My therapy approach: CBT, ACT and DBT

Cognitive behavioural therapy (CBT)

CBT works from a simple observation: thoughts, feelings, physical sensations and behaviour influence each other continuously. A thought such as "I am going to embarrass myself" produces anxiety, which produces a racing heart, which produces avoidance, which prevents you from ever discovering that the feared outcome does not occur. The cycle then repeats and strengthens.

In practice, CBT involves identifying the specific thoughts that arise in difficult moments, examining the evidence for and against them, and testing them through behavioural experiments in real life. It is not positive thinking. Where a thought is accurate, we work on how to respond to a real problem rather than pretending it is not there.

CBT has the strongest evidence base of any psychological treatment for anxiety disorders, depression and OCD, which is why it forms the backbone of the work described on the anxiety, depression and OCD pages.

Acceptance and commitment therapy (ACT)

ACT starts somewhere different. Rather than changing the content of thoughts, it changes your relationship to them. Trying to eliminate anxious thoughts often gives them more power; noticing them as passing mental events, and acting on what matters to you anyway, gives them less.

The core skills are defusion, learning to see a thought as a thought rather than a fact; acceptance, allowing uncomfortable feelings to be present without a struggle that costs more than the feeling itself; contact with the present moment; and clarifying values, so that action is guided by the kind of life you want rather than by what fear dictates.

ACT is particularly useful for chronic worry, for difficulties that cannot be solved outright such as illness or grief, and for people who have already tried to argue with their thoughts and found it exhausting.

Dialectical behaviour therapy (DBT) skills

DBT skills are used where emotions escalate quickly and intensely, or where distress leads to actions that make things worse afterwards. The four skill areas are mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.

These are practical tools: what to do in the ten minutes when an emotion is at its peak, how to reduce vulnerability to emotional swings through sleep, food and routine, and how to ask for something or refuse something without either collapsing or escalating. DBT-informed skills are often combined with CBT rather than delivered as a full programme, and they feature in the work described on the relationship counselling page.

How methods are chosen

The choice is not ideological. It follows from the formulation we build in the first sessions: what set this off, what keeps it going, and what you want to be different. Panic maintained by avoidance calls for exposure-based CBT. Worry maintained by an attempt to control uncertainty often responds better to ACT. Emotional intensity that damages relationships calls for DBT skills first and cognitive work later.

Most courses of therapy use elements of more than one. What stays constant is that you know the plan and can question it.