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Understanding CBT in the UK: Formats, Failures, and Next Steps

Updated: Jun 26

🧠 What is CBT?

CBT is a structured, evidence-based therapy focusing on changing negative thought patterns and behaviours. It blends cognitive strategies (thought restructuring) with behavioural interventions (like exposure therapy or behavioural activation).


CBT can be done in person, online, or on the phone.

You’ll usually have between 5 and 15 sessions of CBT, depending on what you’re having it for.


🔄 Types of CBT

  1. Individual CBT

    • One-to-one sessions (6–18 weekly, 45–60 min).

    • Used for depression, anxiety, PTSD, OCD.

  2. Group CBT

    • 8–12 sessions with multiple participants.

    • Often used for mild-to-moderate depression.

  3. Guided Self‑Help CBT

    • Workbooks/online tools with limited professional support (~6–8 sessions).

  4. Brief CBT

    • 4–8 condensed sessions.

  5. Specialised CBT

    • e.g., CBT-E (Cognitive Behavioural Therapy – Enhanced) for eating disorders, CBTp Cognitive Behavioural Therapy for psychosis) for psychosis, social anxiety-specific CBT.


    🧭 Standard vs Intense CBT

Feature

Standard CBT

Intense CBT (informal term)

Session Frequency

1 per week

2+ per week or even daily

Total Duration

12–20 weeks (depending on condition)

2–6 weeks (condensed)

Setting

Outpatient, primary care

Crisis teams, inpatient/day hospital

Use Cases

Depression, anxiety, PTSD

Severe/urgent need; rapid support

Flexibility

Aligned with NICE guidelines

May be adapted case-by-case

📌 NICE doesn’t use “intense CBT” formally, but allows flexibility in delivery based on patient severity, setting, and recovery goals.


📋 NICE-Recommended Session Durations

  • Depression (NG222, 2022):

    • Guided self-help: 6–8 sessions.

    • Individual CBT: 12–20 sessions.

  • Social Anxiety (CG159): 14–16 sessions.

  • Psychosis (CG178): At least 16 sessions using structured CBTp (Cognitive Behavioural Therapy for psychosis)



🚧 What if CBT Fails After 4 Sessions?

NICE and GMC guidance emphasize a structured approach if there’s poor response:

1. Reassess the Therapy

  • Was CBT delivered per NICE standards?

  • Was the therapist appropriately trained?

  • Any diagnosis or comorbidity missed (e.g. PTSD vs depression)?

2. Step Up or Switch

  • Mild cases: extend sessions or change format (e.g. face-to-face instead of self-help).

  • Moderate/severe: combine CBT with SSRI (e.g. sertraline, citalopram).

  • Switch to other therapies:

    • IPT (Interpersonal Therapy)

    • Behavioural Activation: it is a structured, evidence-based form of therapy that focuses on helping individuals with depression by encouraging them to engage in activities that improve their mood and reduce avoidance.

    • Short-term Psychodynamic Therapy

    • EMDR (if trauma-related) (Eye Movement Desensitisation and Reprocessing.)

3. Pharmacological Options

  • Start antidepressants (SSRIs) alongside CBT for moderate-to-severe cases.

4. Specialist Referral

  • Consider if non-response persists:

    • Refer to secondary care mental health team.

    • Evaluate for complex depression, personality disorders, or suicide risk.


🎯 PLAB 2 Tip:

In stations where a patient says "CBT didn’t work", show:

  • Empathy (“It sounds frustrating”)

  • Structured thinking (“Let’s go over what was tried”)

  • Next steps (suggest therapy switch, medication, or specialist referral)

  • Shared decision-making



📚 References:

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