One of the most common psychotherapy treatment options available to patients in the UK is Cognitive-Behavioural Therapy (CBT). The NHS reported that in 2022-2023, CBT accounted for 41.3% of all courses of therapy in the year (with guided self-help books taking the second spot, for a combined total of 70.9%).
(Image taken from NHS website)
CBT is also one of the most-studied psychotherapies (according to the Institute for Quality and Efficiency in Health Care, 2022) and is, in many cases, a great option for the treatment of anxiety and depression, as well as other mental and physical health problems.
What is CBT?
Cognitive Behavioral Therapy (CBT) is a structured, time-limited psychotherapy that focuses on identifying and changing negative thought patterns and behaviors that contribute to emotional distress.
According to NICE guidelines, it’s recommended as a first-line treatment for various conditions, including:
- Depression
- Anxiety Disorders
- Obsessive-Compulsive Disorder (OCD)
- Post-Traumatic Stress Disorder (PTSD)
NICE suggests that the number of sessions should usually range from 6-20 (depending on the complexity and severity of the disorder) and that they should be scheduled weekly or biweekly. NICE also recommends follow-up or booster sessions to maintain the gains made during therapy, particularly for individuals who are at risk of relapse.
Beck’s Traditional CBT
Following on from the first waves of behavioural therapy in the 1930s and 40s, Aaron Beck’s traditional CBT emerged as a second wave of therapeutic support in the 1960s. According to Beck, negative thoughts and cognitive distortions lead to emotional distress (e.g., depression, anxiety) and maladaptive behaviors (e.g., withdrawal, avoidance).
In therapy, traditional CBT aims to:
- Identify and challenge negative thoughts and cognitive distortions.
- Help individuals reframe their thinking to develop a more balanced and realistic perspective.
- Encourage the development of coping strategies
- and behaviors that promote emotional well-being.
Beck’s traditional model emphasizes the importance of addressing current thought patterns and behaviors rather than focusing extensively on past experiences.
Third Wave CBT
While traditional CBT primarily focused on changing negative thought patterns and behaviors, third wave CBT integrates a broader understanding of emotional processes, context, and the therapeutic relationship. It differed from second wave CBT, in that it:
- Emphasises the role of emotions in psychological distress and well-being.
- Incorporates mindfulness practices and acceptance strategies.
- Acknowledges the importance of context and the therapeutic relationship in influencing mental health.
- Emphasises behavioral activation—encouraging individuals to engage in activities that bring them joy or fulfillment as a way to combat depression and anxiety
- Stresses the importance of building a strong therapeutic alliance between the therapist and the client.
Beyond CBT
Beyond traditional CBT, there are now a number of other effective treatment options which are increasingly backed by strong, significant research findings. In the rest of this article, I’ll take you on a whistlestop tour of a number of alternative treatment types, including the key features that make each treatment unique and the research behind them.
DBT (Dialectical Behaviour Therapy)
Emotion Regulation: Helps individuals manage intense emotions and reduce emotional vulnerability.
‘Dialectical’: means trying to understand how two things that seem opposite could both be true.
Interpersonal Effectiveness: Focuses on improving communication and relationship skills to maintain healthy connections.
DBT Research:
- Ashfari et al. (2022) – 72 generalized anxiety disorder patients were randomly assigned to one of two groups: DBT or CBT. Both groups had reduced scores for depression and anxiety and increased scores for executive function after the psychotherapies. These changes were maintained at follow-up. DBT was more effective for improving executive function.
- Gillespie et al. (2022) – A thematic analysis indicated that participants found DBT had a positive impact on their lives in the years after the programme and enabled further development; gave them control over their lives and the ability to manage setbacks and difficult situations; and contributed to healthier and more meaningful relationships with others.
- Hernadez-Bustamante et al. (2024) – A systematic review with most studies revealing that both short-term DBT and standard DBT improved suicidality in BPD patients, lasting up to 24 months after the treatment period. DBT significantly improved general psychopathology and depressive symptoms in patients with BPD. Improvement of compliance, impulsivity, mood instability, as well as reduction in hospitalisation rate are other findings observed in the trials following DBT.
- DeCou et al. (2019) – A meta analysis demonstrated that DBT reduced self-directed violence and reduced frequency of psychiatric crisis services. There was not a significant effect of DBT with regard to suicidal ideation. The findings may reflect the prioritisation of behaviour over thoughts within DBT.
ACT (Acceptance and Commitment Therapy)
Acceptance: Emphasises accepting thoughts and feelings rather than avoiding or controlling them.
Mindfulness: Encourages being present and aware of experiences without judgment.
Values-Based Action: Focuses on taking actions aligned with personal values, even amid challenges.
ACT Research:
- Gloster et al. (2021) – A review of 20 meta-analyses found that ACT was efficacious for anxiety, depression, substance use, pain, and transdiagnostic groups. ACT was generally superior to inactive controls, treatment as usual, and most active intervention conditions.
- Kelson et al. (2019) – 18 studies reported significant anxiety reduction after iACT treatment (internet-delivered ACT). Participants on average rated their iACT experience with above average to high treatment satisfaction.
- Wang et al. (2022) – A study conducted on 140 patients suffering from insomnia, anxiety, and depression found that ACT was linked to improved psychological flexibility, decreased depression and anxiety scores (self-rated), significantly reduced insomnia and fewer sleep disturbances.
CAT (Cognitive Analytic Therapy)
Focus on Patterns: Identifies recurring patterns in thoughts, emotions, and relationships that cause difficulties.
Collaborative: Therapist and client work together to understand how past experiences influence current behaviours and create change.
Visuals: Use diagrams or “maps” that clarify both the problematic patterns and the healthy/helpful ones.
CAT Research:
- Hallam et al. (2020) – This systematic review and meta-analysis found that CAT produced large pre–post improvements in global functioning, moderate-to-large improvements in interpersonal problems, and large reductions in depression symptoms. All these effects were maintained or improved upon at follow-up.
- Power et al. (2023) – This was a single case design method with a 25-year old male patient with a diagnosis of mixed anxiety and depression in the context of borderline personality disorder (BPD) traits. CAT was shown to effectively enable better connection with emotions and with people and also improved self-worth.
- Owen et al. (2023) – A real-world evaluation to examine the treatment outcomes of NHS Talking Therapies found significant decreases in depression and anxiety scores were observed during the CAT treatment phase. The recovery rate was 46.4%. 71.4% showed a reliable improvement post-treatment. Positive outcomes continued to be observed at follow-up, with a recovery rate of 50% and a reliable improvement rate of 79.4%.
CFT (Compassion Focused Therapy)
Self-Compassion: Encourages developing kindness and understanding toward oneself, especially during difficult times.
Soothing System Activation: Focuses on activating the brain’s calming system to reduce stress and promote emotional well-being.
Balanced Thinking: Helps individuals cultivate more compassionate, balanced thoughts to counteract self-criticism and shame.
CFT Research:
- Au et al. (2017) – By the end of treatment, 9 of 10 participants demonstrated reliable decreases in PTSD symptom severity, while 8 of 10 participants showed reliable reductions in shame. These improvements were maintained at 2- and 4-week follow-up. The intervention was also associated with improvements in self-compassion and self-blame. Participants reported high levels of satisfaction with the intervention. .
- Swee et al (2024) – Exploration into CFT’s possible application in the treatment of CPTSD (complex post traumatic stress disorder). CFT helps individuals learn how to regulate their emotions, shift their emotional response style from shaming and self-critical to wise and understanding, and engage in more compassionate and rewarding patterns of relating to self and others.
- Millard et al. (2023) – A systematic review and meta-analysis showing that CFT improved clinical symptomology from baseline to post-intervention and revealed to be effective across outcomes, compared to controls. Meta-analysis significantly favoured CFT in increasing self-compassion and in improving levels of self-reassurance.
- Wilson et al. (2019) – A systematic review and meta-analysis where the results indicated that self-compassion-related therapies produced greater improvements in all three outcomes examined: self-compassion, anxiety and depressive symptoms.
ST (Schema Therapy)
Core Schemas: Targets deeply ingrained negative beliefs, often formed in childhood, that affect current behaviors and emotions.
Modes: Focuses on shifting between different emotional states or “modes,” such as the vulnerable child, angry child, or healthy adult.
Reparenting: Uses therapeutic techniques to provide emotional needs and healing experiences that were unmet during childhood.
ST Research:
- Taylor et al. (2017) – This was a systematic review into evidence for the efficacy and effectiveness of schema therapy in reducing early maladaptive schema (EMS) and improving symptoms as applied to a range of mental health disorders in adults including BPD, other personality disorders, eating disorders, anxiety disorders, and PTSD. Schema therapy demonstrated initial significant results in terms of reducing EMS and improving symptoms for personality disorders.
- Peeters et al. (2022) – Another systematic review into the evidence regarding the effectiveness of schema therapy for anxiety disorders, OCD, and PTSD. Results showed that schema therapy can lead to beneficial effects in disorder‐specific symptoms and early maladaptive schemas.
- Kopf-Beck et al (2024) – ST for depression as part of a psychiatric care program showed clinical noninferiority compared to CBT, without being superior to IST (Individual Supportive Therapy). ST represents a potentially useful addition to the therapeutic repertoire for the treatment of depression but its efficacy, including long-term efficacy, should be evaluated further.
- Zhang et al. (2023) – A systematic review and meta-analysis on the efficacy of ST for the treatment of personality disorders (PD) found that ST had a moderate effect size compared to control conditions in reducing symptoms of PDs. The effect of ST on different types of PDs varied slightly, finding that group ST was more effective than individual ST. There was a moderate effect size for ST in improving quality of life, and ST was found to reduce early maladaptive schema.
PDT (Psychodynamic Therapy)
Unconscious Processes: Explores unconscious thoughts and feelings to understand how they influence behaviour and emotions.
Early Relationships: Examines the impact of childhood experiences on psychological development and present-day functioning.
Therapeutic Relationship: The therapist-client relationship is central, providing a space to explore feelings, gain insights, and work through unresolved issues.
PDT Research:
- Driessen et al. (2017) – This is the first study that shows that PDT can be at least as efficacious as CBT for depression on important aspects of patient functioning (posttreatment and follow-up anxiety measures as well as for posttreatment pain and quality of life measures) other than depressive symptom reduction.
- Steinert et al. (2017) – A meta-analysis with results suggesting equivalence of PDT to treatments established in efficacy (CBT, Pharmacotherapy). Outcomes focused on “target symptoms” (e.g., depressive symptoms in depressive disorders). Further research should examine who benefits most from which treatment.
- Leichsenring et al. (2023) – An umbrella review finding moderate evidence that suggests that PDT is as efficacious as other active therapies in treating in depressive, anxiety, personality and somatic symptom disorders. Evidence was found for long-term effects, improving functioning, effectiveness, cost-effectiveness and mechanisms of change in the aforementioned disorders.
EMDR (Eye Movement Desensitisation and Reprocessing Therapy)
Bilateral Stimulation: Uses eye movements or other bilateral stimulation to help process and resolve traumatic memories.
Trauma Processing: Helps individuals reprocess distressing memories, reducing their emotional intensity and negative impact.
Structured Protocol: Follows an eight-phase approach, including history-taking, desensitisation, and future template planning.
EMDR Research:
- Wilson et al. (2018) – This was a systematic review of the evidence into the efficacy of EMDR therapy as a treatment for PTSD. Specifically, EMDR therapy improved PTSD diagnosis, reduced PTSD symptoms, and reduced other trauma-related symptoms. EMDR therapy was evidenced as being more effective than other trauma treatments, and was shown to be an effective therapy when delivered with different cultures.
- Shapiro et al. (2024) – A review of randomised studies and significant clinical reports where 7/10 studies reported EMDR therapy to be more rapid and/or more effective than trauma-focused CBT. Twelve randomised studies of the eye movement component noted rapid decreases in negative emotions and/or vividness of disturbing images, with an additional 8 reporting a variety of other memory effects. Numerous other evaluations document that EMDR therapy provides relief from a variety of somatic complaints.
- Baek et al. (2019) – Showed that alternating bilateral sensory stimulation successfully induced a lasting reduction in fear in mice by pairing visual ABS with conditioned stimuli during fear extinction. The results revealed the neural circuit that underlies an effective strategy for sustainably attenuating traumatic memories.
- Rodenburg et al. (2009), Demanuele et al. (2019) – Scientific evidence equally supported both treatments in treating children and adolescents with PTSD however all studies showed that EMDR therapy is more effective in reducing the symptoms of PTSD in children with less sessions than CBT.
IFS (Internal Family Systems)
Multiple Parts: Internal Family Systems (IFS) views the mind as made up of different “parts,” each with its own emotions and roles.
Self-Leadership: Encourages accessing the core “Self,” a calm, compassionate inner leader, to guide and heal the other parts.
Healing Trauma: Works to unburden wounded or suppressed parts, promoting emotional healing and balance within the system.
IFS Research:
- Hodgdon et al. (2020) – A pilot effectiveness study showing that reductions in PTSD symptoms were statistically and clinically significant. Childhood trauma survivors had a moderate-to-severe degree of PTSD prior to treatment and the vast majority (over 90%) who completed treatment no longer met DSM-IV-TR criteria after 16 sessions of IFS.
- Shadick et al. (2013) – This was a randomized trial of an IFS psychotherapeutic intervention on rheumatoid arthritis (RA) disease activity and psychological status. Post-treatment improvements favoring the IFS group occurred in overall pain, and physical function. These improvements were sustained 1 year later in self-assessed joint pain, self-compassion, and depressive symptoms.
- Haddock et al. (2016) – In a pilot study, college women were randomly allocated to IFS treatment or treatment as usual ( cognitive-behavioral therapy [CBT], and interpersonal psychotherapy [IPT]). Results demonstrated a decline in depressive symptoms for both conditions and no significant differences in the magnitude or rate of change.
- Comeau et al. (2024) – Participants completed the Program for Alleviating and Resolving Trauma and Stress (PARTS), an online program including 16 weeks of 90-min IFS-based groups with eight 50-min individual IFS counselling. All respondents reported the program was helpful. PTSD symptom severity was reduced. A clinically meaningful response was demonstrated in 53% of participants. Decentering, self-compassion, and emotion regulation all improved.
SE (Somatic Experiencing)
Body Awareness: Focuses on increasing awareness of bodily sensations to help process and release trauma.
Titration: Involves gently revisiting traumatic experiences in small, manageable doses to avoid overwhelm and promote healing.
Nervous System Regulation: Aims to restore balance in the NS by helping individuals move out of fight, flight, or freeze responses.
SE Research:
- Kuhfuß et al. (2021) – This literature review found preliminary evidence for positive effects of SE on PTSD-related symptoms. Initial evidence suggests that SE has a positive impact on affective and somatic symptoms and measures of well-being in both traumatized and non-traumatized samples.
- Brom et al. (2017) – A randomized controlled study evaluating the effectiveness of somatic experiencing (SE) for PTSD, showed significant intervention effects for posttraumatic symptoms severity and depression both pre‐post and pre‐follow‐up.
- Anderson et al. (2023) – A randomized controlled trial of SE for chronic low back pain and comorbid PTSD symptoms. SE significantly reduced the number of PTSD symptoms compared with TAU. Also, fear of movement was significantly reduced. Both groups achieved a large reduction in pain-catastrophizing, disability and pain.
PRT (Pain Reprocessing Therapy)
Chronic Pain Retraining: Helps retrain the brain to interpret chronic pain signals as non-threatening, reducing pain perception.
Mind-Body Connection: Focuses on changing the brain’s response to pain by addressing emotional and psychological factors.
Somatic Tracking: Encourages observing pain sensations with curiosity and calmness to reduce fear and rewire neural pathways.
PRT Research:
- Ashar et al. (2021) – In this randomized clinical trial, 33 of 50 participants (66%) randomized to 4 weeks of pain reprocessing therapy were pain-free or nearly pain-free at posttreatment, compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care, with gains largely maintained through 1-year follow-up.
- Ashar et al. (2023) – In this secondary analysis of clinical trial data, natural language methods were applied to understand patients’ beliefs about the underlying causes of their primary chronic back pain. PRT led to significant increases in mind- or brain-related attributed causes of pain and increases in mind-brain attributions were associated with reduced pain.
Conclusion
Whilst CBT remains a great treatment option for a wide number of mental and physical health problems (as well as being widely-studied and available), there are an increasing number of alternative options that can be tailored or combined to suit individuals. At Healthy Mind Psychology, our psychologists are experienced in a wide range of treatment modalities so you never have to feel uncomfortable engaging in an approach that’s not right for you. Visit https://www.healthymindpsychology.co.uk/how-we-help/ to find out more about how we can help.
References:
NHS Digital. (2023). NHS Talking Therapies for Anxiety and Depression, Annual Report 2022-23: Therapy-Based Outcomes. Retrieved November 2024, from https://digital.nhs.uk/data-and-information/publications/statistical/nhs-talking-therapies-for-anxiety-and-depression-annual-reports/2022-23/therapy-based-outcomes
National Center for Biotechnology Information (NCBI). (2014). Cognitive Behavioral Therapy: Core Information Document. Retrieved November 2024, from https://www.ncbi.nlm.nih.gov/books/NBK279297/
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