Psychiatry: treatments
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is a structured talking therapy that helps people change unhelpful thought patterns and behaviours. It has strong evidence for depression, anxiety and many other conditions, so every psychiatrist must understand it and be able to deliver at least basic CBT.
Depth by stage, Pre-U → Consultant (details)
What is it?
CBT starts from a simple idea: the way we interpret events affects how we feel and what we do, and what we do in turn shapes our thoughts and feelings. When someone is depressed or anxious, these links can lock into a vicious cycle. CBT helps the person notice the cycle and break it, using practical exercises between sessions.
Sessions are usually weekly for about 6 to 20 weeks. The therapist and patient agree goals, track symptoms, test out fearful predictions through gradual exposure, schedule rewarding activities, and practise new ways of thinking. It is collaborative and time-limited, and it teaches skills that people can keep using after therapy ends.
In Malaysia, CBT is delivered by psychiatrists, clinical psychologists, counsellors and trained nurses. Psychiatrists often deliver brief CBT, adapt it for medical settings, refer for longer therapy, and supervise others.
Why does a psychiatrist need it?
CBT is one of the best-evidenced treatments in psychiatry and is recommended in guidelines for depression, anxiety disorders, OCD, PTSD, eating disorders, insomnia and as an add-on in psychosis. A psychiatrist who understands CBT can explain it, use its techniques in everyday consultations, choose the right patients for referral and combine it sensibly with medicine.
What level is expected at each stage?
Scale: 1. Aware → 2. Understands → 3. Applies → 4. Masters / Teaches. What the levels mean.
- Pre-UNot expected
- Pre-clinicalAwareMeets basic learning theory and the cognitive model in behavioural science.
- ClinicalAwareKnows CBT exists and what conditions it helps.
- HousemanshipNot expected
- Medical officerUnderstandsUses simple CBT techniques such as behavioural activation and psychoeducation under guidance.
- Psych traineeAppliesDelivers supervised CBT cases as part of psychotherapy training and integrates it into care.
- Specialist / consultantAppliesUses CBT principles routinely; those with extra training supervise and teach CBT (Masters level).
What are the key topics?
Theory
- Beck's cognitive model: core beliefs, assumptions and automatic thoughts
- Common thinking errors: catastrophising, black-and-white thinking, mind-reading, overgeneralisation
- Behavioural principles: avoidance, reinforcement, safety behaviours
- Maintenance cycles for depression and specific anxiety disorders
- Formulation: linking early experiences, beliefs and current problems
Core techniques
- Socratic questioning and guided discovery
- Thought records and cognitive restructuring
- Behavioural activation for depression
- Graded exposure and exposure with response prevention (for OCD)
- Behavioural experiments to test predictions
- Problem solving and relapse-prevention plans
- Homework and between-session practice
Disorder-specific models
- Panic disorder and agoraphobia
- Social anxiety disorder
- Generalised anxiety disorder and worry
- Post-traumatic stress disorder (trauma-focused CBT)
- OCD
- Eating disorders (enhanced CBT)
- Insomnia (CBT-I)
- Psychosis (CBT for psychosis)
Practice and adaptation
- Session structure: agenda, review, homework
- Measuring progress with questionnaires
- Adapting CBT for different cultures, religions and languages in Malaysia
- Brief and low-intensity CBT; guided self-help and digital CBT
- Combining CBT with medication
- Knowing when CBT is not the right choice
How is it learned and assessed?
- Introduction to learning theory and cognitive psychology in pre-clinical behavioural science
- Undergraduate psychiatry teaching names CBT as a first-line therapy
- During MMed (Psychiatry) training, trainees typically complete supervised psychotherapy cases, often including CBT, recorded in logbooks
- MRCPsych papers test CBT theory and evidence; CASC stations may require explaining or starting CBT techniques
- Specialist CBT courses and supervision for those who want advanced skills
Typical textbooks and resources
- Cognitive Behavior Therapy: Basics and Beyond — Judith S. Beck
- An Introduction to Cognitive Behaviour Therapy — Kennerley, Kirk & Westbrook
- Mind Over Mood — Greenberger & Padesky (patient workbook often used in therapy)
- Oxford Guide to Behavioural Experiments in Cognitive Therapy — Bennett-Levy and colleagues
Titles are widely used examples; editions change. Use university libraries or legitimate purchases.
Common questions
Do psychiatrists do CBT themselves?
Many do, especially brief CBT within their consultations. Longer courses are often delivered by clinical psychologists, counsellors or trained nurses, with the psychiatrist coordinating care. Psychiatrists usually complete supervised therapy cases during specialist training.
How long does CBT take?
Typically between 6 and 20 weekly sessions, depending on the problem and its severity. It is designed to be time-limited and to give the person skills they can keep using.