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The Application of CBT in Treating Anxiety and Depression

One of the most common psychological therapies offered to people who are experiencing mental health issues is Cognitive Behavioural Therapy (CBT) together with guided self-help books, accounting for 72.7% of all courses of therapy provided in the UK during 2021/2022. The 2021/2022 NHS Digital report shows that in total, 1.81 million referrals to talking therapies were made in 2021/2022, up 24.5% from 1.46 million in 2020/2021. 

Cognitive Behavioural Therapy is recommended in the National Institute for Health and Care Excellence (NICE) guidelines, and CBT approaches can be used with children as well as adults and older adults for many different problems, including:

  • Anxiety disorders (including panic attacks)
  • Depression
  • Obsessive-compulsive disorder (OCD)
  • Post-traumatic stress disorder (PSTD)
  • Psychosis and schizophrenia
  • Bipolar disorder
  • Eating disorders
  • Tinnitus
  • Insomnia
  • Chronic fatigue syndrome (CFS)
  • Irritable bowel syndrome (IBS)
  • Fibromyalgia
  • Chronic pain

In this article we will look in more detail at the application of CBT in treating anxiety and depression.

Understanding Anxiety and Depression

Understanding Anxiety and Depression

Anxiety and depression are two of the most common mental health conditions. 

Anxiety

Most people experience stress and anxiety at some point in their lives. Generally, stress is usually a response to an external cause, such as an impending deadline at work or having an argument with someone, and will usually disappear or reduce once the situation has been resolved. Anxiety is a feeling of unease, such as worry or fear, where there is no actual real threat and is disproportionate to the situation faced. It can be mild or severe. Unlike stress, anxiety persists even after a concern has passed. 

In some cases, anxiety can escalate into an anxiety disorder and can affect day-to-day life. For anxiety to be considered a disorder it is usually experienced as overwhelming and persistent, causing impaired functioning, and is disproportionate to the stressor faced.

In the UK, over 8 million people are experiencing an anxiety disorder at any one time. Younger people are more likely to have some form of anxiety. In 2021, those aged 16 to 29 years were most likely to have some form of anxiety (28% likely). In 2020/2021, anxiety levels in the UK were at their highest for the period between 2011/2012 and 2022/2023, which corresponds to one of the worst periods of the COVID-19 pandemic, which first came to the UK at the end of January 2020.

Anxiety disorders, like other mental health conditions, result from a complex interaction of social, psychological and biological factors. Anyone can have an anxiety disorder, but people who have lived through abuse, severe losses or other adverse experiences are more likely to develop one.

Anxiety feels different for everyone, and signs and symptoms may include:

  • Trouble concentrating or making decisions
  • Feeling irritable, tense, restless, nervous or unable to relax
  • Experiencing nausea or abdominal distress
  • Having heart palpitations
  • Sweating, trembling or shaking
  • Trouble sleeping
  • Having a sense of impending danger, panic or doom, or fearing the worst
  • Worrying is uncontrollable and causes distress
  • Worrying affects daily life, including work, school/college, relationships, and social life
  • Avoiding places and situations that create anxiety
  • Difficulty concentrating
  • Having obsessive thoughts
  • Compulsive behaviour, such as constantly checking things

A person will typically experience these symptoms over an extended period, at least several months. Usually they avoid the situations that make them anxious.

There are several different kinds of anxiety disorders, including:

  • Generalised anxiety disorder – persistent and excessive worry about daily activities or events
  • Panic disorder – panic attacks and fear of continued panic attacks
  • Social anxiety disorder – high levels of fear and worry about social situations that might make the person feel humiliated, embarrassed or rejected
  • Agoraphobia – excessive fear, worry and avoidance of situations that might cause a person to panic or feel trapped, helpless or embarrassed
  • Separation anxiety disorder – excessive fear or worry about being separated from people with whom the person has a deep emotional bond
  • Specific phobias – intense, irrational fears of specific objects or situations that lead to avoidance behaviour and significant distress

People may experience more than one anxiety disorder at the same time, also the chance of developing depression is much higher when an anxiety disorder already exists.

Depression

From time to time, everyone experiences occasions when they feel low or sad, but these feelings usually pass naturally. If these feelings last a long time, or keep coming back and begin to have an impact on everyday life, it could be a sign of depression. Depression is a long-lasting low mood disorder that affects a person’s ability to do everyday things, feel pleasure or take an interest in activities. 

Depression, which is also known as Depressive Disorder, is a common mental disorder. An estimated 3.8% of the population experience depression, including 5% of adults, 4% among men and 6% among women, and 5.7% of adults older than 60 years. That is approximately 280 million people in the world who have depression. 

In the UK, according to the Office for National Statistics (ONS), around 1 in 6 adults in the UK are experiencing depression and it also found that the prevalence of moderate or severe depressive symptoms among adults in Great Britain rose after the start of the pandemic. The ONS has also monitored relationships between the prevalence of depression and the rising cost of living. Its data shows that rates of depression were higher among those who found it hard to afford housing costs or energy bills, and higher among renters than homeowners, although they note that the cost of living crisis will not be the only cause for the increase in depression. 

There is no single cause of depression; it is often caused by a combination and complex interaction of social, psychological and biological factors. It can be different for different people, and for many there is no clear reason. Some possible causes include:

  • Life events – such as, but not limited to:
    – Work-related issues, losing a job, changing job or retirement
    – Experiencing money problems
    – Relationship problems or the end of a relationship such as divorce
    – Illness or difficult diagnosis
    – Bereavement of a family member, friend or pet
    – Major life changes such as having a baby, moving house or getting married
    – Experiencing a crime, or being physically or sexually assaulted
    – Being bullied or abused, including experiencing racism.
  • Genetics – research has shown that if someone has a close family member with depression, they are more likely to experience depression themselves.
  • Childhood experiences – research shows that going through difficult experiences in childhood can make someone more vulnerable to experiencing depression later in life.
  • Hormones – changes in natural hormones can affect mood. Many women notice these changes during their menstrual cycle, pregnancy and menopause. Having low levels of certain B vitamins, such as vitamin B12, may put someone at risk of developing depression.
  • Styles of thinking – those who experience certain patterns of thinking such as Cognitive Distortions may be more likely to develop depression.
  • Lifestyle – alcohol and recreational drugs can both contribute to depression. Some studies have shown that not sleeping enough or not receiving quality sleep, not having a balanced diet, not exercising regularly, or smoking, can also contribute to depression.
  • Medication – depression can be a side effect of many medicines.
  • Other mental health problems – coping with the symptoms of another mental health problem such as eating disorders, post-traumatic stress disorder (PTSD) and anxiety, can trigger depression.

Depression can cause difficulties in all aspects of life, including at home, work, school/college, and in the wider community. A depressive episode lasts most of the day, nearly every day, for at least two weeks. Some common signs and symptoms of depression can include:

  • Feeling down, upset or tearful, restless, agitated or irritable
  • Constant low mood, hopelessness, frustration
  • Unable to relate to other people, feeling isolated and avoiding contact with friends, taking part in fewer social activities
  • Losing interest in the things that used to be enjoyable, not getting any enjoyment out of life
  • Self-harm and suicidal feelings
  • Having low self-esteem
  • Moving or speaking more slowly than usual, lack of energy and motivation
  • Disturbed sleep, for example finding it hard to fall asleep at night or waking up very early in the morning

There are different types of depression, and some conditions where depression may be one of the symptoms:

  • Situational depression often improves after enough time passes after the stressful event; however, if situational depression goes on for a long time and isn’t treated, it may turn into clinical depression.
  • Clinical depression is the more severe form of depression, also known as major depression or major depressive disorder. Symptoms are usually severe enough to cause noticeable problems in relationships with others or in day-to-day activities. Anxiety may occur as a symptom of clinical depression.
  • Postnatal depression. Some women develop depression after they have a baby and it is treated in a similar way to other types of depression.
  • Seasonal affective disorder (SAD), also known as winter depression, is a type of depression with a seasonal pattern usually related to winter.
  • Bipolar disorder – this has also been known as manic depression. There are spells of both depression and excessively high mood (mania). The depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour, such as gambling, going on spending sprees and having unsafe sex.

Depression interferes with different aspects of a person’s life; it might affect their ability to work, their relationships, or managing their finances and can add additional stress to already difficult experiences.

Principles of CBT

Principles of CBT

Cognitive behavioural therapy (CBT) explores the links between thoughts, emotions and behaviour. It is a directive, time-limited, structured approach used to treat a variety of mental health disorders. CBT is based on the idea that how we think about situations can affect the way we feel and behave.

The overarching principle of CBT interventions is that cognitions causally influence emotional experiences and behaviours. In other words, the way that we think about an event influences how we feel about it. For example, a person might think that giving a presentation to colleagues is an opportunity to show people how much they know about a topic and that it showcases their communication skills. The person may look forward to the event and be confident that they will make a good impression. This will lead them to giving a good performance. They have positive thoughts and feelings and this results in positive behaviour.

On the other hand, should the person dread the thought of giving the presentation, think that it will not be good, or feel nervous and stressed about the situation, this may lead them to perform poorly. They have had negative thoughts and feelings, and this may result in a negative result.

The principle of CBT is that changing a person’s negative thoughts to more positive thoughts, will change their feelings, and as a consequence their behaviour(s), from negative to more positive feelings and behaviours. 

With the help of a therapist, CBT enables a person to identify negative or distorted thoughts that contribute to their stress, worry or distress. The therapist will then help the person to challenge these negative thoughts and reframe them into more positive realistic and helpful ones. For example, “I am dreading this presentation, I will forget something and mess it up” (the negative thought), can be reframed as “I have prepared for this presentation, I have all the information that I need, so if I forget something, I can refer to my notes” (a more positive thought). The therapist will encourage the person to keep engaging in reframing their negative thoughts so that they can rewire their brain to think more positively. This will improve their mood, their outlook, their feelings and behaviours and impact their confidence levels.

Anxiety Treatment with CBT

As we have seen above, there are different forms of anxiety, and anxiety is different for each person who experiences it. When a person seeks treatment for their anxiety, their therapist will first want to discover what the source(s) and/or trigger(s) of their anxiety are, and whether there is a pattern to these, as the person’s emotional experience is dictated by the interpretation of the events and circumstances surrounding that experience. The therapist will then personalise the therapy sessions to the specific characteristics of the anxiety disorder and the needs and goals of the individual. 

For someone who is experiencing Generalised Anxiety Disorder (GAD), their anxiety is a long-term condition that causes them to feel anxious about a wide range of situations and issues. A CBT therapist may use Cognitive Restructuring to help the person to recognise any common themes in their anxieties. They can then help them to evaluate the likelihood of their fear occurring and to consider other more realistic outcomes. For example, if the person has anxiety about flying because they fear the plane will crash, encourage them to consider the fact that air travel is much safer compared to other major forms of transportation, and that, for example, in 2023, commercial aviation achieved unprecedented safety levels, surpassing all previous years. By replacing the person’s unhelpful thoughts with more realistic fact-based evidence helps them to become more grounded in reality. 

The therapist may also work with the person to devise a number of coping strategies to use at times and in situations when they feel their anxiety levels rise. 

Panic disorder is an anxiety disorder where a person has sudden attacks of anxiety, stress, fear and panic regularly and at any time, often for no apparent reason. During a panic attack, it is hard for a person to organise their thoughts in a way that makes sense to others. For example, someone who has a fear of crowds might be out with a group of friends, but they lose the group and find themselves alone in a large crowd. Cognitive restructuring can help the person to remember that if in that situation, their life isn’t in danger, and it can help them to come up with ways to cope, and to prevent separations from a group from happening in the future. 

The therapist may also choose to use Exposure Therapy as part of the treatment. Exposure tasks in CBT involve exposing the person to the trigger that causes their panic attacks. With gradual and prolonged exposure, the anxiety related to the trigger begins to decrease and eventually the person can become desensitised to the trigger.

Amongst the coping strategies that the therapist may introduce, breathing exercises for anxiety are a great way to stay grounded during a panic attack. They help the person to focus on what is happening right now and not focus on the what-ifs. A person’s physical state changes during a panic attack, and a breathing exercise can help regulate what is happening in their body, which can help them to calm down.

Social anxiety involves extreme and persistent feelings of worry, nervousness and dread, particularly in social situations, or even at the mere thought of social situations. The person might fixate on how others perceive them, or believe that they will do something to embarrass themselves and feel very self-conscious around others. The most effective CBT treatment approach often depends on the person’s unique symptoms; however, it can help a person learn to recognise their distorted thought patterns and reframe them more realistically through cognitive restructuring. 

The therapist works with the person in order to identify these unhelpful and inaccurate thought patterns as an important first step towards reframing, or restructuring, them. For example, a person might be thinking “I’m so boring, who would want to talk to me?”. This unhelpful thought could be reframed as “I may not have much to say, and am not sure what to talk about, but I can always ask a few questions to get the conversation going”. Restructuring won’t involve overly positive replacement thoughts. Rather, it aims to promote more neutral and realistic ways of thinking.

The therapist may also use visualisation to walk the person through situations to help them get more insight into their distorted thought patterns. During this, the therapist will help the person to restructure the situation and help them focus on the situation as a whole and not just the negatives or positives.

Depression Treatment with CBT

CBT is one of the most effective treatments for depression. Depression is a serious mental health condition that can cause intense sadness, feelings of hopelessness, and changes in mood and behaviour. It can also lead to thoughts of suicide and self-harm

CBT helps a person identify how their understanding of life situations is contributing to their experience of depression. This may involve the therapist asking the person to keep a diary/journal so that they can record daily events, their thoughts and interpretations of the events, and their resulting emotions or mood.

During therapy sessions, the therapist helps the individual evaluate these reactions, thought patterns and cognitive distortions identified in the journal. In depression, these negative thoughts can mean a person feels helpless, hopeless and worthless. The therapist helps the individual challenge these distorted thoughts, develop more realistic perspectives, and learn new ways of thinking.

Activity scheduling is a useful technique used in CBT therapy as it involves the person rewarding themselves for scheduling activities that encourage positive experiences and self-care. By scheduling these activities and rewards, they learn to motivate themselves to complete necessary tasks even when they are feeling low. It also increases the chances of continuing to complete these tasks after they end their formal therapy sessions.

In severe cases, such as in some cases of major depressive disorder (MDD), also known as clinical depression, doctors may recommend a combination of medication and CBT to manage the symptoms of depression and to enable the person to cope with everyday tasks.

Goal Setting

In CBT, goal setting is an important strategy that can help a person in therapy to stay motivated, and to achieve what they set out to accomplish. For example, a person who is depressed and isolated may work with the CBT therapist towards a goal of increasing their social circle and developing meaningful relationships. A person who may be experiencing anxiety related to their job may work with the CBT therapist towards exploring a career change, or making time more often for relaxation and activities outside the workplace.

Goal setting requires exploring what is important to the person and identifying a meaningful goal. Then answering the questions, “Where am I now?”, “Where do I want to get to?”, “What steps do I need to take to get there?” It is also important that the goals are SMART:

  • Specific – the wording should leave no doubt about what is required
  • Measurable – the goal or objective should be readily measurable, and the results should be available quickly and regularly
  • Achievable – the goal or objective should be reasonable and within your ability to accomplish for you to agree
  • Realistic – if the goal or objective offers poor chances of success then it will rapidly turn into a de-motivating force
  • Timed – how much, how soon? A goal or an objective without a time constraint is little more than a wish list

Following these steps will help the person to feel more able to achieve the goals they have set for themselves and also make them easier to achieve, to identify problems or challenges quickly and to plan strategies to overcome them if they occur. This all helps the person to get things done, to experience a sense of accomplishment, to feel good about themselves, and to boost their confidence. 

Coping Strategies

There are many tools and techniques used in cognitive behavioural therapy, many of which can be used outside of therapy in everyday life. These CBT coping skills involve dealing with negative emotions in a healthy way. 

A popular technique is cognitive restructuring; it offers an opportunity to notice unhelpful thoughts as they occur, and then practise reframing them in more accurate and helpful ways. The theory behind this strategy is that if you can change how you look at specific events or circumstances, you may be able to change the feelings you have, and the actions that you take. 

To be able to change an unhelpful thought pattern, you first have to be able to identify the error that you are making. Cognitive restructuring relies on your ability to notice the thoughts that trigger negative feelings and states of mind. It is important to also identify the situations that these triggers occur in. For example, unhelpful thoughts may only happen when you are at work, or at the end of a stressful day. A diary can help you to keep notes on these situations. By knowing the situations that negative thoughts are likely to occur in, you can prepare yourself. Knowing that vulnerability exists can help you catch your negative thought and change it. Being able to identify and change your negative thought patterns has many benefits including lowering your stress levels, relieving anxiety and boosting your confidence.

Behavioural activation is one of the simplest CBT coping strategies you can apply to your life. It is about learning problem-solving skills to help you tackle problems that are affecting your mood. It focuses on exploring the things that you have stopped doing, or things you are struggling to do because of your low mood or depression. By identifying what has changed, you can start to make a plan to restore some of the routine or structure that you have lost. Behavioural activation tries to break the vicious cycle of feeling low, doing less, experiencing less pleasure, having lower energy levels and motivation, feeling worse and so on.

Behavioural activation is a step-by-step process that helps you to make gradual changes to your daily routine by looking at three different types of activities: those that are routine, those that are pleasurable, and those that are necessary. The first step is to recognise that in order to feel better you need to activate yourself. Next, monitor your daily activities to understand the relationships between your activity and your mood. Once you have monitored your activity for about a week you can use your activity monitoring record to look for patterns between your activity and your mood, and you can then work out what really matters to you. You can then schedule and carry out meaningful activities to boost your experiences of pleasure and confidence. The theory behind behavioural activation is that if you do more of what matters to you, then you will begin to feel better about yourself. This will give you more confidence to overcome any challenges.

Exposure therapy is a type of therapy in which you are gradually exposed to the things, situations and activities that you fear and that cause anxiety. A graded step-by-step exposure to the fear would involve first understanding your fear, for example if you fear crowded spaces, what is it about the crowded space that causes you anxiety? Once you identify the specific triggers you can start with confronting things and/or situations that cause you anxiety, but at anxiety levels that you feel able to tolerate. After the first few times, you will find your anxiety does not climb as high and does not last as long. You can then move on to more difficult exposure exercises. 

Exposure therapy can be distressing at first, as you are directly facing your fears. This is why it is a strategy that should be undertaken with the help and support of a therapist, to ensure this therapy is safe and effective.

It can, however, be useful in these exposure situations to use other CBT coping techniques such as deep breathing for managing anxiety, or an exercise called progressive muscle relaxation. This involves alternating between tensing and relaxing different muscle groups throughout the body. By tensing your muscles, a common physical symptom of anxiety, and immediately relaxing them, the symptom of muscle tension may eventually become a signal for your body to relax. This is an effective way to reduce feelings of anxiety and stress.

Homework and Self-Help

Homework and Self-Help

During CBT sessions, a person works with their therapist to look at their thoughts, feelings and behaviours to work out if they are unrealistic or unhelpful, how they affect each other, and how they affect the individual themselves. Outside the session, the therapist may ask the individual to complete questionnaires or worksheets. The therapist may also suggest that they keep a journal or diary noting down how they think, feel and act in different situations day to day. This information is used in the sessions for the therapist to help the person work out how to change upsetting thoughts and unhelpful behaviours.

Another important part of “homework” outside of the therapy session is practising new skills in everyday life. CBT is more effective if these changes in thinking and behaviour are put into practice, because CBT aims to get the individual to a point where they can do this for themselves, and work out their own ways of tackling problems or challenges. 

“Homework” can involve practising questioning negative thoughts of being self-critical, ignoring positives or taking things personally when they occur, and taking time to reshape these unhelpful thinking habits into more helpful and realistic thoughts. 

The therapist may also ask that the person challenges some beliefs as they arise, and test out the truth of that belief. The test may involve identifying a core belief that the person would like to evaluate, and to rate how strong their belief is before challenging it, for example “Going for a walk when I am feeling down is only going to make me feel worse” may be completely believed and rated as 100% true. 

The challenge would involve taking walks and recording evidence to dispute the belief; did they really feel worse during and after the walk? Asking themselves the question “What experiences do I have that show that this belief is not completely true all the time?” and noting them down. These experiences that show that this belief is not completely true all the time might include, for example, “The fresh air helped to clear my head”, “I bumped into a neighbour and had a chat” etc. The person should then review these core beliefs in light of their experiences and re-evaluate them. Are they still 100% true? How has that belief altered?

The therapist may set the person a problem-solving exercise that requires taking positive rather than negative action; for example, rather than avoidance, taking actions that are helpful, and noting down how they feel after taking the positive action.  

When the therapist sets “homework” for between sessions, there is an expectation that the individual may have to step outside their comfort zone in some ways, but the therapist will monitor this, and will not ask the individual to do anything that will have a negative impact. The aim and benefit of “homework” is to enable the individual to put session learning into practice, which will help to build their confidence.

There will be individuals who prefer not to attend CBT sessions with a therapist, but to “do it themselves”. There are a variety of CBT self-help books, online programmes or apps available, but they do require that the person has the motivation to work through all of the exercises to finish the course. It can be useful to get guided self-help from a professional therapist, usually via email or telephone, as this can help to support the self-help process. The NHS provides a guide to self-help CBT techniques.

Effectiveness of CBT

The National Institute for Health and Care Excellence (NICE) recommends CBT as a first choice of treatment for a range of conditions including anxiety and depression, as it views CBT as one of the most effective treatments for these conditions. 

There have been various research studies examining the efficacy of CBT in the treatment of disorders such as anxiety and depression. One of the most recent studies was published online by Cambridge University Press in January 2022. Across different tasks, they observed that brain response in a network of regions involved in salience and interception processing, encompassing fronto-insular (the right inferior frontal gyrus-anterior insular cortex) and fronto-limbic (the dorsomedial prefrontal cortex-dorsal anterior cingulate cortex) cortices was strongly associated with a positive CBT outcome. 

In a 2018 study published in Frontiers in Psychiatry, experts argued CBT to be the “gold standard”, or “best standard we have in the field constantly available” in treating common mental health conditions such as anxiety and depression.

The UK Council for Psychotherapy conducted research to demonstrate the positive impact of psychotherapy (CBT) and counselling on mental health. Crucially, for those who improved following mental health support, a higher percentage had received psychotherapy, counselling and other talking therapies.

Conclusion

CBT is a leading evidence-based therapy, which works very well for many different mental health conditions including anxiety and depression. Using a variety of strategies, tools and techniques such as cognitive restructuring, exposure therapy, relaxation techniques, skill-building exercises and coping strategies, CBT helps individuals to better understand and address the underlying cognitive and behavioural patterns, and to manage their anxiety or depression. CBT therapy enables them to make major changes to their negative thought processes leading to significant improvements in their symptoms and their quality of life.

The practical skills developed during CBT therapy sessions can continue to be used long after the CBT therapy sessions end to help a person continue to manage their anxiety or depression, and to avoid any future relapses. 

For many people, the ability to identify and change their unhelpful thinking patterns, and to replace them with more helpful, positive thoughts, feelings and behaviours, ensures that these become habitual, leading to, in some cases, dispelling the anxiety or depression altogether. 

For others, the ability to apply coping strategies at times of stress, anxiety or depression, helps to alleviate some of the more unhelpful thoughts, feelings and behaviours associated with anxiety and depression, and enables them to manage these situations better, and to lead more fulfilling lives.

For anyone who is interested in CBT therapy for anxiety or depression, they should, in the first instance, speak to their GP, who may recommend a CBT therapist in the local area. In addition, the British Association for Behavioural and Cognitive Psychotherapies provides information on CBT and a list of accredited CBT therapists.

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About the author

Luke Bell

Luke joined the team in February 2024 and helps with content production, working closely with freelance writers and voice artists, along with managing SEO. Originally from Winchester, he graduated with a degree in Film Production in 2018 and has spent the years since working in various job roles in retail before finding his place in our team. Outside of work Luke is passionate about gaming, music, and football. He also enjoys watching films, with a particular love of the fantasy and horror genres.



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