1. COGNITIVE BEHAVIOURAL THERAPY (CBT): A Basic Overview
Carly Welch – University of Birmingham
LEARNING OBJECTIVES
1. To develop a basic knowledge of the importance of CBT in clinical practice
and the conditions for which it can be used
2. To understand the key principals of CBT and the Activating Event – Belief
– Consequence concept
3. To develop the ability to perceive thinking errors in oneself and others
4. To understand the basic techniques that are used for various conditions
5. To be able to set Specific, Positive, Observable, Realistic and Timed goals
for oneself and others
BACKGROUND
The first account of a therapeutically targeted cognitive behavioural therapy was
developed by Albert Ellis in the 1950s, and was termed “Rational Emotive
Therapy (RET)”. He devised this therapy as he was markedly critical of the
shortcomings of psychoanalysis, which were based on Freudian principals. Ellis
took inspiration from his ideas from Stoic philosophers such as Epictetus and
Marcus Aurelius. Epictetus cited in The Enchiridion:
“Men are disturbed not by things, but by the view which they take of them”
Ellis developed and popularised the ABC (Activating Event, Belief,
Consequence) model, which he later expanded into the ABCDE (Activating Event
– Belief – Consequence – Dispute – Effect) approach. Other people who
contributed to the development of modern-day CBT were Alfred Adler, Aaron
Beck, Maxie Maultsby, Michael Mahoney, David Burns and others. Alfred Adler
reportedly stated:
“I am convinced that a person’s behaviour springs from his ideas”i
It is this very principal upon which CBT is based. On a very simplistic level much
of what CBT teaches is based on what seems obvious, and may perhaps be
referred to as pure common sense thinking. However, it is clear that what seems
obvious from an objective viewpoint is quite the opposite to someone
overwhelmed by emotions. CBT aims to separate thoughts from emotions so that
one might rationalise their way of thinking.

2. What is the evidence that CBT really works?
CBT has one of the strongest evidence bases of all psychotherapies and is
constantly being reviewed and improved in respect to new research. The vast
majority of this research related to the implementation of CBT for the treatment of
anxiety and depression, although it has proved effective for many other
conditions as well. Many randomised controlled trials have showed CBT to be
more effective or equivalent to medication for the management of both anxiety
and depression.
To take the example of depression, a one-year follow up of a recent trial
indicates that patients undergoing CBT were less likely to relapse than patients
taking antidepressants alone.ii
A combination of CBT and antidepressants has
also been shown to be more effective than antidepressants alone with reductions
in both clinician-rated and patient-rated depression scores.iii
Interestingly, studies
comparing CBT and antidepressants with CBT alone found no real benefit,
suggesting that the benefit of adding CBT to antidepressants could be derived
from CBT alone.iv
Why is CBT important?
Depression and anxiety are common conditions and antidepressants are some of
the most commonly prescribed medications in the community. Some research
has shown that psychotherapies are more widely accepted by patients than
medication. As CBT has been shown to have a lower risk of relapse, it may
potentially be more cost-effective to the NHS than drug treatment.
Although CBT does not work on everyone, on those who it does work, it works
very well. It has been shown to be superior to other psychotherapies, although
each have their own merits.
PRINCIPALS OF CBT
Many people assume that an event makes them feel a certain way e.g. someone
who treats them inconsiderately makes them feel angry. Some people may even
say that this makes them behave in a certain way. CBT works on the basis that a
thought process lies between the event and the feelings and actions that follow. It
is the thoughts, beliefs and meanings that people give to the event that produce
the emotional and behavioural responses.
It is very interesting to observe how different people might react to the same
event, and the different thought processes that are involved. It is assumed that
less extreme and more reasonable thoughts lead to healthier emotions.

3. Example: Imagine someone close to you treats you inconsiderately. How do you
feel?
Person 1: Angry “That idiot has no right to treat me that way”
Person 2: Depressed “This lack of consideration means they don’t love me”
Person 3: Jealous “This means they care more about someone else”
Person 4: Hurt “I don’t deserve to be treated poorly because I am always
considerate”
Person 5: Guilty “I must have done something to upset them”
Person 6: Anxious “This must mean they’re losing interest in me”
Person 7: Happy “Great now I can use this as an excuse to end our relationship”
Person 8: Annoyed “I’m not prepared to put up with this behaviour”
Person 9: Disappointed “I wish they had been more considerate”
Person 10: Ashamed “They must have found out something about me”
There are many more ways of interpreting the same event, as well as those listed
above. This means that each person should question the accuracy of their
thought process before allowing their emotions to cloud their judgement.
Learning your ABCs
This is the foundation upon which CBT was developed, and is shown more
clearly in Figure 1. It works on the basic principal that our emotions are governed
by our thoughts and gives a simple process for patients to work through.
A is the Activating event: It may refer to a real external event, an external event
that is anticipated to happen in the future or an internal event in the subject’s own
mind (e.g. image, memory, dream)
B refers to the Beliefs of the subject: These include thoughts, personal
expectations of yourself, the world and other people and the meanings attached
to events
C refers to the Consequences: These include emotions, behaviours and the
physical sensations related to certain emotions.
Patients are often encouraged to complete “ABC forms” upon which they work
through in reverse in a “CAB” format. Initially thinking of their emotion or
behaviour and the event which triggered that emotion, and then recalling their
thoughts at the time.
Example: Anxious person
A: Imagines failing an interview
B: “I’ve got to make sure that I don’t mess this up otherwise I’ll prove that I’m a
failure”

4. C: Anxiety (emotion), butterflies in the stomach (physical sensation), drinking
alcohol to calm their nerves (behaviour)
Example: Depressed person
A: Fails job interview
B: “I should’ve done better. I’m a failure”
C: Depression (emotion), loss of appetite (physical sensation), stays in bed to
avoid the world (behaviour)
Figure 1 – The ABC principal:
A development upon this is the ABCDE form (see Appendix), where D stands for
Dispute and E stands for Effect. Here patients are encouraged to question and
examine their beliefs and generate alternatives (dispute) and think of the effect
which these alternatives have. This may be a more healthy feeling e.g. concern
as opposed to anxiety, sadness as opposed to depression or a less extreme
version of the original emotion.
For this reason patients are often encouraged to rate their emotions as a
percentage so that they can be easily re-evaluated later on e.g. someone may
originally state that they feel 70% anxious, which they later lower to 40%.

5. Examples of conditions that can be managed with the use of CBT
Conditions for which NICE has issued guidance for the use of CBT:
- Schizophrenia
- Eating disorders
- Self-harm
- Anxiety
- Depression
- Bipolar disorder
- Depression in children
- Dementia
- Obsessive-Compulsive Disorder (OCD)
- Post Traumatic Stress Disorder (PTSD)
- Disturbed (violent) behaviour
Other conditions for which CBT may prove beneficial:
- Addiction
- Chronic fatigue syndrome
- Chronic pain
- Personality disorders
- Phobias
- Relationship problems
- Psychotic disorders
THINKING ERRORS
Thinking errors are mistakes in thinking that everyone makes from time to time
i.e. they are a normal occurrence. It is these thinking errors which can prevent
people from looking objectively at their situation. There are many different types
of thinking errors, and some people seem to be more prone to particular types of
thinking errors than others.
1. Catastrophising: Taking a relatively minor negative event and imagining
disasters resulting from this one event. Correct this by:
a. Putting your thoughts into perspective
b. Considering less terrifying explanations
c. Weighing up the evidence
d. Focussing on what can be done to overcome the situation
2. All-or-nothing thinking: Extreme thinking that can lead to extreme
emotions. Correct this by:
a. Being realistic
b. Developing “both-and” reasoning skills
3. Fortune telling: Trying to predict what might happen in the future. Correct
this by:
a. Testing out your predictions

6. b. Being prepared to take risks
c. Understanding that the past does not determine the future
4. Mind-reading: Assuming that other people have negative thoughts.
Correct this by:
a. Generating alternative explanations for the way people are
behaving (e.g. tired, preoccupied)
b. Consider the evidence and get more information if appropriate
5. Emotional reasoning: Relying too heavily on our feelings as a guide to
our thoughts. Correct this by:
a. Paying attention to your thoughts and seeing how you use your
emotions to justify what you think
b. Ask yourself what you’d think if you were feeling calmer
c. Allowing time for your feelings to subside
6. Overgeneralising: Drawing global conclusions from events (“always”,
“never”, “people are …”, “the world is ….”). Correct this by:
a. Getting perspective
b. Suspending judgement
c. Being specific
7. Labelling: Globally rating things that are too complex for a definitive label.
Correct this by:
a. Allowing for varying degrees
b. Celebrating complexities
8. Making demands: Thoughts and beliefs that contains words like “must”,
“should”, “need”, “ought”, “got to” and “have to”. Correct this by:
a. Paying attention to language
b. Limiting approval seeking
c. Understanding that the world doesn’t play to your rules
d. Retain your standards and ideals but without the rigid demands
9. Mental filtering: Acknowledging only information that fits with your
particular belief system. Correct this by:
a. Closely examining your filters
b. Gathering evidence
10.Disqualifying the positive: Transforming a positive event into a neutral
or negative event in your mind. Correct this by:
a. Becoming aware of your responses to positivity
b. Practice accepting compliments
11.Low frustration tolerance: Magnifying discomfort and not tolerating it
even temporarily. Correct this by:
a. Pushing yourself to do things that are uncomfortable
b. Giving yourself messages that emphasise your ability to withstand
pain
12.Personalising: Interpreting events as relating to you personally. Correct
this by:
a. Imagining what else may have contributed to the outcome
b. Consider why people may be responding in a certain way

7. CBT aims to correct these thinking errors by encouraging people to take a step
back from a situation and approach it with a healthier mind. Many people feel
differently about an event months or years after it happens, and are able to
“laugh it off”. This is because thinking errors are no longer clouding their
judgement. With the help of CBT, people can be made to feel as they might later
much earlier on.
*Exercise* Match the thoughts to the appropriate thinking errors
1. "Nobody likes me."
2. "I'm the worst student in the world."
3. "I missed the bus, I'm such an incapable person."
4. "I should study longer."
5. "I'm causing problems for a lot of people."
6. "I didn't remember to get a Christmas present for Cassandra's kid, hence
I'm useless (even though I remembered presents for all others)."
7. "I'll never get a job."
8. "I'm a jerk."
9. "It's always my fault."
10."I must get a Distinction in my exam or else I'm worthless."
11."So I scored the goal that won the match, anyone could do it."
12."If I haven't had sex by the time I'm 20 I may as well give up thoughts of
intimate relationships forever."
13."Although I got high distinctions in all my subjects, I failed PE, hence I'm a
failure."
14."I'm angry, so somebody must be trying to take advantage of me."
15."I failed to put out the garbage bins again, the world will end."
16."So I got the University Medal in physics, anyone could do it."
17."I should do better at my work."
18."I'm miserable so I must be a miserable person."
19."So what if David said he was proud of me, he doesn't mean it."
20."I'm so fat I could never succeed in life."
CBT IN PRACTICE
The way in which CBT is implemented is very different for different conditions,
and is also individually based. Below are some of the systems that are used for
some of the most common conditions dealt with by CBT therapists.
Anxiety
A key principal of CBT is FEAR – Face Everything And Recover. The idea is that
through the process of facing up to anxiety (exposure or desensitisation), people
will become more accustomed to it (habituation). Subjects are encouraged to
wait until their anxiety reduces by half before ending the exposure. Upon their

8. next exposure their peak anxiety will be lessened. This is shown more clearly in
Figure 2.
Figure 2 – Reduction of anxiety upon multiple exposures
Depression
It is thought that potentially as many as one in two people will experience
depression at some point in their lives. CBT helps depressed people to learn to
overcome their mood by doing the opposite of what their depression makes them
feel like doing. Depression is characterised by rumination (a pattern of cyclical
thinking, repeatedly going over things in the past), negative thinking, inactivity,
social withdrawal, procrastination, shame, guilt and hopelessness. CBT
encourages individuals to recognise when they are going into rumination so that
they can take steps towards getting out of it.
Rumination can be hindered in a number of ways; by getting busy to focus
concentration elsewhere, by learning to allow thoughts to simply pass by without
reacting to them, by redirecting thoughts elsewhere or sceptically analysing the
thoughts.
Inactivity can be difficult to overcome, however it can be done in small steps.
Making a diary often proves useful. Many people find that, although they do not
necessarily enjoy doing things as much as they did before they became
depressed, they are glad to have done something.
Anxiety
1st
exposure
2nd exposure
3rd
exposure
Time
4th
exposure

9. Obsessive-Compulsive Disorder (OCD)
Individuals are often encouraged to see how their rituals relate to their
obsessions by following out two experiments. They are asked to alternately
reduce and increase their ritual behaviours and observe how their
preoccupations are affected. Patients often find that they become more
preoccupied on the days when they increase their ritual behaviour, clearly
emphasising that the ritual is part of the problem. Sometimes stopping rituals
altogether can be difficult so individuals are encouraged to first delay or modify
their rituals.
Many sufferers of OCD often overestimate their responsibility of a problem.
Filling out a responsibility pie chart can help them to see that they are not entirely
responsible for the outcome. The idea is that they first rate their responsibility for
a feared event as a percentage. They then write down a list of all the possible
factors that could affect the event happening and put them into a pie-chart,
leaving a space for themselves last. Often, they will find that their original
estimate of their responsibility was greater than that on the pie-chart.
CASE 1
Mrs. Olivia Catherine Denton has been feeling “on edge” and anxious for some
time. You see her at home, and she says that she constantly thinks about the
possibility of her house burning down and feels the need to check and re-check
various electrical appliances and has to come home from work several times
each day just to check it’s still there. When asked further about the most recent
time she felt on edge (not long before this consultation), she describes how her
husband put some toast on and she had to stand and watch it. She says she
thought “If I look away for a split second there will be a fire, which will spread to
the rest of the house, and it will all be my fault”.
CASE 2
Mr. B. Down has been feeling particularly low for some time. He spends most of
his time in bed, and when he does get up, he does not feel he has the energy to
do anything. He tells you that he was feeling particularly “low” this morning when
his wife informed him that she was taking the children out for the day. He said
that he thought “She didn’t bother to invite me. I’m a useless pathetic failure and
my wife and kids agree”.

10. CASE 3
Ms. Ann X has an immense fear of social situations, particularly events such as
large parties involving lots of people. She says that she was invited to an event
last weekend but was unable to go. She says she imagined herself making a fool
of herself (e.g. falling over and exposing herself) in front of everyone and being
ridiculed by the other guests. This gave her an overwhelming sense of fear that
manifested as a fast heart rate, wobbly knees, dry throat and butterflies in the
stomach. She said she thought “If I go to this party, then I am bound to draw
attention to myself and be hugely embarrassed”.
SETTING GOALS
Many people fail to achieve the goals they set themselves, because they are too
vague. “SPORT” is a useful acronym that can be used to devise goals that can
be realistically achieved.
Specific – Where/when/with who?
Positive – In positive terms e.g. be more confident as opposed to be less anxious
Observable – Think of a real change that you can observe, so that you know
when you have achieved your goal
Realistic – Focus of goals that are within your reach
Timed – Set a timeframe within which you want to achieve your goal
Remember this acronym for the future. It is a very effective way of helping you to
visualise what you want to achieve, and putting your goals into writing can
improve your motivation. However, it is important to remember that not achieving
these goals is normal and making mistakes is what makes us all human.
REFERENCES:

11. i
() National Association of Cognitive-Behavioral Therapists. History of Cognitive-Behavioural
Therapy. Available via URL: http://www.nacbt.org/historyofcbt.htm [Accessed 8 Nov 2009]
ii
() Dimidjian, S., Hollon, S.D., Dobson, K.S., et al. (2006) Randomized trial of behavioral
activation, cognitive therapy, and antidepressant medication in the acute treatment of adults
with major depression. Journal of Consulting & Clinical Psychology, 74, 658-670.
iii
() Fava, G.A., Ruini, C., Rafanelli, C., et al. (2004) Six-year outcome of cognitive behavior
therapy for prevention of recurrent depression. The American Journal of Psychiatry, 161,
1872-1876.
iv
() Nice Guidelines. CG90 Depression in adults 28 Oct 2009
(5) Wilson R & Branch R. Cognitive Behavioural Therapy for Dummies, John Riley & Sons,
Edition 1, 2005