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Cognitive Behavioural Therapy
“CBT” has become a label attached to almost anything. This page describes what the treatment actually consists of, so you can tell whether you are being offered the real thing.
Why the label has stopped meaning much
CBT is the most recommended psychological treatment in the UK, and therefore the most claimed. The term now covers everything from protocol-driven treatment delivered by someone trained in it to a supportive weekly conversation with a thought record at the end. Only one has the evidence base people rely on.
Many people who contact me have already had something called CBT and concluded it does not work for them. Often what they describe is not CBT: no formulation, no plan, no measurement, nothing to do between sessions. That is worth knowing before you write off a treatment that might have worked.
What CBT actually is
The core proposition is unglamorous. What you think, what you do and how you feel are connected, and the loops between them keep a problem going long after whatever started it has passed. Someone has a panic attack in a supermarket, starts avoiding supermarkets, and never finds out they would have been fine.
So CBT is less interested in why a problem began than in what holds it in place today. That is not a refusal to take history seriously; it is a statement about where the leverage sits. Insight into the origin of a fear does not remove it.
Formulation: the part that should not be skipped
A formulation is a diagram of your particular loop, built with you rather than handed over: trigger, thought, feeling in the body, what you do, what that does to the belief. It takes shape in the first two sessions.
Its value is practical: once you can see the loop on paper, the treatment plan becomes obvious. If your therapist has never shown you one, ask.
Behavioural experiments do most of the work
People expect CBT to be about arguing with thoughts, and some of it is: identifying the prediction, spotting that you are treating a possibility as a certainty. But talking rarely shifts a belief held at gut level, and that is what maintains anxiety.
What shifts it is finding out. A behavioural experiment is a deliberate test with a prediction attached. Someone with social anxiety who is certain that going quiet will be noticed and judged deliberately says nothing for two minutes in a meeting and records what actually happened. Someone with panic who believes a racing heart means collapse runs up two flights of stairs on purpose to produce the sensations and see what follows. Someone with health anxiety goes a week without checking a symptom and records what the anxiety did over that week.
The prediction is written down first, in specific terms, and checked afterwards. “It will be awful” is not testable. “Three people will look at me and one will comment” is.
What a session looks like
- A brief check on the week and any measures we are tracking.
- An agenda, set together in the first few minutes, so the hour is not spent on whatever surfaced first.
- Review of what you tried since last time and what it taught us.
- The main piece of work: refining the formulation, running an experiment, practising a skill, planning an exposure.
- Agreeing the next task, written down, specific enough to actually do.
- A short summary from you, in your words, of what the session was about.
Sessions are active and structured. If something significant happened this week we deal with it, but there is a plan.
Time-limited on purpose
CBT is designed to end. The aim is that you leave able to run the process yourself: notice the loop, set up the test, tolerate the discomfort, draw the conclusion. Towards the end we space sessions out and plan for what to do when symptoms return, because for most anxiety problems they do.
Open-ended therapy has its place and a different purpose. If we are still meeting weekly at session forty with no clear account of what has changed, something has gone wrong.
How this differs from ERP
ERP sits inside the CBT family and is the treatment of choice for OCD. It is also the piece I use most for phobias, panic and health anxiety. Broader CBT has a wider toolkit: cognitive work on beliefs, behavioural activation for depression, attention and imagery work for social anxiety, worry postponement for generalised anxiety.
In OCD the cognitive component needs real care. Examining evidence, weighing likelihoods and reasoning your way to comfort is exactly what OCD wants, and it converts straight into a compulsion. So for OCD I use cognitive work sparingly, to set up exposures rather than settle doubts. For depression or social anxiety the balance is different.
Working with me
I trained in the United States, where CBT is the standard of care rather than an option. I am board certified in Behavioral and Cognitive Psychology by the American Board of Professional Psychology, HCPC-registered, chartered with the British Psychological Society, and a Clinical Instructor at the University of Washington.
Treatment begins with a 90-minute assessment, and by the end of it you will have a formulation, a plan and an honest estimate of length. I do not prescribe, and I work alongside GPs and psychiatrists where medication is part of the picture. I see adults and young people online across the UK and in person near Ravenshead, Nottingham and Mansfield. You can read more about how I work or arrange a free 30-minute call.
Common questions
Everyone says they do CBT. How do I tell whether I am getting the real thing?
Ask three questions. Does the therapist have a written formulation of your problem that you have seen and agreed? Is there a plan with a rough number of sessions and a way of measuring whether it is working? Do you leave with something specific to do before the next appointment? If the answer to all three is no, you may be having supportive counselling rather than CBT. That can be valuable, but it is a different treatment with a different evidence base.
What is a formulation, in plain terms?
A formulation is a shared map of what is keeping your problem going now, rather than a diagnosis or a life history. It sets out the triggers, what runs through your mind, what happens in your body, what you then do, and how that response keeps the whole thing in place. We draw it out together in the first two sessions and you take a copy. If it is accurate, the treatment plan falls out of it obviously.
Is CBT just positive thinking?
No, and if it is being delivered that way it is being delivered badly. CBT is not about replacing negative thoughts with cheerful ones. It is about testing beliefs that have never been tested, mostly through behaviour rather than argument, and finding out what is actually true. Sometimes the finding is that the feared thing happens and is survivable, which is more useful still. Nobody is asked to pretend that a genuine difficulty is fine.
How many sessions will I need?
CBT is time-limited by design. For a single, clearly defined problem such as panic, a phobia or social anxiety, a typical course is around 8 to 16 sessions after the 90-minute assessment. OCD and longstanding depression usually take longer. I will give you an estimate after the assessment and we will review progress at intervals rather than continuing by default. If it is not working, I would rather say so and change the plan.
What is the difference between CBT and ERP?
ERP is a specific behavioural treatment within the CBT family, and it is the treatment of choice for OCD. Broader CBT includes cognitive work, behavioural experiments, activity scheduling and attention training, and is used for depression, generalised anxiety, social anxiety, panic and health anxiety. Most courses draw on both. For OCD specifically, the cognitive elements need handling with care, because reasoning about the fear very easily turns into another compulsion.
Do I have to do homework?
Realistically, yes, and it is where most of the change happens. An hour a week cannot outweigh the other hundred and sixty-seven. Homework in CBT is not written exercises for their own sake; it is usually a specific thing to try, once or several times, with a note of what you predicted and what actually happened. If it repeatedly does not get done, the task was pitched wrong or something is in the way, and we adjust it.
Related pages
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