Can cognitive behavioural therapy really change our brains?

Cognitive behavioural therapy (CBT) is a type of talking therapy that’s used to treat a wide range of mental health problems, from depression and eating disorders to phobias and obsessive-compulsive disorder (OCD). It recommends looking at ourselves in a different way that might prove useful for all of us in everyday life. But what happens to our brains when we have CBT?

What is cognitive behavioural therapy?

CBT is based on the idea that problems aren’t caused by situations themselves, but by how we interpret them in our thoughts. These can then affect our feelings and actions.

Situation affects thoughts, which then affect feelings and actions
The way we think about a situation can affect how we feel and how we act

For example, if someone you know walks by without saying hello, what’s your reaction?

You might think that they ignored you because they don’t like you, which might make you feel rejected. So you might be tempted to avoid them the next time you meet. This could breed more bad feeling between you both and more “rejections”, until eventually you believe that you must be unlikeable. If this happened with enough people, you could start to withdraw socially.

But how well did you interpret the situation in the first place?

Common errors in thinking style

  • Emotional reasoning – e.g. I feel guilty so I must be guilty
  • Jumping to conclusions – e.g. if I go into work when I’m feeling low, I’ll only feel worse
  • All-or-nothing thinking – e.g. if I’ve not done it perfectly, then it’s absolutely useless
  • Mental filtering – e.g. noticing my failures more than my successes
  • Over generalising – e.g. nothing ever goes well in my life
  • Labelling – e.g. I’m a loser

CBT aims to break negative vicious cycles by identifying unhelpful ways of reacting that creep into our thinking.

“Emotional reasoning is a very common error in people’s thinking,” explains Dr Jennifer Wild, Consultant Clinical Psychologist from Kings College London. “That’s when you think something must be true because of how you feel.”

CBT tries to replace these negative thinking styles with more useful or realistic ones.

This can be a challenge for people with mental health disorders, as their thinking styles can be well-established.

How do we break negative thinking styles?

Some psychological theories suggest that we learn these negative thinking patterns through a process called negative reinforcement.

Graded exposure can help people confront their phobias

For example, if you have a fear of spiders, by avoiding them you learn that your anxiety levels can be reduced. So you’re rewarded in the short term with less anxiety but this reinforces the fear.

To unlearn these patterns, people with phobias and anxiety disorders often use a CBT technique called graded exposure. By gradually confronting what frightens them and observing that nothing bad actually happens, it’s possible to slowly retrain their brains to not fear it.

How does cognitive behavioural therapy work on the brain?

Primitive survival instincts like fear are processed in a part of the brain called the limbic system. This includes the amygdala, a region that processes emotion, and the hippocampus, a region involved in reliving traumatic memories.

Brain scan studies have shown that overactivity in these two regions returns to normal after a course of CBT in people with phobias.

What’s more, studies have found that CBT can also change the prefrontal cortex, the part of the brain responsible for higher-level thinking.

So it seems that CBT might be able to make real, physical changes to both our “emotional brain” (instincts) and our “logical brain” (thoughts).

Intriguingly, similar patterns of brain changes have been seen with CBT and with drug treatments, suggesting that psychotherapies and medications might work on the brain in parallel ways.

How effective is cognitive behavioural therapy?

Of all the talking therapies, CBT has the most clinical evidence to show that it works.

Studies have shown that it is at least as effective as medication for many types of depression and anxiety disorders.

But unlike many drugs, there are few side effects with CBT. After a relatively short course, people have often described long-lasting benefits.

“In the trials we’ve run with post-traumatic stress disorder [PTSD] and social anxiety disorder, we’ve seen that even when people stop the therapy, they continue improving because they have new tools in place and they’ve made behavioural and thinking style changes,” Dr Wild explains.

CBT may not be for everyone, however.

Since the focus is on tackling the here and now, people with more complicated roots to their mental problems which could stem from their childhood, for example, may need another type of longer-term therapy to explore this.

CBT also relies on commitment from the individual, including “homework” between therapy sessions. It can also involve confronting fears and anxieties, and this isn’t always easy to do.

Ultimately, as with many types of treatment, some people will benefit from CBT more than others and psychologists and neuroscientists are beginning to unravel the reasons behind this.

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Stakeholder Event Southwark: Matthew’s blog

SLaM’s mother and baby unit praised

The specialist Mother and Baby Unit at the Bethlem Royal Hospital has been recognised as providing an example of “best practice” in caring for women suffering with severe mental illness during pregnancy or post-birth.

An NSPCC report released last week suggests the wellbeing of more than one in 10 newborn babies in England could be improved if all new mothers with mental illness had equal access to good services.

The report states there is evidence to show that the work carried out at the Channi Kumar Mother and Baby Unit, part of the South London and Maudsley NHS Foundation Trust, leads to significant improvements in mental state in approximately three quarters of women, in the sensitivity of mothers with schizophrenia and postpartum psychosis when interacting with their babies and major improvements in the interaction of the babies of mothers with schizophrenia, psychosis and depression.

The 13-bed unit was set up for women who develop or have a relapse of serious mental illness during pregnancy or following the birth of their baby. The unit offers a wide range of treatment, therapy and care which is not offered on the same scale in any other unit in the UK.

One unique factor is the work of a developmental psychologist who works closely with the mothers and infants.

Dr Susan Pawlby works clinically as a developmental psychologist at the unit and academically at the King’s College London’s Institute of Psychiatry.

She said: “I think our unit stands out because we have a developmental psychologist to work with nursery nurses and nurses on the ward and most other units do not have that.

“It means we can give mothers and infants more support in forming and maintaining this early and most fundamental relationship. We have developed video feedback interventions so that mothers can see how their babies respond to them. Together we watch video clips of play sessions, talk about the communication between the mother and her baby in order to help mothers develop their relationship with their baby.

“We systematically evaluate this intervention and see how effective it is. Our work is to encourage mothers to respond to their babies’ cues, so that mothers become more sensitive and babies more co-operative in their interaction with one another. I am delighted our work has been recognised by the NSPCC.”

Alongside this support, the Mother and Baby Unit also treats mothers with medication where needed. The unit also offers various forms of therapy (psychological, art psychotherapy, cognitive behavioural therapy and cognitive analytical therapy), life skills, health skills, leisure activities, baby massage and dance therapy.

Following the release of the report the NSPCC is calling on health ministers to lead a drive to address major gaps in access to mental health services for pregnant and new mums.

Mental health problems including depression, anxiety, postpartum psychosis, obsessive compulsive disorders,  eating disorders , schizophrenia, post-traumatic stress disorderand personality disorder can begin or escalate when a woman is pregnant or in her infant’s first year. They can have a damaging effect on family life, and in the worst cases, impact on babies’ health and welfare.

Evidence shows that the vast majority of these illnesses are preventable and treatable, and with the right support, the negative effects on families can be avoided.

Sally Hogg, author of the NSPCC report, said: “The Mother and Baby Unit at Royal Bethlem Hospital provides excellent support for mothers suffering from perinatal mental illnesses and their babies. They do fantastic work to help mums to care for and bond with their babies, which helps ensure these children have the best possible start in life.

“It is crucial that more units like this are made available across the country for all families who need them, as without access to specialist units such as this some mothers don’t get the right help and can be separated from their babies, which is traumatic for the whole family.”

For more information on the NSPCC report:

Read Susan’s story here

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SLaM leading the way in talking therapies

South London and Maudsley NHS Foundation Trust is one of only two trusts in the country to have been awarded funding from the Department of Health to increase access to psychological therapies for people with psychosis and their carers.

The funding means that the Psychosis CAG is an IAPT-SMI (Improving Access to Psychological Therapies – Severe Mental Illness) Psychosis Demonstration Site. Expanding access to talking therapies services for people with severe mental illness is part of the Government’s four year plan for talking therapies (2011-2015).

SLaM has a long history of providing innovative and exemplary practice in psychological treatments for psychosis, Cognitive Behavioural Therapy (CBTp) and Family Intervention (FI). Indeed, staff members from the Trust and the Institute of Psychiatry were involved in the initial development and evaluation of both treatment approaches.

The additional funding from the Department of Health will be used to increase therapy provision by 50%. The IAPT-SMI service spans three clinical teams: an Early Intervention team (STEP), a specialist recovery service (SHARP), and a psychological therapy team (PICuP).

The benefits for service users and their carers is improved access to NICE recommended psychological therapies for psychosis (CBTp and FI) across all four SLaM boroughs, with clear referral pathways, including self-referral, reduced waiting times and regular assessment of progress to ensure that therapy is helpful.

Philippa Garety, Clinical Director and Joint leader, Psychosis Clinical Academic Group (CAG), said: “We are delighted that the Department of Health has selected the SLaM Psychosis CAG as a demonstration site. It reflects well on all the hard work and commitment of the staff in promoting access to psychological therapies, which we know to make a real difference in people’s lives.”

A demonstration site open day will take place on Monday 1 July for people to find out more about the IAPT-SMI service from clinicians, service users and carers. There will be presentations, feedback on progress and an opportunity for informal discussions and networking. The event is free, but you are asked to book your place beforehand.

When: 1pm to 5pm 1 July 2013

Where: Ortus Learning Centre at the Maudsley Denmark Hill Campus


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Avatars ease voices for schizophrenia patients

By Lorna Stewart

Use of an avatar can help treat patients with schizophrenia who hear voices, a UK study suggests

The trial, published in the British Journal of Psychiatry, focused on patients who had not responded to medication.

Using customised computer software, the patients created avatars to match the voices they had been hearing.

After up to six therapy sessions most patients said their voice had improved. Three said it had stopped entirely.

The study was led by psychiatrist emeritus professor Julian Leff, who spoke to patients through their on-screen avatars in therapy sessions. Gradually he coached patients to stand up to their voices.

“I encourage the patient saying, ‘you mustn’t put up with this, you must tell the avatar that what he or she is saying is nonsense, you don’t believe these things, he or she must go away, leave you alone, you don’t need this kind of torment’,” said Prof Leff.

“The avatar gradually changes to saying, ‘all right I’ll leave you alone, I can see I’ve made your life a misery, how can I help you?’ And then begins to encourage them to do things that would actually improve their life.”

By the end of their treatment, patients reported that they heard the voices less often and that they were less distressed by them. Levels of depression and suicidal thoughts also decreased, a particularly relevant outcome-measure in a patient group where one in 10 will attempt suicide.

Treatment as usual

The trial, conducted by Prof Leff and his team from University College London, compared 14 patients who underwent avatar therapy with 12 patients receiving standard antipsychotic medication and occasional visits to professionals.

Later the patients in the second group were also offered avatar therapy.

Only 16 of the 26 patients completed the therapy. Researchers attributed the high drop-out rate to fear instilled in patients by their voices, some of which “threatened” or “bullied” them into withdrawing from the study.

New treatment options have been welcomed for the one in four patients with schizophrenia who does not respond to medication. Cognitive behaviour therapy can help them to cope but does not usually ease the voices.

Paul Jenkins, of the charity Rethink Mental Illness, said: “We welcome any research which could improve the lives of people living with psychosis.

“As our Schizophrenia Commission reported last year, people with the illness are currently being let down by the limited treatments available.

“While antipsychotic medication is crucial for many people, it comes with some very severe side effects. Our members would be extremely interested in the development of any alternative treatments.”

Next phase

A larger trial featuring 142 patients is planned to start next month in collaboration with the King’s College London Institute of Psychiatry.

Prof Thomas Craig, who will lead the larger study, said: “The beauty of the therapy is its simplicity and brevity. Most other therapies for these conditions are costly and take many months to deliver.

“If we show that this treatment is effective, we expect it would be widely available in the UK within just a couple of years as the basic technology is well developed and many mental health professionals already have the basic therapy skills that are needed to deliver it.”

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Love letters and kindness may improve mental health

By Lorna StewartHealth Check, BBC World Service

“You matter to me. In a way I cannot explain, you matter to me. And you, you are a marvel… you and all the parts of you.”

It’s not the kind of thing you normally write to a complete stranger.

But after graduating from college and moving to New York City, Hannah Brencher was feeling anxious and depressed. She found herself not wanting to be around other people and “just really unravelling”.

Then she started writing love letters to strangers and leaving them all over the city. The first letter she left on a train simply addressed: “If you find this letter then it’s for you.”

Since then she has left letters in libraries and cafes, and even hidden them around the United Nations building.

You and I don’t know one another. We may never sit and laugh over cups of coffee. We may never dance in the same circles or yawn together by the midnight hour. None of that really matters to me. It is so small and meaningless to the things I wish you would know on a daily basis: that you are lovely. That you are worthy. That those hands of yours were made for mighty, mighty things.

You probably think I am crazy. You are probably sitting here with this letter in your hands thinking, you cannot know that… you don’t know me… you don’t know a stitch of me. Yes, you’re right. But I know all the things I thought I never deserved. I know how very hard it once was to love myself and value myself and even find myself worth the reflection in the mirror. And so I know I am not alone in needing a boost some days, in needing to know that I matter to someone somewhere.

You matter to me. In a way I cannot explain, you matter to me. And you, you are a marvel… you and all the parts of you.


A girl just trying to find her way

“What I noticed was that my sadness and loneliness got backburnered,” she told the BBC. “I found something that allowed me to take the focus off of myself.”

Hannah and her More Love Letters campaign are part of a growing number of organisations shouting about the beneficial effects of random acts of kindness for givers as well as receivers.

It might sound a bit like new-age nonsense to some people, but new research suggests being kind might actually be good for your mental health.

A study published in the journal Emotion reports that performing acts of kindness may help people with social anxiety to feel more positive.

Dr Lynn Alden and Dr Jennifer Trew, from the University of British Columbia, asked volunteers with high levels of social anxiety to commit multiple acts of kindness on two days a week over a four-week period.

“Sometimes people would give a small gift to somebody, or picking somebody up from work, visiting sick people, thanking a bus driver. They were actually fairly small acts,” explained Dr Alden.

They were small acts perhaps, but ones which had a much bigger impact.

Challenging beliefs

More standard treatment for social anxiety disorder is cognitive behavioural therapy (CBT) adapted specifically for people who fear they will do or say something embarrassing in a social situation.

In Dr Alden’s experiment a comparison group of anxious volunteers were asked to perform small “belief-challenging” tasks similar to these therapeutic ones.

Just like the kind acts group, this group were also increasing their levels of social contact, engaging in unfamiliar behaviour, and paying attention to others’ responses; all things which have been suggested to be important components in overcoming social anxiety.

At the end of the four weeks, participants in the kind acts group avoided social situations less and also reported increased relationship satisfaction. Performing kind acts appeared to have a bigger effect than CBT-like behaviour tasks.

A London-based initiative called the Kindness Offensive have been organising give-away events and encouraging kind acts since 2008.

They hold the world record for the largest ever random act of kindness for distributing 39 tonnes of goods in one day.

“It’s practically impossible to do an act of kindness without feeling good about yourself,” said the aptly named David Goodfellow, one of the founding members of the group.

“If you can make someone’s day a little bit better it will actually make your day a little bit better.”

Dr Nick Grey, consultant clinical psychologist and clinic director at the Centre for Anxiety Disorders and Trauma in London, was initially wary of the idea that performing kind acts might have therapeutic value for patients with anxiety disorders.

“I hadn’t seen the paper and I was sceptical from the title to be honest. But it’s a good paper and comes from a well-respected team.

“I don’t think that’s ever going to be a therapy in and of itself, but it could well be the kind of activity that could be integrated as part of a broader treatment.”

Dr Alden suggests that acts of kindness might be an initial step in a longer therapeutic pathway.

“Engaging in kind acts may help the person to get out and encounter other people and then we can use other techniques to help the person change their beliefs about themselves.”

But she urges caution about performing acts of kindness chosen by someone else or just to impress others.

“I think it has be done in such a way that the individual has a sense of autonomy. They are performing the act because they want to and not because it’s required by the group.”

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Insufficient evidence to suggest that exercise has a treatment effect on the symptoms of anxiety disorder

Anxiety disorders are identified by NICE clinical guidelines as a common mental health issue. The term refers to a range of disorders including generalised anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and social anxiety disorder. The typical treatment plan consists of medication and/or psychotherapy, however NICE acknowledges that access to psychological interventions is still limited, despite patient preference often being towards these non-pharmacological treatments.

While the potential benefits of exercise in depression have been widely explored and debated, the role of exercise in anxiety disorders has been less explored. Physical activity reduces feelings of stress and anxiety in healthy individuals, but it remains unclear to what extent it can benefit people with an anxiety disorder.

The authors of this new study therefore conducted a systematic review of the evidence surrounding the effect of exercise as a treatment for anxiety disorder.


Evidence showing a positive impact of exercise on depression is increasing all the time

Evidence showing a positive impact of exercise on depression is increasing all the time

The authors were interested in randomised control trials (RCTs) in which exercise was used as an intervention for anxiety disorder. They conducted an extensive database and journal search, and also referred to bibliographies of included studies and related review articles, to identify relevant RCTs. Papers identified from the initial search were then assessed by 2 researchers according to relevance to topic and study design.

Data were then extracted from the selected papers, and effect sizes recorded or calculated (for some studies, but not others, these effect sizes are reported). The quality of included studies was assessed using Cochrane Collaboration rating systems.


They identified 8 studies that were both relevant to the topic and appropriately controlled trials. Oddly one article is described as still ‘awaiting assessment’ but no explanation is given as to why. Considering only a handful of studies were identified for the review it seems a shame this study was not assessed as it may have been relevant!

Main findings

  • Group exercise versus no exercise (1 RCT): both groups improved, but no significant difference between groups on a quality of life measure at both 20 weeks (programme duration) and 32 weeks (follow-up period).
  • Exercise versus placebo pill (1 RCT): exercise group (10 week programme of running) showed significantly greater improvement in scores on 6 out of 9 anxiety and depression scales.
  • Exercise versus antidepressant (Clomipramine) (1 RCT): antidepressant group showed significantly greater improvement in scores on 5 out of 9 anxiety and depression scales.
  • Exercise (10 weeks of “aerobic exercise”) and antidepressant medication (Paroxetine) combined versus “relaxation” and placebo pill combined (1 RCT): exercise/antidepressant group showed significantly greater improvement on the Clinical Global Impression scale.
  • Exercise (10 weeks of “aerobic exercise”) and placebo pill combined versus “relaxation” and placebo pill (1 RCT): no significant difference between groups
  • Group CBT and walking exercise (8 week programme) combined versus group CBT and “educational sessions” combined (1 RCT): CBT/exercise group showed significantly greater improvement on depression scale, but no significant difference between groups on the anxiety and stress scales.
  • Exercise, occupational therapy and lifestyle changes (16 week programme) combined versus standard GP care (1 RCT): at 20 weeks and at a 10 month follow-up those in the exercise/occupational therapy/lifestyle changes group had significantly greater improvement in scores on Beck Anxiety Inventory and fewer panic attacks.
  • Three RCTs then compared different types of exercise. No significant differences were found between aerobic and non-aerobic exercise (1 RCT), or between walking and jogging (1 RCT). The third RCT found a significantly greater reduction in panic attack rate and panic symptoms after one session of moderate-hard exercise compared to one session of very light exercise.

There is considerable variation across studies in the treatments studied and the specific anxiety diagnoses included in the sample

There was considerable variation across the included RCTs in the treatments studied and the specific anxiety diagnoses included in the study population

Strengths of the review

As the authors highlight, the strengths of this review include the extensive search for relevant literature and the systematic appraisal of research quality of included studies.

Limitations of the review

Research to date is limited. There is considerable variation across studies in the treatments studied and the specific anxiety diagnoses included in the sample. No meta-analysis could be conducted due to this heterogeneity, and as the authors note no assessment of publication bias could be conducted. As the authors also highlight, many of the studies had methodological issues and relatively short duration of follow-up. Unfortunately reporting of results in the review is often unclear and details about individual studies are limited.


The authors conclude:

It seems that exercise shows a treatment effect beyond the placebo effect. Although it appears that the antianxiety effects of exercise are lesser than antidepressants for clinical anxiety disorders, it can still be beneficial as an adjunctive treatment.

As it stands there is not enough evidence to suggest exercise has a treatment effect on symptoms of anxiety disorder

As it stands there is not enough evidence to suggest exercise has a treatment effect on symptoms of anxiety disorder

However I think we need to be cautious with these conclusions. The comparison to placebo is based on just one study finding. Additionally there were only two studies including exercise as a stand-alone treatment, and these found contradictory results. Other trials assessed exercise combined with other interventions, so conclusions cannot be drawn regarding the unique effect of exercise from these studies. Consequently the authors’ conclusion that exercise “can still be beneficial as an adjunctive treatment” has not actually been tested in the studies discussed. Meanwhile antidepressants and CBT have a large evidence base for treatment of anxiety disorders, and indeed as the authors conclude antidepressants led to a greater improvement in anxiety symptoms when compared to exercise in one of the studies reported here.

Better controlled trials with appropriate control comparisons are needed. As it stands there is not enough evidence to suggest exercise has a treatment effect on symptoms of anxiety disorder.

However, while the evidence for a treatment effect of exercise in anxiety disorders is currently lacking, us woodland elves still love to keep active! Exercise is good for your physical health and mental wellbeing. Keeping active is a great way to keep a healthy heart and mind!


Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic review. Br J Sports Med. 2013 Jan 7. [Epub ahead of print] [PubMed abstract]

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