgp.org.uk/gp-training-and-exams//
major depression. Journal of Consulting and media/Files/GP-training-and-exams/Curriculum-
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0022-006X.76.3.468 Problems.ashx
. Edinger, J. & Sampson, W. (2003). A primary care . Royal College of Psychiatrists (2012) Description of
‘friendly’ cognitive behavioral insomnia therapy. CBT. Retrieved from www.rcpsych.ac.uk/mental-
SLEEP, 26, 177–182. Retrieved from www.journal- healthinfoforall/treatments/cbt.aspx
sleep.org/Articles/260209.pdf . Salkovskis, P. (1996). Trends in Cognitive and
. Eels, T. (1997). Handbook of Psychotherapy Case Behavioural Therapies. Chichester: John Wiley
Formulation. New York: Guilford Press . Scott, A. (2009). Cognitive behavioural therapy
. Fennell, M. (1999). Overcoming Low Self-Esteem: and young people: an introduction. Journal of
A Self-Help Guide Using Cognitive-Behavioural Family Health Care, 19(3), 80–82
Techniques. London: Constable Robinson . Scott, J., Paykel, E., Morriss, R., Bentall, R.,
. Greenberger, D., & Padesky, C. (1995). Mind Over Kinderman, P., Johnson, T., . . . Hayhurst, H.
Mood: A Cognitive Therapy Treatment Manual for (2006). Cognitive-behavioural therapy for severe
Clients. New York: Guilford Press and recurrent bipolar disorders: randomised con-
. Hayes, S., Strosahl, K., & Wilson, K. (1999). trolled trial. British Journal of Psychiatry, 188,
Acceptance and Commitment Therapy: An 313–320. doi: 10.1192/bjp.188.4.313
Experiential Approach to Behavior Change. New . Teasdale, J., Segal, Z., & Williams, J. (1995). How
York: Guilford Press does cognitive therapy prevent relapse and why
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relapse/recurrence in major depression by mind- 173–178. Retrieved from http://focus.psychia-
fulness-based cognitive therapy. Journal of tryonline.org/data/Journals/FOCUS/2634/173.pdf
Consulting and Clinical Psychology, 68, 615–623.
doi: 10.1037/0022-006X.68.4.615
. Wright, J. (2006). Cognitive behavior therapy:
basic principles and recent advances. Focus 4,

Miss Kristina Fenn

King’s College, University of London
Email: [email protected]

Dr Majella Byrne
Clinical Psychologist, Outreach and Support in South London (OASIS) and Institute of Psychiatry,
King’s College, University of London

DOI: 10.1177/1755738013497646
............................................................................................................................................................

AKT question relating to central retinal

vein occlusion
Single Best Answer Question A. Branch retinal artery occlusion
..........................................................................................................

B. Branch retinal vein occlusion

An 82-year-old woman attends your morning surgery
C. Central retinal artery occlusion
complaining of acute, unilateral loss of vision that has
D. Central retinal vein occlusion
developed overnight. She denies a headache, but does
E. Diabetic retinopathy
smoke and has a history of hypertension.
Answer DOI: 10.1177/1755738013497647
On examination her corrected visual acuity is 6/60 and
there is no evidence of an afferent pupillary defect.
Fundoscopy reveals the following appearance.

Sue Ford/Science Photo Library

What is the SINGLE MOST likely diagnosis in this

patient? Select ONE option only.

Dr Ranbir Rajput
GP, Craigmillar Medical Group, Edinburgh

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