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Just as some knowledge of a client’s background can be helpful in understanding his current state, an appreciation of how CBT developed can help us to understand its modern form. Modern CBT has two main influences: first, behaviour therapy as developed by Wolpe and others in the 1950s and 1960s (Wolpe, 1958); and second, the cognitive therapy approach developed by A.T. Beck, beginning in the l960s but becoming far more influential with the ‘cognitive revolution’ of the 1970s.

Behaviour therapy (BT) arose as a reaction against the Freudian psychodynamic paradigm that had dominated psychotherapy from the nineteenth century onwards. In the 1950s, Freudian psychoanalysis was questioned by scientific psychology because of the lack of empirical evidence to support either its theory or its effectiveness (Eysenck, 1952). BT was strongly influenced by the behaviourist movement in academic psychology, which took the view that what went on inside a person’s mind was not directly observable and therefore not amenable to scientific study. Instead behaviourists looked for reproducible associations between observable events, particularly between stimuli (features or events in the environment) and responses (observable and measurable reactions from the people or animals being studied). Learning theory, a major model in psychology at that time, looked for general principles to explain how organisms learn new associations between stimuli and responses.

In this spirit, BT avoided speculations about unconscious processes, hidden motivations and unobservable structures of the mind, and instead used the principles of learning theory to modify unwanted behaviour and emotional reactions. For instance, instead of trying to probe the unconscious roots of an animal phobia, as Freud famously did with ‘Little Hans’ (a boy who had a fear of horses: Freud, 1909), behaviour therapists constructed procedures, based on learning theory, which they believed would help people learn new ways of responding. The BT view was that someone like Little Hans had learned an association between the stimulus of a horse and a fear response, and the task of therapy was therefore to establish a new, non-fearful, response to that stimulus. The resulting treatment for anxiety disorders, known as systematic desensitisation, asked clients to repeatedly imagine the feared stimulus whilst practising relaxation, so that the fearful response would be replaced by a relaxed response. Later developments often replaced imaginal exposure (e.g. thinking about a mental picture of the horse) with in vivo exposure (approaching a real horse).

BT rapidly became successful, especially with anxiety disorders such as phobias and obsessive-compulsive disorder (OCD), for two main reasons. First, in keeping with its roots in scientific psychology, BT had always taken an empirical approach, which soon allowed it to provide solid evidence that it was effective in relieving anxiety problems. Second, BT was a far more economical treatment than traditional psychotherapy, typically taking 6-12 sessions.

Despite this early success, there was some dissatisfaction with the limitations of a purely behavioural approach. Mental processes such as thoughts, beliefs, interpretations, imagery and so on, are such an obvious part of life that it began to seem absurd for psychology not to deal with them. During the 1970s this dissatisfaction developed into what became known as the ‘cognitive revolution’, wherein ways were sought to bring cognitive phenomena into psychology and therapy, whilst still trying to maintain an empirical approach that would avoid ungrounded speculation.

Beck had trained as a psychiatrist and as a psychodynamic psychotherapist, but he increasingly felt that there was more that he could offer ethe clients who did not respond to a psychodynamic intervention. During the 1950s and early 1960s, he and others had already begun to develop ideas about cognitive therapy (CT) and considered the fusion of insight with BT, but their ideas became increasingly influential from the 1970s onwards. The publication of Beck’s book on CT for depression (Beck et al., 1979), and research trials showing that CT was as effective a treatment for depression as anti-depressant medication (e.g. Rush, Beck, Kovacs & Hollon, 1977), fuelled the revolution. Over the succeeding years, BT and CT grew together and influenced each other to such an extent that the resulting amalgam is now most commonly known as ‘cognitive behaviour therapy’ - CBT.

So, what elements of BT and CT have emerged to form the foundation of modern CBT? Here we set out what we see as the most basic principles and beliefs on which our model of CBT is based, so that you can decide for yourself whether you think they make sense – or at least enough sense to be worth giving CBT a try. Below are what we consider to be the fundamental beliefs about people, problems and therapy that are central to CBT. We are not suggesting that these beliefs are necessarily unique to CBT – many of them may be shared by other approaches – but the combination of these principles goes some way towards characterising CBT.

The Cognitive Principle

The core idea of any therapy calling itself ‘cognitive’ is that people’s emotional reactions and behaviour are strongly influenced by cognitions (in other words, their thoughts, beliefs and interpretations about themselves or the situations in which they find themselves – fundamentally the meaning they give to the events of their lives). What does this mean?

It may be easiest to start from a ‘non-cognitive’ perspective. In ordinary life, if we ask people what has made them sad (or happy, or angry, or whatever), they often give us accounts of events or situations: for example, ‘I am fed up because I have just had a row with my girlfriend’. However, it cannot be quite that simple. If an event automatically gave rise to an emotion in such a straightforward way, then it would follow that the same event would have to result in the same emotion for anyone who experienced that event. What we actually see is that to a greater or lesser degree, people react differently to similar events. Even events as obviously terrible as suffering a bereavement, or being diagnosed with a terminal illness, do not produce the same emotional state in everyone: some may be completely crushed by such events, whilst others cope reasonably well. So it is not just the event that determines emotion: there must be something else. CBT says that the ‘something else’ is cognition, that is, the interpretations people make of the event. When two people react differently to an event it is because they are seeing it differently, and when one person reacts in what seems to be an unusual way, it is because he has unusual thoughts or beliefs about the event: it has an idiosyncratic meaning for him. Figure 1.1 illustrates this.

Let’s look at a simple example of this process. Suppose you are walking down the street and you see someone you know coming the other way, but she does not seem to notice you.

Here are a number of possible thoughts about this event – note how the possible emotional responses arising from those interpretations vary:

• ‘I can’t think of anything to say to her, she’ll think I'm really boring and stupid.’ [Leading to anxiety]
• ‘Nobody would ever want to talk to me anyway, no one seems to like me.’ [Causing depression]
• ‘She’s got a nerve being so snooty, I’ve not done anything wrong.’ [Triggering anger]
• ‘She’s probably still hung over from that party last night!’ [Resulting in amusement]

This illustrates the fundamental cognitive principle, that different cognitions give rise to different emotions. It also shows the association between certain kinds of cognition and corresponding emotional states: for instance, that thoughts about others being unfair, or breaking rules that we hold dear, are likely to be associated with anger. We shall have more to say about this idea later.

There is, of course, nothing new about the idea that meaning is important. The ancient Greek Stoic philosopher Epictetus said over 1,800 years ago that ‘Men are disturbed, not by things, but by the principles and notions which they form concerning things.’ Yet as we shall see in the rest of this book, the ramifications and elaborations of this simple idea have led to the development of a powerful approach to helping people in distress. By helping people to change their cognitions, we may be able to help them change the way they feel.

The Behavioural Principle

Part of the inheritance from BT is that CBT considers behaviour (what we do) as crucial in maintaining – or in changing – psychological states. Consider the above example again. If you had either the first or second cognition, then your subsequent behaviour might have a significant effect on whether your anxiety or depression persisted. If you approached your acquaintance and chatted, you might discover that she was actually friendly towards you. As a result, you might be less inclined to think negatively in future. On the other hand, if you pretended not to see her, you would not have a chance to find out that your thoughts were inaccurate, and negative thoughts and associated emotions might persist. Thus, CBT believes that behaviour can have a strong impact on thought and emotion, and, in particular, that changing what you do is often a powerful way of changing thoughts and emotions.

The ‘Continuum’ Principle

In contrast to some more traditional medical approaches, CBT believes that it is usually more helpful to see mental health problems as arising from exaggerated or extreme versions of normal processes, rather than as pathological states that are qualitatively different from, and inexplicable by, normal states and processes. In other words, psychological problems are at one end of a continuum, not in a different dimension altogether. Related to this belief are the further ideas that (a) psychological problems can happen to anyone, rather than being some freakish oddity; and (b) that CBT theory applies to therapists as much as to clients.

The ‘Here and Now’ Principle

Traditional psychodynamic therapy took the view that looking at the symptoms of a problem – for example, the anxiety of a phobic person - was superficial, and that successful treatment must uncover the developmental processes, hidden motivations and unconscious conflicts that were supposed to lie at the root of a problem. BT took the view that the main target of treatment was the symptoms themselves and that one could tackle the anxiety (or whatever) directly, by looking at what processes currently maintained it and then changing those processes. Psychoanalysis argued that treating symptoms rather than the supposed ‘root causes’ would result in symptom substitution, that is, the unresolved unconscious conflict would result in the client’s developing new symptoms. In fact, a wealth of research in BT showed that such an outcome, although possible, was rare: more commonly, tackling symptoms directly actually resulted in more global improvement.

Modern CBT has inherited BT’s approach. The main focus of therapy, at least most of the time, is on what is happening in the present, and our main concerns are the processes currently maintaining the problem, rather than the processes that might have led to its development many years ago. Having said that, CBT does not dismiss the past, far from it, and Chapter 4 on assessment and formulation discusses this further.

The ‘Interacting Systems’ Principle

This is the view that problems should be thought of as interactions between various ‘systems’ within the person and in their environment, and it is another legacy from BT (Lang, 1968). Modern CBT commonly identifies four such systems:

• cognition;
• affect, or emotion;
• behaviour;
• physiology.

These systems interact with each other in complex feedback processes and also interact with the environment – where ‘environment’ is to be understood in the widest possible sense, including not just the obvious physical environment but also the social, family, cultural and economic environment. Figure 1.2, based on what is sometimes called the ‘hot cross bun’ model (Padesky & Mooney, 1990), illustrates these interactions.

This kind of analysis helps us to describe problems in more detail, to target specific and dynamic aspects of a problem and to gain a richer understanding of its maintenance. We can also to consider times when one or more systems are not correlated with the others. For example, ‘courage’ could be said to describe a state where a person’s behaviour is not correlated with emotional state: although a woman is feeling fearful, her behaviour is not overtly fearful. Clinically it can be crucial to identity mis-matches between clients’ thoughts, feelings and actions so that we can better understand a person’s strengths, needs and perceptions.

The Empirical Principle

CBT believes we should evaluate theories and treatments as rigorously as possible, using scientific evidence rather than just clinical anecdote. This is important for several reasons:

• Scientifically, so that our treatment can be founded on sound, well-established theories. One of the characteristic features of CBT is that, in contrast to some schools of therapy that have remained little changed since they were first devised, it has developed and made steady advances into new areas through the use of scientific research.
• Ethically, so that we can have confidence in telling people who are receiving and/or purchasing our treatments that they are likely to be effective.
• Economically, so that we can make sure that limited mental-health resources are used in the way that will bring most benefit.

The Interpersonal Principle

As Beck’s early psychodynamic training taught him, CBT takes place in the context of a dynamic relationship. In CBT this is a working alliance as CBT is not ‘administered’ or ‘done to’ a client. Instead, we foster a milieu that enables us to work with a person, who engages with full knowledge and consent. This is such an important principle that we have dedicated Chapter 3 to its exploration.

Contrary to what some might expect, we hypothesise about intention and unspoken feelings and we monitor our own cognitive and emotional reactions to clients. Sometimes there is much to be learnt from this and we formulate its impact on our therapy. For example, we might hypothesise that a fleeting look of discomfort during a session is significant and usefully explored because it might reveal a client’s relevant but shameful secret, one which serves to maintain the problem. On the other hand it might simply reveal a bout of cramp – so we should always be prepared for our hypotheses to be refuted!

Summary of CBT Principles

These then are what we would take as the basic principles at the heart of CBT. To summarise:

• The cognitive principle: It is interpretations of events not events themselves which are crucial.
• The behavioural principle: what we do has a powerful influence on our thoughts and emotions.
• The continuum principle: mental-health problems are best conceptualised as exaggerations of normal processes.
• The here-and-now principle: it is usually more fruitful to focus on current processes rather than the past.
• The interacting-systems principle: it is helpful to look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates.
• The empirical principle: it is important to evaluate both our theories and our therapy empirically.
• The interpersonal principle: we work with an informed and active person and we consider and formulate dynamic aspects of our relationship.

Let us now turn to an elaboration of the fundamental cognitive principles.

So far we have talked about ‘cognition’ as if it were a single concept. In fact, CBT usually distinguishes between different kinds or ‘levels’ of cognition. The following account of levels of cognition is based on what has been found clinically useful; a later section will briefly consider the scientific evidence for some of these ideas.

When we talk of cognitions, we refer not only to thoughts – which can readily be put into words – btu to images, too. This convention is rather confused by CBT therapists’ widespread use of terms such as ‘automatic thoughts’ (Ats) and ‘negative automatic thoughts’ (NATs) as we seem to be excluding images. Be assured that images are relevant cognitions just as thoughts are.

It is worth noting that different CBT practitioners might categorise cognitions differently, and although the following classification is commonly used, it is not the only one.

Automatic Thoughts (ATs)/ Negative Automatic Thoughts (NATs)

Automatic thoughts (ATs) is a term used to describe a stream of thoughts that almost all of us can notice if we try to pay attention to them. They can be positive, neutral or negative in content. Negative automatic thoughts, as first described by Beck in his work with depressed clients, are often fundamental to CBT. These are negatively tinged appraisals or interpretations – meanings we take from what happens around us or within us. Any of us might experience them.

Think of a recent time when you became upset: anxious, annoyed, fed up or whatever. Put yourself back in that situation and remember what was going through your mind. Most people can fairly easily pick out NATs. For example, if you were anxious, you might have had thoughts about the threat of something bad happening to you (‘Oh no- now I’m messing up…’) or people you care about (‘He’s not going to manage this alone…’); if you were annoyed, you might have had thoughts about others being unfair, or not following rules you consider important (‘Come on – that’s so out of order!’); if you were fed up, there might have been thoughts about loss or defeat, or negative views of yourself (‘Here I go again – there’s just no point…’).

ATs (and therefore NATs) are thought to exert a direct influence over mood from moment to moment, and they are thus of central importance to any CBT therapy. They have several common characteristics:

• As the name suggests, one does not have to try to think NATs - they just happen, automatically and without effort (although it may take effort to pay attention to them and notice them).
• They are specific thoughts about specific events or situations. Although they may become stereotyped, particularly in chronic problems, they may also vary a great deal from time to time and situation to situation.
• They are, or can easily become, conscious. Most people are either aware of this kind of thought, or can soon learn to be aware of them with some practice in monitoring them.
• They may be so brief and frequent, and so habitual, that they are not ‘heard’. They are so much a part of our ordinary mental environment that unless we focus on them we may not notice them, any more than we notice breathing most of the time.
• They are often plausible and taken as obviously true, especially when emotions are strong. Most of the time we do not question them, but simply swallow them whole. If I think ‘I am useless’ when I am feeling fed up about something’s having gone wrong, it seems a simple statement of the truth. One of the crucial steps in therapy is to help clients stop accepting their ATs in this way, so that they can step back and consider their accuracy. As a common CT motto has it, ‘Thoughts are opinions not facts’ - and like all opinions they may or may not be accurate.
• Although we usually talk about ATs as if they were verbal constructs (e.g. ‘I’m making a mess of this’), it is important to be aware that they may also take the form of images. For example, in social phobia, rather than thinking in words, ‘Other people think I’m peculiar’, a person may get a mental image of himself looking red-faced, sweaty and incoherent.
• Because of their immediate effect on emotional states, and their accessibility, ATs are usually tackled early on in therapy.

Core Beliefs

At the other end of the scale from ATs, core beliefs represent a person’s ‘bottom line’ (a term coined by Fennell, 1997), their fundamental beliefs about themselves, others, the world in general, or the future. Characteristics of core beliefs are:

• Most of the time they are not immediately accessible to consciousness. They may have to be inferred by observation of one’s characteristic thoughts and behaviours in many different situations.
• They manifest as general and absolute statements (e.g. ‘I am bad’, or ‘Others are not to be trusted’). Unlike ATs, they do not typically vary much across times or situations but are seen by the person as fundamental truths that apply in all situations.
• They are usually learned early on in life as a result of childhood experiences, but they may sometimes develop or change later in life (e.g. as a result of adult trauma).
• They are generally not tackled directly in short-term therapy for focal problems such as anxiety disorders or major depression (although they may change anyway). Tackling them directly may be more important in therapy for chronic problems like personality disorders (see Chapter 17).

Underlying assumptions (UAs) can be considered as bridging the gap between core beliefs and ATs. They develop as a response to the core belief and are often referred to as dysfunctional assumptions (DAs) when they backfire and hinder rather than help a person.

Core beliefs give us our fundamental (and often thematic) perspectives whilst UAs can be thought of as ‘rules for living’, more specific in their applicability than core beliefs, but more general than ATs. They often take the form of conditional ‘If… then…’ propositions, or are framed as ‘should’ or ‘must’ statements. They often represent attempts to live with negative core beliefs. For example, if I believe that I am fundamentally unlovable, I may develop the assumptions that

• ‘If I always try to please other people then they will tolerate me, but if I stand up for my own needs I will be rebuffed’, or
• ‘If I keep a low profile, no-one will see the real me and never know that I am unlovable’, or
• ‘I must always put other’s needs first, otherwise they will reject me’.

Such UAs offers me a guide to how to live my life so as to overcome some of the effects of the core belief, but it is always a fragile truce: if I fail to please someone, then I am in trouble. When one of my DAs is violated, then NATs and strong emotions are likely to be triggered. Characteristics of DAs are:

• Like core beliefs, they are not as obvious as NATs and may not be easily verbalised. They often have to be inferred from actions or from patterns of common NATs.
• They are usually conditional statements, taking the form of ‘If… then ...’, or ‘should / must… otherwise…’ statements.
• Some may be culturally reinforced: for example, beliefs about putting others first, or the importance of success, may be approved of in some cultures.
• What makes them dysfunctional is that they are too rigid and over-generalised, not flexible enough to cope with the inevitable complications and setbacks of life.

Figure 1.3 illustrates these levels of cognitions for one kind of belief and also shows some of the dimensions along which the levels vary.

It is easy to assume that core beliefs are ‘at the root’ of the problem, or are the ‘underlying’ cause, and that therefore they must be tackled directly for therapy to be effective. Although this can be the case, we would question this blanket assumption. Core beliefs are certainly more general than ATs, but that does not necessarily mean they are more important. Most successful CBT research to date targets ATs, but that does not make the therapy ineffective or short-lived. This is probably for two reasons:

• People with common mental-health problems such as anxiety or depression have a range of core beliefs, not just negative and unhelpful ones. Through the process of therapy, they can bring their more positive beliefs back into operation.
• Reviewing and building evidence that tests ATs can have an impact, a ‘knock-on effect’, on core belief so we don’t have to target core beliefs directly.

Although there is not yet much research evidence, working with core beliefs may be more important in lifelong problems such as very chronic difficulties and personality disorders, where clients may never have formed much in the way of longer-term functional beliefs. So often a child of young person evolves a ‘rule for living’ that helps them at the time. For example, ‘ If I please everyone and keep out of trouble no-one will hurt me’ would be protective for a bullied and abused child but would hold back the adult. In adulthood it would have lost its usefulness and become dysfunctional, it would need to be reviewed and revised, and because of its long-standing and unchallenged status at therapist might well need to focus on it.

We mentioned earlier that modern CBT theories see characteristic forms of cognition associated with particular kinds of problems. These characteristic patterns involve both the content of cognitions and the process of cognition. If we take depression as an example, then the thoughts of depressed people are likely to contain characteristic contents (e.g. negative thoughts about themselves or others). Depressed people are also likely to show characteristic general biases in the way that they think (e.g. towards perceiving and remembering negative events more than positive ones; or tending to see anything that goes wrong as being their fault; or over-generalising from one small negative event to a broad negative conclusion). Here, we briefly consider some examples. (See also later chapters on specific problems.)

Depression

As first described by beck, the characteristic cognitions in depression are the negative cognition triad, namely negative biased views of oneself, of the world in general, and of the future. In other words, the typical depressed view is that I am bad (useless, unlovable, incompetent, worthless, a failure, etc.); the world is bad (nothing good happens, life is just a series of trials); and the future is also bad (not only myself and the world bad, but it will always be like this and nothing I can do will make any difference).

Anxiety

The general process here is a bias towards the over estimation of threat (i.e. perceiving a high risk of some unwanted outcome) and/or the underestimation of ability to cope (i.e. perceiving oneself as lacking necessary skills). The exact nature of the threat, and therefore the content of cognitions, is different in different disorders. For example:

• In panic, there is catastrophic misinterpretation of harmless anxiety symptoms as indicating some imminent disaster (e.g. dying or ‘going mad’).
• In health anxiety, there is a similar misinterpretation of harmless symptoms as indicating illness, but on a longer time scale (e.g. I might have a disease that will make me die sometime in the future).
• In social anxiety, thoughts are about being negatively evaluated by others (e.g. ‘They will think I am stupid/boring/peculiar’).
• In OCD, thoughts are about being responsible for, and/or needing to prevent, some harm to oneself or others.

Anger

In anger, the thoughts are usually about others’ behaviour being unfair, breaking some implicit or explicit rule, or having hostile intent. ‘They ought not to do that, it’s not fair, they’re trying to put me down’. Just as we saw with anxiety, rapid and extreme conclusions are drawn, thus illustrating the cognitive process and content that leads to anger. In both anxiety and anger this is fuelled by adrenaline, reminding us of the interacting systems of psychological experiences.

Now we can put together the ideas introduced so far to develop a broad picture of how CBT sees the development of problems (see Figure 1.4). This generic model proposes that through experience (most commonly childhood experiences, but sometimes later experience), we develop core beliefs and assumptions which are to a greater or lesser extent functioned, and which allow us to make sense of our world and find a way through it. There is nothing inherently pathological about this, it simply recognises that we all learn from things that happen to us. As a result of our experiences, most of us have a mixture of functional and dysfunctional beliefs, with the functional ones allowing us to cope reasonably well most of the time. Even quit dysfunctional beliefs may not cause any particular problems for many years, if at all.

However, if we encounter an event (or series of events) that violates a core belief or assumption and cannot be handled by our more positive beliefs (sometimes called a critical incident), then unhelpful assumptions can become more active, negative thoughts evoked, and unpleasant emotional states such as anxiety or depression can result. The problem has been ‘switched on’.

Subsequent interactions between negative thoughts, emotions, behaviour and physiological changes may then result in persisting dysfunctional patterns, and we get locked into vicious cycles or feedback loops that maintain the problem. This prevents the problem from ‘switching off’ once circumstances change. This is where CBT therapists look to understand the persistence of difficulties and to generate ideas about recovery through breaking cycles.

Finally, since we have talked about CBT’s commitment to empiricism, we should consider the empirical status of CBT. Just what is the evidence that CBT is effective? And what is the evidence that CBT theory is an accurate model of human functioning?

Evidence Regarding CBT Treatment

Roth and Fonagy (2005), in the second edition of What works for whom? (their landmark summary of psychotherapy efficacy), report evidence showing that CBT is strongly supported as a therapy for most of the psychological disorders in adults that they studied, and has more support in more kinds of problems than any other therapy. Table 1.1 summarises this.

Key to summary:

✓ = Clear evidence of efficacy

? = Some limited support for efficacy

○ = Not currently well validated (NB this indicates a lack of sufficient evidence to support efficacy; it does not necessarily imply that there is good evidence of ineffectiveness)

In addition to this evidence of CBT’s efficacy (i.e. that it works in tightly controlled research trials), there is also some useful evidence demonstrating its effectiveness (i.e. that it can also work well in ordinary clinical practice, outside specialist research centres). See, for example, Merrill, Tolbert and Wade (2003), Stuart, Treat and Wade (2000) and Westbrook and Kirk (2005).

A second useful source of evidence is the UK National Institute for Health and Clinical Excellence (NICE). This is the agency charged by the government with the task of surveying the evidence for the effectiveness of different treatments and making recommendations about which treatments ought therefore to be made available in the National Health Service (NHS). Its guidelines on mental health conditions are periodically updated and so it is wise to visit the NICE website (www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions, accessed 22 May 2016).

NICE has produced guidelines on several major mental health problems, which include the following recommendations:

• Depression (NICE, 2009b):
  • ‘For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of. . . individual guided self-help based on the principles of cognitive behavioural therapy (CBT); computerized cognitive behavioural therapy (CCBT)’ (p. 9).
  • ‘For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT or IPT)’ (p. 9).
  • ‘People with depression who are considered to be at significant risk of relapse . . . or who have residual symptoms, should be offered one of the following . . . individual CBT; mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression’ (p. 10).
• Generalised anxiety disorder (GAD) and panic disorder (NICE, 2011a): ‘The 2004 guidelines recognized that ‘interventions that have evidence for the longest duration of effect, in descending order, are: [first] cognitive behavioural therapy’ (p.6). The 2011 guidelines recommend low intensity interventions for mild GAD and CBT/applied relaxation for established GAD.
• Post-traumatic stress disorder (PTSD) (NICE, 2005a): ‘All people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioural therapy [CBT] or eye movement desensitisation and reprocessing [EMDR])’ (p.4).
• Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (NICE, 2005b): people with OCD or ODD should be offered CBT (including exposure and response prevention), either in group or individual format and, depending on severity and preference, also consider SSRI medication; also says that ‘when adults with OCD request forms of psychological therapy other than cognitive and/or behavioural therapies as a specific treatment for OCD... they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments’ (pp.18-21).
• Eating disorders (NICE, 2004b): ‘Cognitive behaviour therapy for bulimia nervosa… should be offered to adults with bulimia nervosa…’ (p. 4); ‘Cognitive behaviour therapy for binge eating disorder… should be offered to adults with binge eating disorder…’ (p.5).
• Psychosis and schizophrenia (NICE, 2014a): Offer cognitive behavioural therapy (CBT), with or without family intervention, to those at risk and to all people with psychosis or schizophrenia. This can be in conjunction with medication.

NICE also recommends CBT in the management of other conditions such as chronic fatigue syndrome (2007), alcohol-use disorders (2011b), antenatal and post-natal mental health problems (2014b).

In summary then, at the time of writing, CBT is the psychological therapy with the most solid and wide evidence base for efficacy and effectiveness.

Evidence regarding CBT Theory

It is a fallacy to think that demonstrating the efficacy of a treatment proves the truth of the theory on which that treatment is based. The treatment’s efficacy could be due to some combination of factors not imagined in the theory. Thus, for most of us, even a randomised controlled trial (RCT) showing that a treatment based on traditional witchcraft was effective for depression would not necessarily convince us that depression was in fact caused by evil spirits; instead we might investigate whether there was a powerful placebo effect, or perhaps whether the herbal potions used in the treatment contained a psychoactive substance. In the same way, the efficacy of CBT as a treatment does not show that CBT theory is true. In fact, the evidence for some of the fundamental theoretical ideas of CBT is more patchy than the evidence for the treatment’s efficacy. Clark, Beck and Alford (1999) present a detailed consideration of the balance of scientific evidence in the case of the cognitive theory of depression. In summary, they conclude that regarding the supposed patterns of negative thinking in depression, there is evidence that there is:

• an increase in negative thinking about oneself, the future and (less clearly) the world;
• a reduction in positive thinking about the self, but this change is less marked and may be less specific to depression (in other words, the same thing also happens in other problems);
• a specific increase in thoughts and beliefs about loss and failure (more so than people who suffer from anxiety problems).

Regarding the proposed causal role of negative thoughts, (i.e. the suggestion that negative thinking can provoke low mood), Clark et al. (1999) conclude that there is some experimental evidence that negative self-referent thinking can indeed induce subjective, behavioural, motivational and physiological features similar to mild to moderate depression. If we experimentally provoke negative thoughts about themselves in non-depressed people, we can produce temporary states quite similar to depression.

There is also some evidence that the proposed cognitive processing biases can be identified in experiments, with evidence that in depressed people there is:

• a bias towards processing negative information relevant to themselves (but no such bias for neutral or impersonal information);
• enhanced recall of negative events, and increased negative beliefs.

Furthermore, there is evidence that these changes in processing can occur at an automatic, pre-conscious level.

The least well-supported part of the theory is the suggestion that people are vulnerable to depression because of negative beliefs that are still present in ‘latent’ form even when they are not depressed. Clark et al. (1999) suggest that there is a little supportive evidence for this idea, but that it has proved difficult to get clear evidence (perhaps not surprisingly, when one considers the difficulties of identifying such ‘latent’ beliefs experimentally).

A similar picture is found for specific CBT models for other disorders: in some areas there is good solid research support and in others the evidence is equivocal. Overall, then, the evidence is:

1. That CBT is undoubtedly an effective treatment for many problems; and
2. That there is support for CBT theory but that there is still room for exploring and developing this approach further in some areas.

Summary

• Modern CBT is derived from the legacy of BT (with its emphasis on the importance of behaviour change in overcoming mental health problems), CT (with its emphasis on understanding and changing the meaning of events), and Beckian CBT is also coloured by his experience of psychodynamic training (so there is recognition of the importance of the therapeutic relationship and developmental factors).
• Problems can usefully be described in terms of the interactions between four ‘systems’:
  • The cognitive system - what a person thinks, imagines, believes;
  • The behavioural system – what they do or say that can be directly observed by others;
  • The affective system – their emotions;
  • The physiological system – what happens to their body, such as automatic arousal or changes in appetite.
• We distinguish three ‘levels’ of cognition:
  • automatic thoughts (ATs) – specific thoughts that arise spontaneously in various situations, which have a negative effect on mood, and which are relatively accessible to consciousness;
  • underlying assumptions (UAs) – ‘rules for living’ that guide behaviour and expectations in a variety of situations, and which are often in conditional (if . . . then . . .) form.
  • core beliefs – very general beliefs about oneself, other people or the world in general, which operate across a wide range of situations, but which are often not immediately conscious.
• Different kinds of psychological problems have different characteristic cognitions, in context, style or both (e.g., in anxiety there is a preoccupation with threat, and associated biases towards perceiving threat).
• There is considerable evidence that CBT can be an effective way of helping various mental health problems and less clear, but still significant, evidence for the theories lying behind the treatment.