Cognitive Behavioural Therapy (CBT)

What is CBT?

Cognitive behavioural therapy (CBT) is a talking therapy. The NHS describes it as a therapist helping you change how you think and act.

You and your therapist look at the situations you find hard. Together you work out what you think, feel and do in them. Then you try something different.

CBT is a family of therapies rather than one method. The best known forms each have a section on this page.

Source: NHS: CBT overview

How it works

A hard moment can start a loop. A thought changes how you feel, and the feeling changes what you do. What you do then feeds the thought.

Say a friend does not reply to a message. You decide they are cross with you, feel low and stay in. Alone at home, nothing tests the thought.

CBT works on one part of the loop at a time. The NHS names three ways in:

• Thoughts. Questioning unhelpful thoughts and beliefs, and looking for other ways to see things
• Feelings. Noticing emotions and body sensations without reacting to them
• Actions. Changing what you do, such as returning to something you have avoided

CBT can include work on thoughts and behaviour. The balance depends on the client and the problem.

Changing what you do is the behavioural side of CBT. It has its own page, covering behavioural activation and exposure.

Source: NHS: CBT overview

What sessions look like

Each session has a plan. You talk about a situation you found hard, then look at what you thought, felt and did.

The NHS says a course usually runs to between five and fifteen sessions. The number depends on what you are having it for. You can meet one to one, join a group or work through guided self-help.

Between sessions you practise what you have worked on. The NHS says this practice matters, and you may keep a worksheet or diary. When the course ends, your therapist helps you plan how to carry on alone.

Source: NHS: CBT overview

Who is it best suited to?

NICE writes the treatment guidance the NHS follows. Its guidelines name CBT for several difficulties. The table keeps NICE's own verbs.

CBT can be a good fit if you:

• Want a clear plan and a set number of sessions
• Would rather work on what is happening now than on your past
• Are ready to practise between sessions
• Like to try something out and see what happens

You do not need a diagnosis to get CBT on the NHS. In England you can refer yourself to NHS Talking Therapies for many problems, without speaking to a GP.

Sources: NICE NG222, NICE CG113, NICE CG159, NICE CG31, NICE NG116, NICE NG193, NHS: CBT overview, NHS: talking therapies

The evidence

A 2012 review gathered 269 meta-analyses of CBT. Its authors found the strongest support for anxiety disorders, bulimia, anger problems and general stress, among others.

For depression, a 2023 review pooled 409 trials. CBT had moderate to large effects against control conditions such as usual care and waiting lists.

Sources: Hofmann et al. 2012, Cuijpers et al. 2023

Where the evidence stops

The same review compared CBT with other talking therapies. CBT came out ahead by a small margin, which disappeared in most of the checks the authors ran.

Trials report averages. They cannot say how one person will get on with one therapist.

Source: Cuijpers et al. 2023

Cognitive therapy

Cognitive therapy is the best known strand of CBT. The Beck Institute describes it as a specific therapy that Aaron Beck developed in the 1960s. It rests on the idea that the way we see a situation shapes how we think, feel and behave.

The Beck Institute calls CBT an umbrella term for a group of therapies. Outside the United States the two names are often used for the same thing.

Some cognitive therapies are written for one difficulty. Cognitive therapy for PTSD is one of the trauma-focused CBT therapies NICE names. Mindfulness-based cognitive therapy builds on it, and has its own page.

Sources: Beck Institute: CT vs CBT, NICE NG116

Rational emotive behaviour therapy

Rational emotive behaviour therapy (REBT) came first. Albert Ellis developed it in 1955, and the Albert Ellis Institute calls it the pioneering form of CBT.

Its starting point is that our thinking about an event, more than the event itself, leads to emotional upset. You learn to examine and challenge that thinking. The institute calls the main technique disputing: reworking a belief into something more realistic.

A 2018 review found 84 studies of REBT. Against other treatments it found a medium effect, and its authors call REBT a sound psychological intervention. NICE does not name it in its guidance on depression or anxiety.

Sources: Albert Ellis Institute: REBT, David et al. 2018, NICE NG222, NICE CG113

CBT for insomnia

CBT for insomnia (CBT-I) is the version built for sleep. NICE's summary for primary care says to offer it first for long-term insomnia, at any adult age.

It usually joins behavioural work, such as stimulus control and sleep restriction, with cognitive therapy and relaxation training. A GP may offer it face to face, or as an online programme.

NICE recommends one such programme, Sleepio. It is for people who would otherwise get sleep hygiene advice or sleeping pills.

NICE says face-to-face CBT-I is of limited availability in the UK. A digital programme could widen access to it.

A 2015 review pooled 20 trials of face-to-face CBT-I. People fell asleep about 19 minutes sooner. They also spent about 26 minutes less awake in the night.

Those trials left out people whose insomnia came with another sleep or health problem.

See a GP if sleep has been bad for months, or if it is making daily life hard to manage. Our sleep page covers what else can be going on.

Sources: NICE CKS: insomnia, NHS: insomnia, NICE HTG624, Trauer et al. 2015

CBT for chronic pain

For chronic primary pain, NICE says to consider CBT for pain for people aged 16 and over. It gives acceptance and commitment therapy as the other option. Chronic primary pain has no clear underlying condition, or it hurts more than an injury explains.

This work does not treat the pain as imagined. NHS inform says the way people think and feel about pain affects how they experience it and how they cope.

It sets out pacing: you start an activity, stop when it hurts, then build up the time you manage.

NHS inform is plain that CBT does not promise to reduce pain. It says the techniques can leave you feeling more in control, with pain having less impact on your life.

A 2020 Cochrane review drew on 59 studies of CBT for chronic pain. It found small or very small benefits for pain, disability and distress. Most of that evidence was moderate quality.

Pain that is new, or that has changed, needs a GP first. Our chronic illness page covers living with a long-term condition.

Sources: NICE NG193, NHS inform: chronic pain, Williams et al. 2020

Guided self-help and bibliotherapy

Guided self-help means working through a workbook or online course based on CBT, with a therapist alongside you. NICE describes a trained practitioner who encourages you to finish it and reviews how it is going.

For less severe depression, NICE says to consider the least intrusive option first, and names guided self-help as that option. For generalised anxiety it names guided self-help as an early step, usually five to seven short sessions.

A 2010 review compared guided self-help with face-to-face therapy for depression and anxiety. Across 21 studies it found no meaningful difference between them.

Books used this way are sometimes called bibliotherapy. Reading Well, run by The Reading Agency, lists books that health experts and people with lived experience recommend. A health professional can suggest a title, or you can borrow one from your local library.

Sources: NHS: talking therapies, NICE NG222, NICE CG113, Cuijpers et al. 2010, Reading Agency: Reading Well

If CBT does not feel right

If CBT sounds too structured, person-centred therapy lets you set the pace. If you want to understand how your past shapes you now, psychodynamic therapy looks there.

If testing a thought feels like arguing with yourself, acceptance and commitment therapy takes another route. An integrative therapist can blend CBT with other ways of working.

For trauma, trauma-focused CBT and EMDR each have a page of their own.