Psychotherapy accounts for approximately 5% of Paper B marks — roughly 7–8 questions. This is a small proportion, but the questions are predictable and high-yield. Most candidates lose marks here not because psychotherapy is difficult, but because they do not study it systematically.
The MRCPsych curriculum requires knowledge of the major psychotherapeutic modalities, their theoretical underpinnings, the evidence base for each, and the indications for referral. This guide covers each modality in the depth required for Paper B.
Cognitive Behavioural Therapy (CBT)
CBT is the most examined modality in Paper B. It has the strongest evidence base and the widest range of indications.
Theoretical basis: The cognitive model proposes that emotional distress is maintained by dysfunctional patterns of thinking (automatic thoughts, intermediate beliefs, core beliefs) and behaviour (safety behaviours, avoidance). The goal of CBT is to identify, challenge, and modify these patterns.
Key figures: Aaron Beck (cognitive triad: negative view of self, world, and future). Albert Ellis (Rational Emotive Behaviour Therapy, ABC model: Activating event → Belief → Consequence).
Indications (NICE-recommended):
- Depression (mild to moderate: low-intensity CBT; moderate to severe: high-intensity CBT combined with medication)
- Generalised anxiety disorder
- Panic disorder
- Social anxiety disorder
- OCD (CBT including Exposure and Response Prevention)
- PTSD (trauma-focused CBT)
- Bulimia nervosa (CBT-ED, specifically adapted for eating disorders)
- Health anxiety
- Psychosis (CBTp — CBT for psychosis, recommended for all patients with schizophrenia, though access is limited)
Structure: Typically 12–20 sessions. Each session follows a structure: agenda setting → review of homework → session content → practise new skill → set homework → session summary and feedback. The collaborative empiricism between therapist and patient is a defining feature.
Third wave CBT: Includes Mindfulness-Based Cognitive Therapy (MBCT — for relapse prevention in recurrent depression), Acceptance and Commitment Therapy (ACT), and Dialectical Behaviour Therapy (DBT). The exam sometimes asks how third wave approaches differ from traditional CBT: greater emphasis on the relationship with thoughts (rather than changing content), and acceptance rather than control.
Psychodynamic Psychotherapy
Theoretical basis: Unconscious mental processes influence conscious thoughts, feelings, and behaviour. Early attachment patterns shape relational templates that repeat in adult life (transference). Defence mechanisms protect the ego from anxiety.
Key figures: Freud (structural model: id, ego, superego; developmental stages; defence mechanisms). Klein (paranoid-schizoid and depressive positions, object relations). Winnicott (transitional objects, good-enough mothering). Bowlby (attachment theory).
Common defence mechanisms (exam favourites):
- Splitting: Dividing people into all-good or all-bad. Common in borderline personality disorder.
- Projection: Attributing unacceptable feelings to others.
- Projective identification: Projecting a feeling and then unconsciously inducing that feeling in the other person.
- Denial: Refusing to acknowledge reality.
- Displacement: Redirecting an impulse to a safer target.
- Sublimation: Channeling unacceptable impulses into socially acceptable activities.
- Intellectualisation: Using logic and reasoning to avoid emotional distress.
Indications: The evidence base is strongest for borderline personality disorder (mentalisation-based therapy, transference-focused psychotherapy), depression (particularly where relational difficulties are central), and medically unexplained symptoms. Long-term psychodynamic psychotherapy (over 12 months) has evidence for complex or chronic conditions.
Dialectical Behaviour Therapy (DBT)
DBT was developed by Marsha Linehan specifically for borderline personality disorder. It combines CBT with acceptance-based strategies (from Zen) and dialectical philosophy (synthesis of opposites).
Core dialectic: Acceptance (validating the patient’s experience) and change (helping the patient develop new skills). The therapist holds both simultaneously: “You are doing the best you can, and you need to try harder.”
Four modules of skills training:
- Mindfulness (observing, describing, participating, non-judgementally, one-mindfully, effectively)
- Distress tolerance (crisis survival strategies: TIPP, STOP, ACCEPTS, IMPROVE)
- Interpersonal effectiveness (DEAR MAN, GIVE, FAST)
- Emotion regulation (identifying emotions, reducing vulnerability, opposite action)
DBT structure: Weekly individual therapy (1 hour), weekly group skills training (2 hours), telephone coaching (between sessions for crisis management), and therapist consultation team (weekly). This multimodal structure is a defining feature and often examined.
Cognitive Analytic Therapy (CAT)
Developed by Anthony Ryle. Integrates cognitive and psychodynamic approaches. Time-limited (usually 16–24 sessions).
Key concepts:
- Reciprocal roles: Patterns of relating learned in childhood that are replayed in adult relationships. For example, a patient who was criticised as a child may alternate between being critical of themselves and feeling criticised by others.
- Target Problem Procedure (TPP): A written reformulation that maps the patient’s unhelpful patterns and their origins. The patient and therapist agree on the TPP and work to recognise and revise these patterns.
Indications: Depression, anxiety, eating disorders, personality disorders, and interpersonal difficulties. CAT is particularly useful where brief intervention is needed and the patient has a history of relational difficulties.
Family Therapy and Systemic Practice
Theoretical basis: Problems are understood in the context of relationships and systems, not as individual pathology. Change in one part of the system affects the whole.
Key figures: Minuchin (structural family therapy, boundaries, enmeshment, disengagement). Haley (strategic family therapy, paradoxical interventions). Milan group (circular questioning, positive connotation).
Indications: Child and adolescent mental health, eating disorders (Maudsley model for anorexia), psychosis (family interventions reduce relapse rates), relationship difficulties, and where a systemic factor maintains the problem.
How the Exam Tests Psychotherapy
Paper B questions on psychotherapy follow predictable patterns:
- Which therapy for this condition? For mild depression: CBT. For bulimia: CBT-ED. For BPD with self-harm: DBT. For childhood trauma: trauma-focused CBT or psychodynamic therapy depending on presentation.
- Who developed this therapy? Beck = CBT, Linehan = DBT, Ryle = CAT, Freud/Klein = psychodynamic, Minuchin = structural family therapy.
- Key theoretical concept: Be able to define and give an example of: transference, countertransference, defence mechanisms, the cognitive triad, reciprocal roles, the dialectic in DBT.
- Evidence question: Which therapy has the strongest evidence for X? Typically CBT for most conditions, DBT for BPD, family therapy for first-episode psychosis.
PsychStar’s Paper B question bank includes dedicated psychotherapy questions that test both factual knowledge and clinical application. Start with 5 free questions at psychstar.io/try.