Introduction

Cognitive Behavioural Therapy, commonly referred to as CBT, is an umbrella term for a type of therapy that is recommended for treatment of social anxiety amongst other mental health difficulties.

CBT is primarily offered by the NHS as a talking therapy however the principles of CBT are also applied in other scenarios – see self-help.

This article aims to provide a brief overview of CBT, what it is and isn’t, and help dispel any myths you may have heard about it. It is intended to give you some idea of what you can expect and, in the case of therapist led CBT, roughly how the treatment will be conducted. Therapist led (or therapist supported) CBT can be tailored for the things you find particularly difficult.

Overview

Cognitive Behavioural Therapy is based on the idea that your thoughts, feelings, physical sensations, and behaviour are all interconnected, and our thoughts and perceptions about situations strongly influence our emotional responses and actions. The idea is if one of these can be changed, it can alter the others to help us feel better. This is sometimes referred to as having a ‘here and now’ focus, unlike other therapies, as it does not delve into an in-depth examination of your past.

CBT therapists work collaboratively with clients to identify negative thought patterns or cognitive distortions that might contribute to emotional distress or problematic behaviours. To help us understand our thoughts, interpretations, and beliefs, a psychological formulation is often used to understand the factors that led to and maintain the difficulties we are faced with. It’s a structured process where a therapist and client together gather and analyse information about a person’s thoughts, emotions, behaviours, and life experiences to develop a comprehensive understanding of their difficulties.

CBT is often described as a very active therapy. This means it is more than talking about your difficulties. There are often practical tasks to carry out, sometimes in sessions and often between sessions as homework. Regular and consistent practice is one of the most important factors in using CBT. This can be difficult, as it may initially increase anxiety. Maintaining the motivation to confront feared situations, even when some may not go well, is key.

Other characteristics of CBT are being a highly structured and goal orientated therapy. Most sessions start with setting an agenda, where you and your therapist would agree what you will talk about, and how you will achieve your goals.

You may find that while you can agree with new thoughts and behaviours intellectually, you find it hard to ‘feel’ them and believe them. It is important to keep at it, even if it is challenging. The more you practise new thoughts and behaviours, the more they will start to become second nature, until gradually they become automatic, and you may begin to notice these changes and feel better.

CBT can be offered on a one-to-one basis, or part of a group. The number of sessions depends on your difficulty or how you are accessing it. For example, some NHS services may have a limit to the number of sessions that can be offered. Sessions usually last around 50 minutes to 1 hour, but some sessions can be up to 90 minutes (when agreed in advance). Sessions can be face-to-face or remote via online video call depending on your preference.

Why CBT?

CBT is considered to be the frontline treatment for social anxiety and is recommended because it is evidence-based. This means the UK National Institute for Health and Clinical Excellence (NICE) have surveyed and reviewed the efficacy and effectiveness of different treatments for mental health conditions, and thus made recommendations for what should be made available in the NHS, including guidance for treatment. The treatments recommended would have been tested in tightly controlled research trials, as well as ordinary clinical practice outside specialist research centres, to be proven to be effective. CBT is strongly supported as a therapy for most psychological disorders in adults.

NICE periodically updates its recommendations and is a useful resource providing an overview of treatment options. It is available for the general public to see, and you can access the recommendations for social anxiety here. If you feel CBT is not for you, NICE also includes alternative approaches to treatment.

CBT and Social Anxiety

On the recommendation of NICE, NHS CBT uses two types of models for how thoughts and behaviours interact with one another in social anxiety: either the Clark and Wells Model or Heimberg Model.

Although there are guiding protocols for treating social anxiety, and other mental health problems, every client and therapist are different, and the therapy is tailored to the specific client’s needs. There are usually a range of behavioural (e.g., experiments or gradual exposure) and cognitive (e.g., thought challenging or restructuring) interventions used, what works for you may not work for someone else with social anxiety, and vice versa. You and your therapist can work together and try out new techniques or interventions that work for you. This is the collaborative nature of CBT.

What might this look like in social anxiety? Let’s take an example that has been formulated using the principles of CBT. If we were faced with an anxiety-provoking situation such as having to give a presentation in front of work colleagues, how would we feel? What would be going through our mind? How might we behave to manage or prevent this anxiety? If we could learn strategies to help us manage our physical symptoms, would we still feel as anxious or scared? If we could restructure our thoughts to review the evidence and realise our prediction may not be true, might our behaviour reflect this? If we gradually expose ourselves to this situation, might this in turn reduce the severity of our physical symptoms? CBT offers us the chance to practise various interventions that help facilitate change across these areas.

Changing what we do or how we think is often a powerful way to support changing our emotions and physical sensations, and in turn our overall psychological state. It is important to remember change can take time and practice. It is never as simple as turning a negative thought into a positive one. This is why CBT equips individuals with a range of practical tools and skills they can use independently to manage their emotions and behaviours even after therapy ends.

Common techniques that a CBT therapist might use in the treatment of social anxiety include:

You can try some of these techniques out for yourself! It is sometimes referred to as guided self-help. Some people find this just as effective as working with a professional. If you are stuck on where to start, we have listed several options of guided self-help books here.

How to access CBT?

You can access talking therapies, including CBT, through the NHS. You can refer yourself directly to your local talking therapy service without a referral from your GP. Alternatively, your GP can refer you if you prefer.

You will then be offered an opportunity to speak with a clinician about your difficulties and consider what treatment and/or service would be best suited to support you and your current needs. The NHS NICE guidance recognises that attending a doctor’s appointment – or talking to a clinician – can be very difficult for those with SA. It provides a series of recommendations to make communication and appointments easier. You may be able to ask your GP to ring you rather than you having to attend the GP practice in person. You could ask friends or family to help you make the first phone call. You could ask your health and social care team to communicate with you over text or email.

You can find an NHS Talking Therapies service here. Different areas often have different services and policies, and the waiting times might vary. This might mean you want to choose a different way to access therapy, and you might want to work with a therapist privately, through means of self-funding or a health insurance policy.

If you are going to work with a private therapist, it is important to find the right one. In the UK, ‘therapist’ is not a protected title which means anyone can call themself a therapist. We recommend checking if they are ‘accredited’, which means they are governed by a professional body (in the UK, this is BABCP). More information is included on our pages on finding a private therapist.

If CBT does not sound like the right approach for you, there are other psychological therapy approaches available.

Common Misconceptions

The idea of simply changing our thoughts might suggest CBT is a simplistic therapy.

“It’s just positive thinking”.

CBT is not simply learning to think more positively. It involves identifying and changing negative thinking patterns into more realistic and balanced thoughts to see if there are other ways to view ourselves or situations. It’s not about ignoring problems but addressing them in a constructive way.

“CBT is too short, I can’t fix all my problems in this time”.

When we have been experiencing our difficulties for a long time, we can often feel like a short-term intervention is not enough support. While CBT is often more short-term compared to some other therapies, it’s not an overnight solution. It requires commitment and practice over time to see lasting results.

“I don’t have an opportunity to talk about my past”.

CBT focuses on ‘the here and the now’. It can involve exploring past experiences that influence current thought patterns, though the emphasis remains on the present and future. It may not explore this in as much depth as some other therapies.

“It’s too structured and rigid”.

While CBT has a structured framework, it’s not overly rigid. Not every technique works the same for everyone. Therapists can adapt the approach based on individual needs, circumstances, age and personalities.

Conclusion and Links

For further exploration and a deeper understanding of CBT:
NHS website: Overview – Cognitive behavioural therapy (CBT)
NHS website: How it works – Cognitive behavioural therapy (CBT)
British Association for Behavioural and Cognitive Psychotherapies (BABCP) website: What-is-CBT
MIND provide valuable insights into the nature and practice of CBT including video: Cognitive behavioural therapy (CBT)

References
Kennerley, H., Kirk, J., & Westbrook, D. (2016). An introduction to cognitive behaviour therapy (3rd ed.). SAGE Publications.

Overview: Social anxiety disorder: Recognition, assessment and treatment: Guidance. NICE. (2013, May 22). https://www.nice.org.uk/guidance/cg159

Roth, A., & Fonagy, P. (2005). What works for whom: A critical review of psychotherapy research (2nd ed.). Guilford Publications.

Butler, Gillian (1999). Overcoming Social Anxiety and Shyness: A Self-Help Guide Using Cognitive Behavioural Techniques. London: Constable & Robinson Ltd.

National Institute for Health and Care Excellence (NICE), Social anxiety disorder: recognition, assessment and treatment, Full Guidance, Section 6.11.2