Cognitive-behavioral therapy

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Overview

Cognitive Behavioral Therapy (CBT) is a psychotherapy based 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 neuroses 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. 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.

An example of sex 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 a dysfunctional cognitive-affective-behavioral process or habit with a more reasonable, salutary one.

The cognitive model especially emphasized in psychiatrist Aaron Beck's cognitive therapy says that a person's core beliefs (often formed in childhood) contribute to "automatic thoughts" that pop up in everyday 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.

History

The roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behavior therapeutical approaches appeared as early as 1924[1], with Mary Cover Jones' work on the unlearning of fears in children[2]. However, it was during the period 1950 to 1970 that the field really emerged, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull.[1] 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 desensitization[3], the precursor to today's fear reduction techniques.[1]. 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" [4], and presented behavior therapy as a constructive alternative.[5][1]. In the United States, psychologists were applying the radical behaviorism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior[6][1] and autism[7][1].

File:Albert Ellis 2003 emocionalmente sentado.jpg
Albert Ellis (1913 – 2007) was a pioneer in the development of CBT.

Although the early behavioral approaches were successful in many of the neurotic disorders, it had little success in treating depression.[1] Behaviorism was also losing in popularity due to the so-called "cognitive revolution". The therapeutic approaches of Aaron T. Beck and Albert Ellis gained popularity among behavior therapists, despite the earlier behaviorist rejection of "mentalistic" concepts like thoughts and cognitions. Both these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Ellis' system, originated in the early and mid 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.[8] Aaron T. Beck, inspired by Ellis, developed cognitive therapy, in the 1960s.[9] 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. During the 1980s and 1990s, cognitive and behavioral techniques was 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.[1]

Concurrently with the 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 behavioral therapy. [10]. He later broadened the focus of behavioral treatment to incorporate cognitive aspects[11]. When it became clear that optimizing therapy's effectiveness and effecting durable treatment outcomes often required transcending more narrowly focused cognitive and behavioral methodsTemplate:Clarifyme, 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.

Cognitive Behavioral Therapy

CBT can be seen as an umbrella term for many different therapies that share some common elements.[12] 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.[8] Aaron T. Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s.[9] 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). 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 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. 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.[13] 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.[14]

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

See also Clinical 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.

Causes of depression according to cognitive theory

One etiological theory of depression is the Aaron Beck cognitive theory of depression. His theory is regarded as the most verified psychological theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to Beck’s theory of the etiology of depression, depressed people acquire a negative schema of the world in childhood and adolescence. (Children and adolescents who suffer from depression acquire this negative schema earlier.) Depressed people acquire such schemas through a loss of a parent, rejection of peers, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles in some way, even remotely, the conditions in which the original schema was learned, the negative schemas of the person are activated. [15]

Beck also included a negative triad in his theory. A negative triad is made up of the negative schemas and cognitive biases of the person. A cognitive bias is a view of the world. Depressed people, according to this theory, have views such as “I never do a good job.” 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, overgeneralization, magnification and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.[16]

Another cognitive theory of depression is the Hopelessness Theory of depression. This is the latest theory of the helpless/hopeless theories of depression. According to this theory, hopelessness depression is caused by a state of hopelessness. A state of hopelessness obtains when the person believes that no good outcomes will happen and that bad ones will happen instead. Also, the person feels that he or she has no ability to change the situation so that good things will happen. Stressors (negative life events) are thought to interact with a diathesis (in this case, a predisposing factor to depression) to create a sense of hopelessness.[17]

Some proposed diatheses are attributing negative events to stable and global factors, low self-esteem, and a tendency to believe that negative life events will have severe negative consequences. Such diatheses increase the possibility that a person will experience hopelessness depression.

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.[18] This theory is sometimes known as a revised version of learned helplessness theory.

In 1989, this theory was challenged by Hopelessness Theory.[19] This theory emphasized attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasizes that beliefs about the consequences of events, and rated importance of events, may be at least as important as causal attributions in understanding why some people react to negative events with clinical depression.

The ABCs of Irrational Beliefs

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs.[8] The first three steps analyze the process by which a person has developed irrational beliefs. They 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 believes 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[20] 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 behavior therapy and that particular discontinued 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.[21]

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,[22] which states: 1000people 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.[23]

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 practice for the treatment of anxiety in children by the World Health Organization.Combining the Biofeedback method with the CBT process is very effective.(( cite-book Biofeedback You Are In Control Editor Dr.Yigal Gliksman,)) ((www.lulu.com/content/1800043)) date 2008. CBT has been used with children and adolescents to treat a variety of conditions with good success.[24][25]

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.[26] 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 computerized 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 innermost problems can be off-putting. In this respect, CCBT (especially if delivered online) can be a good option.

Randomized controlled trials have proven its effectiveness, and in February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that CCBT 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. antidepressant pills).[27]

A new UK government initiative for tackling Mental Health issues[3] has recently been launched by the Care Services Improvement Partnership.[4] This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE[5] 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

Notable Contributors to Modern Cognitive Behavioral Therapy

Related Techniques & Therapies

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Rachman, S (1997). "The evolution of cognitive behaviour therapy". In Clark, D, Fairburn, CG & Gelder, MG. Science and practice of cognitive behaviour therapy. Oxford: Oxford University Press. pp. 1–26. ISBN 0-19-262726-0.
  2. ↑ Jones, MC (1924). "Elimination of children's fears". Journal of Experimental Psychology. 7: 382–397.
  3. ↑ Wolpe, J (1958). Psychotherapy by reciprocal inhibition. Stanford University Press.
  4. ↑ Eysenck, H (1960). Behavior therapy and the neuroses. Pergamon, Oxford.
  5. ↑ Eysenck, H (1952). "The effects of psychotherapy: An evaluation". Journal of Consulting Psychology. 16: 971–982.
  6. ↑ Ayllon, T & Azrin, N (1968). The token economy. Wiley.
  7. ↑ Lovaas, OI (1951). "Interaction between verbal and non-verbal behaviour". Child Development. 32: 329–336.
  8. ↑ 8.0 8.1 8.2 Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall. ISBN 0-13-370650-8.
  9. ↑ 9.0 9.1 Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-8236-0990-1
  10. ↑ Lazarus, A. A. "New methods in psychotherapy: a case study". South African Medical Journal, 1958, 32, 660-664
  11. ↑ Lazarus, Arnold A. (1971). Behavior therapy & beyond. New York: McGraw-Hill. ISBN 0-07-036800-7.
  12. ↑ "A Guide to Understanding Cognitive and Behavioural Psychotherapies" British Association of Behavioural and Cognitive Psychotherapies. Retrieved on 2007-1-11
  13. ↑ "Group Therapy". Stress and Anxiety Services of New Jersey. Retrieved 2006-06-25.
  14. ↑ "What is CBT? …What's in a Name?". Association for Behavioral and Cognitive Therapies. Retrieved 2007-1-11. Check date values in: |accessdate= (help)
  15. ↑ Gerald C. Davison, John M. Neale, Abnormal Psychology, 8th edition, page 247. 2001, John Wiley & Sons, Inc.
  16. ↑ Gerald C. Davison, John M. Neale, Abnormal Psychology, 8th edition, page 248. 2001, John Wiley & Sons, Inc.
  17. ↑ Gerald C. Davison, John M. Neale, Abnormal Psychology, 8th edition, pages 249. 2001, John Wiley & Sons, Inc.
  18. ↑ Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74
  19. ↑ Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.
  20. ↑ Keller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression. New England Journal of Medicine Volume 342:1462-1470 May 18, 2000.
  21. ↑ this citation 404's
  22. ↑ "The Depression Report: A New Deal for Depression and Anxiety Disorders". The Centre for Economic Performance's Mental Health Policy Group. 2006-06-19. Retrieved 2006-06-25. Check date values in: |date= (help)
  23. ↑ "Treatment Recommendations for Patients with Major Depressive Disorder (Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition)". American Psychiatric Association. 2000. Retrieved 2006-07-02.
  24. ↑ Kendall, Philip C. (ed)., ed. (2005-12-05). Child and Adolescent Therapy: Cognitive-Behavioral Procedures, (3rd ed.). Guilford Press. ISBN 1-59385-113-8.
  25. ↑ Reinecke, Mark A.; Dattilio, Frank M.; Freeman, A. (eds)., ed. (2003-05-02). Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (2nd ed.). Guilford Press. ISBN 1-57230-853-2.
  26. ↑ Briere, John; Scott, Catherine (eds)., ed. (2006). Principles of Trauma Therapy. Sage. ISBN 0-7619-2921-5. (see especially Chapter 7, "Cognitive Interventions", pp. 109-119).
  27. ↑ National Institute for Health and Clinical Excellence. (2006). Depression and anxiety - computerised cognitive behavioural therapy.

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
  • 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

External links

Professional Organizations & Institutes


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