Cognitive Behavioral Therapy
Cognitive behavioral therapy (or cognitive behavioral therapies or CBT) is a psychotherapeutic approach that aims to solve problems concerning dysfunctional emotions, behaviours and cognitions through a goal-oriented, systematic procedure. The title is used in diverse ways to designate behaviour therapy, cognitive therapy, and to refer to therapy based upon a combination of basic behavioral and cognitive research.
There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Treatment is often manualised, with specific technique-driven brief, direct, and time-limited treatments for specific psychological disorders. CBT is used in individual therapy as well as group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are more cognitive oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (in vivo exposure therapy). Other interventions combine both (e.g. imaginal exposure therapy).
CBT was primarily developed through a merging of behaviour therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the "here and now", and on alleviating symptoms. Many CBT treatment programs for specific disorders have been evaluated for efficacy and effectiveness; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favoured CBT over other approaches such as psychodynamic treatments. In the United Kingdom, the National Institute for Health and Clinical Excellence recommends CBT as the treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression, and for the neurological condition chronic fatigue syndrome/myalgic encephalomyelitis.
History of Cognitive Behavioral Therapy (CBT)
The roots of CBT can be traced to the development of behaviour therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behaviour therapeutical approaches appeared as early as 1924, with Mary Cover Jones' work on the unlearning of fears in children. In 1937 Abraham Low developed cognitive training techniques for patient aftercare following psychiatric hospitalisation. Low designed his techniques for use in his organisation, Recovery International, which supports people recovering from mental illness. Although Low originally led Recovery International, he later adapted the techniques for use in lay-run self-help groups operating under the same name.
It was during the period 1950 to 1970 that CBT became widely utilsed, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviourist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull. In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitisation, the precursor to today's fear reduction techniques. British psychologist Hans Eysenck, inspired by the writings of Karl Popper, criticized psychoanalysis in arguing that "if you get rid of the symptoms, you get rid of the neurosis", and presented behaviour therapy as a constructive alternative. In the United States, psychologists were applying the radical behaviourism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behaviour.
Although the early behavioral approaches were successful in many of the neurotic disorders, it had little success in treating depression. Behaviourism was also losing in popularity due to the so-called "cognitive revolution". The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behaviour therapists, despite the earlier behaviourist rejection of "mentalistic" concepts like thoughts and cognitions. Both these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Albert Ellis's system, originated in the early 1950s, was first called rational therapy, and can arguably be called one of the first forms of cognitive behavioral therapy. It was partly founded as a reaction against popular psychotherapeutic theories at the time, mainly psychoanalysis. Aaron T. Beck, inspired by Albert Ellis, developed cognitive therapy, in the 1960s. Cognitive therapy rapidly became a favourite 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. During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive behavioral therapy. Pivotal in this merging was the successful developments of treatments of panic disorder by David M. Clark in the UK and David H. Barlow in the US.
Concurrently with the contributions of Albert 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 behavioral therapy. He later broadened the focus of behavioral treatment to incorporate cognitive aspects. When it became clear that optimising therapy's effectiveness and effecting durable treatment outcomes often required transcending more narrowly 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.
Samuel Yochelson and Stanton Samenow pioneered the idea that cognitive behavioral approaches can be used successfully with a criminal population. They are the authors of, Criminal Personality Vol.I. This book has an extensive amount of information regarding the dynamics of criminal thinking and application of cognitive behavioral approaches.
Approaches and systems within Cognitive Behavioral Therapy (CBT)
CBT includes a variety of approaches and therapeutic systems, some of the most well known including cognitive therapy, rational emotive behaviour therapy and multimodal therapy. Defining the scope of what constitutes a cognitive–behavioral therapy is a difficulty that has persisted throughout its development.
The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem/issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviours; 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, mindfulness and distraction techniques are also commonly included. CBT is often also used in conjunction with mood stabilising medications to treat conditions like bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognised by the NICE guidelines within the British NHS.
Going through CBT generally is not an overnight process for clients. Even after clients have learned to recognise when and where their mental processes go awry, it can in some cases take considerable time or effort to replace a dysfunctional cognitive-affective-behavioral process or habit with a more reasonable and adaptive one.
Computerised Cognitive Behavioral Therapy (CBT)
There are CBT sessions 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. This 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. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their innermost problems can be off-putting. In this respect, Computerised CBT (especially if delivered online) can be a good option.
Randomised controlled trials have proven its effectiveness, and in February 2006 the UK's National Institute for Health and Clinical Excellence recommended that CCBT be made available for use within the NHS across England and Wales, for patients presenting with mild to moderate depression, rather than immediately opting for antidepressant medication.
Specific applications of Cognitive Behavioral Therapy (CBT)
CBT is applied to many clinical and non-clinical conditions and has been successfully used as a treatment for many clinical disorders, personality conditions and behavioral problems. Whilst CBT is highly effective for a number of disorders it is important to note that cognitive behavioral therapy is unlikely to be effective in patients with substance dependence and/or abuse problems as CBT itself cannot change drug or alcohol induced mental health symptoms.
Treatment of anxiety disorders with CBT
A basic concept in CBT treatment of anxiety disorders is in vivo exposure—a gradual exposure to the actual, feared stimulus. This treatment is based on the theory that the fear response has been classically conditioned and that avoidance positively reinforces and maintains that fear. This "two-factor" model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this conditioning can be unlearned; this is referred to as extinction and habituation. A specific phobia, such as fear of spiders, can often be treated with in vivo exposure and therapist modelling in one session. Obsessive compulsive disorder is typically treated with exposure with response prevention.
Social phobia has often been treated with exposure coupled with cognitive restructuring, such as in Heimberg's group therapy protocol. Evidence suggests that cognitive interventions improve the result of social phobia treatment.
CBT has been shown to be effective in the treatment of generalized anxiety disorder, and possibly more effective than pharmacological treatments in the long term. In fact, one study of patients undergoing benzodiazepine withdrawal who had a diagnosis of generalized anxiety disorder showed that those who received CBT had a very high success rate of discontinuing benzodiazepines compared to those who did not receive CBT. This success rate was maintained at the twelve month follow up. Furthermore in patients who had discontinued benzodiazepines it was found that they no longer met the diagnosis of general anxiety disorder and that patients no longer meeting the diagnosis of general anxiety disorder was higher in the group who received CBT. Thus CBT can be an effective tool to add to a gradual benzodiazepine dosage reduction program leading to improved and sustained mental health benefits.
Treatment of mood disorders with CBT
One etiological theory of depression is Aaron Beck's cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events. When the person with such schemata encounters a situation that in some way resembles the conditions in which the original schema was learned, the negative schemata of the person are activated.
Beck also described a negative cognitive triad, made up of the negative schemata and cognitive biases of the person; Beck theorised that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as "I never do a good job," "It is impossible to have a good day," and "things will never get better." A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. This is the negative triad. Also, Beck proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalisation, magnification and minimization. These cognitive biases are quick to make negative, generalised, and personal inferences of the self, thus fuelling the negative schema.
CBT has been shown as an effective treatment for clinical depression . A large-scale study in 2000 showed substantially higher results of response and remission (73% for combined therapy vs. 48% for either CBT or a particular discontinued antidepressant alone) when a form of cognitive behaviour therapy and that particular discontinued anti-depressant drug were combined than when either modality was used alone.
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 remain in employment, see The Depression Report, which states: 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.
The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, CBT and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder.
Treatment of insomnia with CBT
Cognitive behavioral therapy has been found to be effective in reducing benzodiazepine usage in the treatment of insomnia. A large-scale trial utilising CBT for chronic users of sedative hypnotics including nitrazepam, temazepam and zopiclone found the addition of CBT to improve outcome and reduce drug consumption in the treatment of chronic insomnia. Persisting improvements in sleep quality, sleep latency, and increased total sleep, as well as improvements in sleep efficiency and significant improvements in vitality and physical and mental health at 3-, 6- and 12-month follow-ups were found in those receiving cognitive behavioral therapy with hypnotics compared with those patients receiving hypnotics alone. A marked reduction in total sedative hypnotic drug use was found in those receiving CBT, with 33% reporting no hypnotic drug use. Authors of the study suggested that CBT is potentially a flexible, practical, and cost-effective treatment for insomnia and that CBT administered coincident to hypnotic treatment leads to a reduction of benzodiazepine drug intake in a significant number of patients.
Chronic use of hypnotic medications is not recommended due to their adverse effects on health and the risk of dependence. A gradual taper is usual clinical course in getting people off of benzodiazepines but even with gradual reduction a large proportion of people fail to stop taking benzodiazepines. The elderly are particularly sensitive to the adverse effects of hypnotic medications. A clinical trial in elderly people dependent on benzodiazepine hypnotics showed that the addition of CBT to a gradual benzodiazepine reduction program increased the success rate of discontinuing benzodiazepine hypnotic drugs from 38% to 77% and at 12 month follow-up from 24% to 70%. The paper concluded that CBT is an effective tool for reducing hypnotic use in the elderly and reducing the adverse health effects that are associated with hypnotics such as drug dependence, cognitive impairments and increased road traffic accidents.
A further study in older people with insomnia comparing the hypnotic drug zopiclone against CBT found that CBT actually improved EEG slow wave sleep as well as increased time spent asleep and found that the benefits were maintained at 6 month follow-up. Zopiclone however worsened sleep by suppressing slow wave sleep. A lack of slow wave sleep is linked to impaired functioning and sleepiness. Zopiclone reduced slow wave sleep and was similar to placebo in that it produced no lasting benefits after treatment had finished and at 6 month follow-up whilst CBT did have significant lasting benefits. The authors stated that CBT was superior to zopiclone both in the short term and in the long term. A comparison of CBT and the hypnotic drug zolpidem (Ambien) found similar results with CBT showing superiority and sustained benefits after long term follow up. Interestingly the addition of CBT and zolpidem offered no benefit over CBT alone.
Treatment of severe mental disorders with CBT
Several meta-analyses have shown CBT effective in schizophrenia and the American Psychiatric Association includes CBT in its schizophrenia guideline as an evidence-based treatment. There is also some limited evidence of effectiveness for CBT in bipolar disorder and severe depression.
CBT can help patients with severe mental disorders to make sense of experiences that lead to symptoms, and to associate key thoughts and feelings with factors that predispose to or precipitate them. For instance, it can help to make rational connections between precipitating causes such as stimulants or hallucinogenic drugs and symptoms such as psychotic episodes. With the help of a therapist, patients may even devise and carry out behavioral experiments that can help them to learn how to improve their quality of life.
Cognitive Behavioral Therapy (CBT) with children and adolescents
The use of CBT has been extended to children and adolescents with positive results. It is often used to treat major depressive disorder, anxiety disorders, and symptoms related to trauma and posttraumatic 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 recognised as best practice 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. CBT is also used as a treatment modality for children who have experienced complex posttraumatic stress disorder and chronic maltreatment.
Research in Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy most closely allies with the scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalisation of the problem, an emphasis on measurement (and measurable changes in cognition and behaviour) and measurable goal-attainment.
Criticism of Cognitive Behavioral Therapy (CBT)
CBT has recently come under fire from non-CBT therapists who claim that the data does not fully support the extent of attention and funding it receives nor its extension beyond psychotherapy into matters such as reducing unemployment, and that the limitations of the CBT model when used to blanket-address psychological suffering are unrecognised. Psychotherapist and professor at the University of Essex, Andrew Samuels, stated that this constitutes "a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money. Science isn't the appropriate perspective from which to look at emotional difficulties. Everyone has been seduced by CBT's apparent cheapness." He considers CBT "a second-class therapy for citizens deemed to be second class."
Presenters at a psychotherapy conference at the University of East Anglia (UEA) in July 2008 criticised the increased spending on CBT and the widespread belief that CBT is more effective than other forms of psychotherapy. In this conference professors Mick Cooper and Robert Elliott (both at University of Strathclyde), William B Stiles (Miami University) and Art Bohart (Saybrook Graduate School) issued a joint statement, which briefly stated:
- As more research focuses on CBT, more studies are published on CBT. This reinforces the logical error that CBT is superior and this has a direct negative effect on other forms of therapy, which are well documented but have smaller bodies of research.
- People who get therapy improve substantially, regardless of the type of therapy they get. When therapies are compared to one another, they usually show to be equally effective.
- Excessive spending on CBT and discouraging other forms of therapy, hurts the public.
At the same conference, professors Robert Elliott and Beth Freire presented their unpublished meta-analysis of more than 80 studies where person-centred psychotherapy was shown to be as effective as other forms of psychotherapy, including CBT.
In a 2009 article in Psychological Medicine entitled "Cognitive behavioral therapy for the major psychiatric disorder: does it really work?", the authors found that no trial employing both blinding and psychological placebo has found CBT to be effective in schizophrenia. The authors also found few well-controlled studies of CBT in depression that found the therapy to be effective, and that CBT is also ineffective in preventing relapses in bipolar disorder.
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