Cognitive behavioral therapy

A Cognitive Behavioral Therapy (CBT) is a psychotherapy based on modifying cognitions, assumptions, beliefs and behaviors, with the aim of influencing disturbed emotions. The general approach, developed out of behavior modification, Cognitive Therapy and Rational Emotive Behavior Therapy, has become widely used to treat various kinds of neurosis and psychopathology, including mood disorders and anxiety disorders. The particular therapeutic techniques vary according to the particular kind of client or issue, but commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation and distraction techniques are also commonly included. CBT is widely accepted as an evidence- and empiricism-based, cost-effective psychotherapy for many disorders and psychological problems. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages.

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An example will illustrate the process: Having made a mistake, a person believes, "I'm useless and can't do anything right." This, in turn, worsens the mood, leading to feelings of depression; the problem may be worsened if the individual reacts by avoiding activities and then behaviorally confirming his negative belief to himself. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks and behaves in response to similar situations and by developing more flexible ways to think and respond, including reducing the avoidance of activities. If, as a result, the client escapes the negative thought patterns and destructive behaviors, the feelings of depression may, over time, be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.

The objectives of CBT typically are to identify irrational or maladaptive thoughts, assumptions and beliefs that are related to debilitating negative emotions and to identify how they are dysfunctional, inaccurate, or simply not helpful. This is done in an effort to reject the distorted cognitions and to replace them with more realistic and self-helping alternatives.

Cognitive behavioral therapy is not an overnight process. Even after patients have learned to recognize when and where their mental processes go awry, it can take months of effort to replace any dysfunctional cognitive-affective-behavioral processes or habit with a more reasonable, salutary one.

The cognitive model especially emphasized in Aaron Beck's cognitive therapy says that a person's core beliefs (often formed in childhood) contribute to 'automatic thoughts' that pop up in every day life in response to situations. Cognitive Therapy practitioners hold that clinical depression is typically associated with negatively biased thinking and irrational thoughts.

Cognitive behavioral therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS.

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Cognitive Behavioral Therapy

CBT can be seen as an umbrella term for many different therapies that share some common elements.^[2] While similar views of emotion have existed for millennia, the earliest form of Cognitive Behavior Therapy was developed by Albert Ellis (1913-2007) in the early 1950s. Ellis eventually called his approach Rational Emotive Behavioral Therapy, or REBT, as a reaction against popular psychoanalytic methods at the time.^[3] Aaron T. Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s.^[4] Cognitive therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.

Concurrently with the pioneering contributions of Ellis and Beck, starting in the late 1950s and continuing through the 1970s, Arnold A. Lazarus developed what was arguably the first form of "Broad-Spectrum" Cognitive-Behavior Therapy. Indeed, in 1958, Arnold Lazarus was the first person to introduce the terms "behavior therapy" and "behavior therapist" into the professional literature (i.e., Lazarus, A. A. New methods in psychotherapy: a case study. South African Medical Journal, 1958, 32, 660-664).^{[citation needed]} He later broadened the focus of behavioral treatment to incorporate cognitive aspects (e.g., see Arnold Lazarus' 1971 landmark book "Behavior Therapy and Beyond," perhaps the first clinical text on CBT). When it became clear that optimizing therapy's effectiveness and effecting durable treatment outcomes often required transcending more narrow focused cognitive and behavioral methods, Arnold Lazarus expanded the scope of CBT to include physical sensations (as distinct from emotional states), visual images (as distinct from language-based thinking), interpersonal relationships, and biological factors. The final product of Arnold Lazarus' approach to psychotherapy is called Multimodal Therapy and is, perhaps, the most comprehensive form of CBT in addition to REBT that also shares many of the same assumptions and theorizing.

Cognitive Behavioral Group Therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg.^[5] In this case, clients participate in a group and recognize they are not alone in suffering from their problems.

A sub-field of cognitive behavioral therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. (The specific technique, Exposure with Response Prevention (ERP) has been demonstrated to be more effective than the use of medication—typically SSRIs—alone). CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia and Panic Disorder. In recent years, CBT has been used to treat symptoms of schizophrenia, such as delusions and hallucinations. This use has been developed in the UK by Douglas Turkington and David Kingdon.

Other types of Cognitive Behavioral Therapy include Dialectical Behavior Therapy, Self-Instructional Training, Schema-Focused Therapy and many others.^[6]

CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse. It has been clinically demonstrated in over 400 studies to be effective for many psychiatric disorders and medical problems for both children and adolescents. It has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.

Cognitive Behavioral Therapy most closely allies with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment.

Depression

Negative thinking dominates when a person experiences depression. The depressed person can experience negative thoughts as being beyond their control, thereby allowing them to become automatic and self-perpetuating.

Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.

Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad."

Attributional style

An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First advanced by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves.^[7] This theory is sometimes known as a revised version of learned helplessness theory.

In 1989, this theory was challenged by Hopelessness Theory.^[8] This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions.

The ABCs of Irrational Beliefs

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs.^[3] The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

• A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.

• B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to him or her.

• C - Consequence. The third column is for the negative disturbed feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. These could be anger, sorrow, anxiety, etc.

For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.

• Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.

From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study more effectively from then on.

Effectiveness of CBT with or without drugs for depression

A large-scale study in 2000^[9] showed substantially higher results of response and remission (73% for combined therapy vs. 48% for either CBT or antidepressants alone) when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either modality was used alone.

The effectiveness of combination therapy is endorsed by the Australian depressioNet group:

Currently the most effective treatment for major (clinical) depression is considered to be a combination of antidepressant medication and Cognitive Behavioral Therapy.^[10]

For more general results confirming that CBT alone can provide lower but nonetheless valuable levels of relief from depression, and result in increased ability for the patient to stay in employment, see The Depression Report,^[11] which states:

The typical short-term success rate for CBT is about 50 percent. In other words, if 100 people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work.

The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder, although they noted that rigorous evaluative studies had not been published.^[12]

CBT with children and adolescents

The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression, anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder. Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago. Paula Barrett and her colleagues have also validated CBT as effective in a group setting for the treatment of youth and child anxiety using the Friends Program she authored. This CBT program has been recognized as best practise for the treatment of anxiety in children by the World Health Organisation.

CBT has been used with children and adolescents to treat a variety of conditions with good success.^[13][14]

CBT is also used as a treatment modality for children who have experienced Complex Post Traumatic Stress Disorder, chronic maltreatment, and Post Traumatic Stress Disorder.^[15] It would be one component of treatment for children with C-PTSD, along with a variety of other components, which are discussed in the Complex Post Traumatic Stress Disorder article.

Computerized CBT

As the name suggests, this is a computerised form of CBT, in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face-to-face with a therapist.

Computerized CBT is not a replacement for face-to-face therapy but can provide an option for patients, especially in light of the fact that there are not always therapists available, or the cost can be prohibitive. Computerized CBT is clinically proven and drug-free. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their deepest problems can be off-putting. In this respect, CCBT (especially if delivered online) can be a good option.

It has been proven to be effective in randomized controlled trials, and in February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that CCBT should be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for medication (i.e. anti-depressant pills).^[16]

A new UK government initiative for tackling Mental Health issues[1] has recently been launched by the Care Services Improvement Partnership.[2] This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE[3] has confirmed that by 31 March 2007 PCTs should have ST Solutions' "FearFighter" and Ultrasis' "Beating the Blues" CCBT products in place and the NICE Guidelines should be met.

Notable Behavioral Theorists

• Albert Bandura
• Ivan Pavlov
• B.F. Skinner
• Edward Thorndike
• John B. Watson
• Joseph Wolpe

Notable Contributors to Modern Cognitive Behavioral Therapy

• Aaron T. Beck
• Judith Beck
• Albert Ellis
• Paula Barrett
• David D. Burns
• Windy Dryden
• Albert Bandura
• Edna B Foa Prolonged Exposure Therapy
• Isaac Marks
• Martin Seligman
• Steven C. Hayes
• Alan Kazdin
• Arnold Lazarus
• Peter Lewinsohn
• Marsha Linehan
• Donald Meichenbaum

Related Techniques & Therapies

• Cognitive Therapy (CT)
• Cognitive analytic therapy (CAT)
• Rational Emotive Behavior Therapy (REBT)
• Cognitive-behavior Modification
• Acceptance and Commitment Therapy
• Reality Therapy
• Applied Behavioral Analysis
• Anxiety Management Training
• Behavior Modification
• Cognitive behavioral analysis system of psychotherapy
• Contingency Management
• Dialectical Behavior Therapy (DBT)
• Direct therapeutic exposure
• Exposure and response prevention
• Functional Analytic Psychotherapy (FAP)
• Integrated Behavioral Couples Therapy
• Mindfulness-based Cognitive Therapy
• Motivational Enhancement Therapy
• Parent-Child Interaction Therapy (PCIT)
• Parent Management Training (PMT)
• Relapse Prevention
• Schema-Based Therapy
• Self Instructional Training
• Stress Inoculation Training
• Systematic desensitization
• Prolonged Exposure Therapy

References

Further reading

• Beck, A., Cognitive Therapy and the Emotional Disorders, NY: Penguin, 1993. ISBN 9780452009288
• Dryden, Windy. Ten Steps to Positive Living. Sheldon Press, 1994.
• Burns, David D. Feeling Good: The New Mood Therapy. Revised Edition. Avon, 1999. ISBN 0-380-81033-6
• Ellis, Albert. Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy. Prometheus Books, 2001. ISBN 978-1573928793
• Tanner, Susan and Ball, Jillian. Beating the Blues: a Self-help Approach to Overcoming Depression. 1989/2001. ISBN 0-646-36622-X [4]
• McCullough Jr., James P. Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press, 2003. ISBN 1-57230-965-2
• Albano, M. & Kearney, Ca., (2000) When children refuse school: a cognitive behavioral therapy approach: Therapist guide. Psychological Corporation.
• Deblinger, E. & Heflin, A. (1996) Treating sexually abused children and their non-offending parents: a cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.
• Leahy, R L and Holland, S J (2000) Treatment Plans and Interventions for Depression and Anxiety Disorders. New York: Guilford

Professional Organizations & Institutes

• Academy of Cognitive Therapy
• The Albert Ellis Institute
• Association for Behavioral and Cognitive Therapies (ABCT)
• Beck Institute for Cognitive Therapy and Research
• William Glasser Institute
• The Lazarus Institute
• The British Association of Behavioural and Cognitive Psychotherapies