Cognitive behavioural therapy (CBT)

What is CBT?
As the name suggests, CBT is a form of therapy that aims to change thoughts and behaviours in order to improve mental health well-being. It is known as a talking therapy that focuses on the ‘here and now’ rather than trying to make links between current problems and the past. Its basic tenet is that by changing thought and behavioural patterns, a powerful effect may be seen on a person’s emotions. By identifying and analysing counterproductive thoughts and behaviours, an individual can be helped to alleviate feelings of anxiety and depression. CBT is seen as a collaborative relationship between therapist and patient and is most effective with motivated people who want to help themselves feel better (Beck, 1995). It is most successfully used in cases of depression, anxiety, obsessive/compulsive disorder and post-traumatic stress disorders. It is the therapy of preference in many of these instances because it has good scientific evidence to back up its efficacy, unlike many of the other talking therapies. It is recommended in the National Institute for Health and Clinical Excellence guidelines that pertain to mental disorders such as anxiety, (National Institute for Health and Clinical Excellence, 2007).

Using CBT skills
To practise as a CBT practitioner requires prolonged training; however, some understanding of the fundamental principles of the therapy can be useful when using active listening skills within a consultation situation.

In essence, CBT works through making sense of problems which at the time seem overwhelming to an individual. Thus, an individual will respond to a situation by having thoughts, emotions, physical feelings and actions. All these various components will have an effect on one another, e.g. how someone thinks about a problem will affect how they feel about it emotionally and physically. Helping an individual to pass through a process of appraisal is a useful place to start. Within the context of CBT, this involves appraising the personal meaning and significance of an event and then appraising the capacity of an individual to cope with the event. For each situation, there are helpful and unhelpful ways of responding (see Box 6.3 for an example).

Box 6.3 Helpful and unhelpful ways of responding to a situation A young professional man with eczema on his face tells you that he was at the gym and the young female instructor who had been friendly and spent half an hour with him before, barely acknowledged his presence. An unhelpful cycle would be: Appraisal She ignored me because I have eczema on my face Thought I hate my eczema Emotion Feelings of rejection and sadness Behaviour Not going back to the gym A helpful cycle would be: Appraisal She ignored me because she is very busy Thought I will come when the gym is less busy Emotion Feelings of hope and expectation Behaviour Going back to the gym at a less busy time

Persistently having negative thoughts about situations leads to uncomfortable feelings, including rejection and sadness, as well as unhelpful behaviour, such as not returning to the gym. Helping patients involves reframing their experiences, so that rather than producing unhelpful emotions the individual feels more comfortable in specific situations. This may simply involve drawing the person’s attention to the fact that they view situations negatively and help them to view things more positively. It may be easier for people to do this if they understand the direct connection between thoughts and feelings, i.e. having more positive thoughts is more likely to lead to more positive feelings.

As part of this process, it is useful to help patients to learn that physical/bodily feelings can be changed. This can be done through deep breathing exercises or progressive muscle relaxation achieved by consciously tensing and relaxing muscles. Slow deep breathing is one of the quickest ways to counteract the effects of the sympathetic nervous system which stimulates the ‘flight or fight’ response. When fear or stress takes over, breathing tends to be shallow and limited to the chest. Deep breaths which fill the lungs and expand the abdomen will invoke a greater feeling of well-being and relaxation. Yoga and T’ai Chi use slow, steady breathing and movement to support a steady central nervous system response (Pick, 2009).

Changing people’s habitual responses to a situation takes time and as has already been mentioned, it requires the patient to be motivated towards those changes. For those with skin disease, there is the added challenge of coping with the physical discomfort of the problem. But using some of these CBT principles may help to reduce the level of psychological anxiety associated with the conditions.


In summary, particular focus should be paid to three key areas:

1. Helping patients to cope with their disease by providing information about it and how to treat it effectively;
2. Promoting relaxation and anxiety management, using some of the techniques discussed here;
3. Using appraisal to work with patients to develop helpful rather than unhelpful patterns of thought.

A programme that used all three of these elements successfully showed that people who enrolled showed significantly greater improvements in disease severity, anxiety, depression, psoriasis-related stress and disability, than those who just had conventional treatment (Fortune et al., 2002).