Cognitive Behavioral Therapy (CBT) in Richmond is common and represents an effective set of approaches that are effective for the treatment for a variety of mental health conditions. These include anxiety, depression and obsessive-compulsive disorder. Third-wave CBT approaches such as mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) differ from Beckian Cognitive Therapy by incorporating concepts like mindfulness, acceptance and emotional regulation. Third wave approaches often don’t focus on challenging thoughts. An emphasis is on changing behaviours. These more modern approaches have measurable effects on the brain. Understanding which areas of the brain are impacted by third-wave CBT can provide insight into how these therapies facilitate psychological change.

Third-Wave CBT: An OverviewThird-wave CBT approaches lay an emphasis on acceptance and the relationship individuals have with their thoughts and emotions. Unlike traditional Beckian Cognitive Therapy, which focuses on identifying and restructuring distorted thoughts, third-wave therapies help individuals change the relationship with relevant internal experiences by observing thoughts, accepting discomfort whilst engaging in a direction that is in line with one’s values. Mindfulness meditation, defusion (observing internal experiences) and emotional regulation represent important elements.

Key Brain Areas Impacted by Third-Wave CBT1. Prefrontal Cortex (PFC): Enhancing Executive ControlThe prefrontal cortex is responsible for executive functions such as decision-making, impulse control and emotional regulation. Mindfulness-based approaches like MBCT strengthen the PFC by improving self-awareness and cognitive flexibility.

• Impact of Mindfulness and ACT: Regular mindfulness practice is an element of third-wave therapies which increases activity in the PFC. This enhanced activation allows individuals to pause and respond to situations rather than reacting impulsively.
• Emotional Regulation: By strengthening the PFC, third-wave CBT helps clients manage emotions and reduce rumination.

The PFC may be underactive in problems such as anxiety and depression. Third wave therapies restore balance and improve mental clarity.

2. Amygdala: Reducing Emotional ReactivityThe amygdala is a small almond-shaped structure deep in the brain and plays a role in processing emotions, particularly fear and stress responses. With anxiety, PTSD, or depression, the amygdala is often hyperactive which can lead to heightened emotional reactivity and a subsequent exaggerated stress response.

• Impact of Mindfulness-Based Techniques: Mindfulness meditation, a central component of third-wave CBT, reduces amygdala activation. Regular mindfulness practice helps individuals observe emotions without these controlling their life.
• Cognitive Defusion in ACT: Cognitive defusion as used in ACT, allows clients to learn to see thoughts as mental events rather than absolute truths. This also helps to reduce emotional reactivity. By learning to observe distressing thoughts, the amygdala's stress response gets less.

This change allows individuals to manage situations with greater calm.

​3. Anterior Cingulate Cortex (ACC): Improving Attention and AwarenessThe anterior cingulate cortex (ACC) is involved in attention regulation and emotional awareness. Third-wave therapies, particularly mindfulness-based interventions, strengthen the ACC’s role in maintaining focus whilst minimising mental interference.

• Mindfulness and Focus: MBCT and DBT help people focus on the present, improving the ACC’s ability to sustain attention.
• Reducing Rumination: By enhancing the ACC’s function, third-wave CBT helps individuals break free from patterns of overthinking and rumination which is common in depression and anxiety disorders.

Strengthening the ACC supports a more balanced response towards daily stressors.

4. Insula: Increasing Interoceptive AwarenessThe insula is a region of the brain related to the awareness of bodily sensations such as the heartbeat, breathing and emotional states. Third-wave CBT approaches, particularly mindfulness and ACT, emphasise body awareness.

• Mindfulness Meditation: Practices like body scans activate the insula, thereby increasing awareness of bodily sensations and their connection towards emotional states.
• Emotional Acceptance: By improving interoceptive awareness, third-wave CBT helps clients accept discomfort and respond to emotions in a better way.

This heightened connection between body and mind fosters helps in many ways.

Neuroplasticity: The Brain’s AdaptabilityThird-wave CBT impacts the brain in ways that lead towards neuroplasticity, the brain’s ability to reorganize itself by creating novel neural connections. The regular practice of mindfulness, acceptance and emotional regulation related techniques strengthens connections between the prefrontal cortex, amygdala and other relevant regions.

Perfectionism can sometimes lead to excessive self-criticism and an unhealthy pursuit of unattainable standards. While striving for high standards can be positive, some types of perfectionism can bring significant emotional and mental distress. Types of distress that are common include anxiety, procrastination and burnout. Cognitive Behavioural Therapy (CBT) is an approach that helps address the harmful effects of perfectionism. This is how CBT can help you take practical steps toward finding balance:

1. Understand Yourself:
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First you need to understand what perfectionism looks like for yourself. Some for example engage in a critical self focus which keeps them stuck by preventing them from expanding their behavioural repertoire.


2. Unrealistic Standards:

Perfectionism can make people set unattainable goals whilst feeling defeated when they’re not met. Not feeling good enough deep down can make people always want to change their current state, whilst pursuing the futile quest of chasing unrealistic goals.

Perfectionism can make people view outcomes as either total successes or absolute failures.

Fear of Failure: Some people procrastinate because of the fear of not meeting their unrealistic standards.

The first step in overcoming perfectionism is understanding these patterns and recognizing how they contribute to stress, procrastination and maintain low self-esteem.

3. Be aware of Perfectionist Thinking:

CBT helps individuals identify and manage unhelpful thoughts. This includes:
Write down perfectionistic thoughts like, “If I don’t do this perfectly, I’m a failure,” and try to understand how this fits within the overall presentation of yourself. Being aware when these thoughts play out AS THEY OCCUR will help you not recognise that you are not your thoughts and you have far more control of what and how you do what you do in your life.


4. Defining Goals:

Set goals that are beneficial for yourself. It is crucial to avoid the trappings of over extending yourself after you have met predefined goals. Have a baseline that you want to cover and do not indulge in self criticism if you do not regularly exceed that baseline. Over extending yourself can become an addiction.

Focus on Progress: Shift the emphasis from achieving perfection to making consistent progress that is not black and white (do not do a lot one day and very little the other).

By adopting a more realistic approach, you’ll find tasks less daunting and more attainable.


5. Embrace Imperfection

Intentional Imperfection: Try completing a task to a “good enough” standard rather than a perfect one. For example, send an email without endlessly reviewing it.

Reflect often: Look back at your behavioural patterns and reflect how these interacted with aspects of your environment. If you know what drives your perfectionism and other problems then you will learn how so many helpful things such as understanding what prevents the snowball from getting bigger.

Overcoming Procrastination: Break tasks into smaller, actionable steps.

Balance Rest and Work: Schedule regular breaks and set boundaries to avoid burnout. Remind yourself that rest is essential for productivity.

By addressing these patterns, you can establish healthier routines and reduce stress.

6. Build Resilience to Criticism

A common fear among perfectionists is external judgment or criticism. CBT equips individuals with tools to cope:

Reframe Criticism: View feedback as an opportunity to grow rather than a personal attack.
Role-Playing: Practice responding to imagined criticisms in a therapy session to build confidence for handling real-life situations.
Learning to accept constructive feedback without equating it to failure will help you overcome perfectionism.

There are many ways to work on perfectionism and what is best for some may not be a good solution for others. In order to understand how you can best work on your own perfectionist tendencies, you need to understand yourself and then make use of that understanding in the best way you can. It does not make a difference whether you try and use CBT for perfectionism through in person sessions, online therapy or over the phone. Research has shown that all of these mediums are effective in addressing such difficulties.

Obsessive-Compulsive Disorder (OCD) is a mental health condition in which individuals experience intrusive thoughts (obsessions) and short term reward behaviours (compulsions) which aim to reduce the anxiety caused by these thoughts. Brain imaging studies have provided valuable insights into the affected brain areas that underpin OCD. Repeat research has highlighted specific brain areas that play a significant role in the disorder. The key brain regions related to OCD include:

1. Orbitofrontal Cortex (OFC): The OFC is involved in decision-making and the processing of rewards and punishments. Sufferers of OCD experience that this region is often overactive. This is seen as a contributing factor to the excessive anxiety and doubt that is often experienced by individuals. This overactivity leads to the repetitive thoughts (obsessions) that drive compulsive behaviors.
2. Striatum: The striatum is a part of the basal ganglia and is responsible for the formation of habits and motor control. In OCD, there is a dysfunction in the cortico-striato-thalamo-cortical loop, which leads to the persistence of compulsions. The striatum can reinforce compulsive behaviour when it is overactive.
3. Thalamus: The thalamus acts as a relay station for sensory information. It is believed that in OCD, abnormal thalamic function may contribute to the loop of repetitive thoughts and behaviours. Dysfunctional communication between the thalamus and the OFC leads to the persistence of obsessive thoughts.

These brain areas work together in a feedback loop that perpetuates the cycle of obsessions and compulsions in OCD.

Cognitive Behavioural Therapy (CBT) is widely regarded as one of the most effective treatments for OCD. Many styles of CBT aim to address the reinforcing cycle of obsession and compulsion. Since the pandemic, online CBT for OCD, such as those offered by therapists in London or through online platforms, has become increasingly popular, as it provides flexible access to treatment. Many individuals specialised in working with OCD may work further away.

CBT focuses on exposure and response prevention (ERP), a key technique in which individuals often gradually expose themselves towards feared situations or thoughts (exposure) whilst reducing, or stopping the performing of compulsive rituals (response prevention). This process helps to reduce the anxiety associated with their obsessions over time whilst consequently disrupting the compulsive behaviours that reinforce obsessive thoughts.

UCL Case Formulation ModelThe UCL Case Formulation Model of CBT offers a structured framework for understanding and treating OCD and was devised by the founder of ERP. This model places significant emphasis on understanding the individual's unique cognitive and other internal and external processes that contribute to the development and maintenance of OCD. By working with an OCD therapist online​, over the phone or in person, individuals can identify their respective factors that lead to compulsive behaviours. This allows for more tailored interventions.

The UCL model encourages clients to explore their own individual circumstances and contributing factors. Common elements can be the overestimation of the risk of harm or an excessive need for certainty, which can fuel obsessive thoughts.

Acceptance and Commitment Therapy (ACT)ACT, is a form of therapy that falls within the third wave of CBT, is often used in the treatment of OCD. ACT focuses on acceptance of intrusive thoughts rather than trying to eliminate them. It teaches individuals to view their obsessions as thoughts that do not necessarily require action. By further developing mindfulness skills, they also train impulse controls which fuels psychological flexibility and helps with OCD. ACT helps clients develop the ability to engage in values-based actions even in the presence of distressing thoughts.
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ACT can be particularly effective for those who struggle with the overwhelming anxiety that accompanies their obsessions, as it encourages acceptance of discomfort without resorting to compulsive behaviours. One can make use of it when pursuing therapy online, making it accessible for those looking for online options for treating their OCD through therapy. These often include phone therapy or video sessions.

How Different Forms of CBT Address Brain Areas Affected by OCDCBT works to address the brain regions associated with OCD by managing how individuals respond to intrusive thoughts and by reducing the overactivity in the regions responsible for compulsive behaviours.

• Orbitofrontal Cortex (OFC): CBT helps to recalibrate the overactive OFC by helping individuals tolerate anxiety and uncertainty whilst stopping compulsive actions from reinforcing obsessive thoughts.
• Striatum: The practice of ERP means that individuals can weaken the habit formation processes in the striatum by reducing the compulsive behaviours that this brain area promotes. ACT further reinforces this by encouraging individuals to engage in behaviours that are aligned with their values, even when impulses want to tell them otherwise. This breaks the automatic response loop.
• Thalamus: The communication between the thalamus and other brain regions is also addressed. By having a lessened need for compulsive responses, CBT and ACT help to interrupt the cycle that keeps obsessive thinking and compulsive behaviour going.

The Rise of Online Therapy for OCDAs many competent therapists that specialise in OCD are hard to find, pursuing therapy over the phone or online can provide a big benefit for many clients. Many therapists and clients also find the it easier to talk about intrusive thoughts they find embarrassing remotely or through the telephone.
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Whether through phone therapy, video call, or online CBT programs, doing CBT remotely offers the flexibility to engage in treatment that is evidence based. Especially with something as uncommon as the UCL Case Formulation Mode. OCD therapists that work online are trained to be able to work remotely and / or face to face.