OVERVIEW

Cognitive-behavioral therapy (CBT) is one of the most extensively researched forms of psychotherapy and is increasingly recognized as the treatment of choice for many disorders.¹ Findings from randomized controlled trials typically suggest that CBT is better than wait-list control groups, as well as supportive treatment and other credible interventions, for specific disorders. Early implementations of CBT were largely indicated for anxiety and mood disorders.² However, more recent clinical research efforts have begun to develop CBT for an increasingly wider array of problems (including bipolar disorder,³ eating disorders,⁴ attention-deficit/hyperactivity disorder,⁵ and psychotic disorders⁶).

The empirical evidence for the use of CBT for a broad range of conditions is promising.⁷ However, there remains a noticeable gap between encouraging reports from clinical trials and the widespread adoption of CBT interventions among general practitioners.⁸ Moreover, questions remain regarding the limits of and indications for the efficacy of CBT in general practice.⁹ Nevertheless, it is clear that CBT interventions represent the best of what the psychotherapy community currently has to offer in terms of evidence-supported treatment options.

CBT generally refers to a treatment that uses behavioral and cognitive interventions; it is derived from scientifically supported theoretical models.^10,11 Thus, there exists a theoretically consistent relationship between CBT treatment techniques and the disorders that they are designed to treat.¹² Depending on the disorder, interventions may be directed toward eliminating cognitive and behavioral patterns that are directly linked to the development or maintenance of the disorder, or they may be directed toward maximizing coping skills to address the elicitation or duration of symptoms from disorders driven by other (e.g., biological) factors.

BEHAVIORAL THERAPY, COGNITIVE THERAPY, AND COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapies represent an integration of two strong traditions within psychology: behavioral therapy (BT) and cognitive therapy. BT refers to any of a large number of specific techniques that employ principles of learning to change human behavior. These techniques include exposure, relaxation, assertion training, social skills training, problem-solving training, modeling, contingency management, and behavioral activation. Many of these interventions are a direct outgrowth of principles of operant and respondent conditioning. Operant conditioning is concerned with the modification of behaviors by manipulation of the rewards and punishments, as well as the eliciting events. For example, in the treatment of substance dependence, the use of specific contingencies between drug abstinence (as frequently confirmed by urine or saliva toxicology screens) and rewards (e.g., the chance to win a monetary reward) has proven to be a powerful strategy for achieving abstinence among chronic drug abusers.¹³ Included as an operant strategy are also the myriad of interventions that use stepwise train-ing to engender needed new skills for problem situations. For example, assertiveness training, relaxation training, and problem-solving training are all core behavioral strategies for intervening with skill deficits that may be manifest in disorders as diverse as depression, bipolar disorder, or hypochondriasis. One approach to treating depression, for example, has emphasized the return to pleasurable and productive activities, and the specific use of these activities to boost mood. Interventions involve the step-by-step programming of activities rated by patients as relevant to their personal values and likely to evoke pleasure or a sense of personal productivity. Behavioral activation will typically consist of construction of an activity hierarchy in which up to (approximately) 15 activities are rated ranging from easiest to most difficult to accomplish. The patient then moves through the hierarchy in a systematic manner, progressing from the easiest to the most difficult activity.¹⁴ Depending on the patient, additional interventions or skill development may be needed. For example, assertion training may include a variety of interventions such as behavioral rehearsal, which is acting out appropriate and effective behaviors, to manage situations in which assertiveness is problematic.

Respondent conditioning refers to the changing of the meaning of a stimulus through repeated pairings with other stimuli, and respondent conditioning principles have been particularly applied to interventions for anxiety disorders. For example, influential theories such as Mowrer’s¹⁵ two-factor theory of phobic disorders emphasized the role of respondent conditioning in establishing fearful responses to phobic cues, and the role of avoidance in maintaining the fear. Accordingly, BT focuses on the role of exposure to help patients re-enter phobic situations and to eliminate (extinguish) learned fears about these phobic stimuli through repeated exposure to them under safe conditions. Exposure treatments may include any number of modalities or procedures. For example, a patient with social phobia may be exposed to a series of social situations that elicit anxiety, including in vivo exposure (e.g., talking on the phone, talking with strangers, giving a speech), imaginal exposure (e.g., imagining themselves in a social situation), exposure to feared sensations (termed interoceptive exposure because exposure involves the elicitation of feared somatic sensations, typically sensations similar to those of anxiety and panic), and exposure to feared cognitions (e.g., exposure to feared concepts using imaginal techniques). Exposure is generally conducted in a graduated fashion, in contrast to flooding, in which the person is thrust into the most threatening situation at the start. Exposure is designed to help patients learn alternative responses to a variety of situations by allowing fear to dissipate (become extinguished) while remaining in the feared situation. Once regarded as a passive weakening of learned exposures, extinction is now considered an active process of learning an alternative meaning to a stimulus (e.g., relearning a sense of “safety” with a once-feared stimulus),¹⁶ and ongoing research on the principles, procedures, and limits of extinction as informed by both animal and human studies has the potential for helping clinicians further hone in on the efficacy of their exposure-based treatments. For example, there is increasing evidence that the therapeutic effects of exposure are maximized when patients are actively engaged in and attentive to exposure-based learning; when exposure is conducted in multiple, realistic contexts; and when patients are provided with multiple cues for safety learning.¹⁷ Therapists should also ensure that the learning that occurs during exposure is independent of contexts that will not be present in the future (e.g., in the presence of the therapist). Effective application of exposure therapy also requires prevention of safety behaviors that may undermine what is learned from exposure. Safety behaviors refer to those behaviors that individuals may use to reassure themselves in a phobic situation. For example, a patient with panic disorder may carry a cell phone or a water bottle for help or perceived support during a panic attack. These safety behaviors, while providing reassurance to patients, appear to block the full learning of true safety.^18,19 That is, when such safety behaviors are made unavailable, better extinction (safety) learning appears to result.^20,21

Cognitive therapy was initially developed as a treatment for depression with the understanding that thoughts influence behavior and it is largely maladaptive thinking styles that lead to maladaptive behavior and emotional distress.^22,23 Currently, however, cognitive therapy includes approaches to a wider range of disorders.^24,25

As applied to depression, the cognitive model posits that intrusive cognitions associated with depression arise from a synthesis of previous life experiences. The synthesis of such experiences is also described as a schema, a form of semantic memory that describes self-relevant characteristics. For example, the cognitive model of depression posits that negative “schemas” about the self that contain absolute beliefs (e.g., “I am unlovable” or “I am incompetent”) may result in dysfunctional appraisals of the self, the world, and the future. On exposure to negative life events, negative schemas and dysfunctional attitudes are activated that may produce symptoms of depression. Thus, maladaptive cognitive patterns and negative thoughts may also be considered risk or maintaining factors for depression.²⁶ Negative automatic thoughts can be categorized into a number of common patterns of thought referred to as cognitive distortions. As outlined in Table 16-1, cognitive distortions often occur automatically and may manifest as irrational thoughts or as maladaptive interpretations of relatively ambiguous life events.

Table 16-1 Examples of Cognitive Distortions

Adapted from Beck JS: Cognitive therapy: basics and beyond, New York, 1995, Guilford Press.

Cognitive therapy,²⁷ and a similar approach known as rational-emotive therapy,²⁸ provides techniques that correct distorted thinking and offer a means by which patients can respond to maladaptive thoughts more adaptively. In addition to examining cognitive distortions (see Hollon and Garber²⁹ and Table 16-1), cognitive therapy focuses on more pervasive core beliefs (e.g., “I am unlovable” or “I am incompetent”) by assessing the themes that lie behind recurrent patterns of cognitive distortions. Those themes may be evaluated with regard to a patient’s learning history (to assess the etiology of the beliefs with the goal of logically evaluating and altering the maladaptive beliefs).

A commonly used cognitive technique is cognitive restructuring. Cognitive restructuring begins by teaching a patient about the cognitive model and by providing a patient with tools to recognize (negative) automatic thoughts that occur “on-line” (most therapists use a daily log or a diary to monitor negative automatic thoughts). The next step in cognitive restructuring is to provide the patient with opportunities to evaluate his or her thoughts with respect to their usefulness, as well as their validity. Through the process of logically analyzing thoughts, a patient is provided with a unique context for replacing distorted thoughts with more accurate and realistic thoughts. One method for helping a patient engage in critical analysis of thinking patterns is to consider the objective evidence for and against the patient’s maladaptive thoughts. Thus, questions such as, “What is the evidence that I am a bad mother? What is the evidence against it?” might be asked. Another useful technique places the patient in the role of adviser (this is often referred to as the double-standard technique²⁷). In the role of adviser, a patient is asked what advice he or she might give a family member or friend in the same situation. By distancing the patient from his or her own maladaptive thinking, the patient is given the opportunity to engage in a more rational analysis of the issue. These techniques allow patients to test the validity and utility of their thoughts; as they evaluate their thinking and see things more rationally, they are able to function better. In addition to techniques for changing negative thinking patterns, cognitive therapy also incorporates behavioral experiments. Behavioral tasks and experiments are employed in cognitive therapy to provide corrective data that will challenge beliefs and underlying negative assumptions.

Concerning the mechanism of relapse prevention in cognitive therapy, there is growing attention to the importance of the processing and form of negative thoughts, not just their content.^30,31 Studies suggest that cognitive interventions may be useful for helping patients gain perspective on their negative thoughts and feelings so that these events are not seen as “necessarily valid reflections of reality” (Teasdale et al.,³⁰ p. 285). Indeed, there is evidence that changes in metacognitive awareness may mediate the relapse prevention effects of cognitive therapy.^30,32 Accordingly, shifting an individual’s emotional response to cognitions may be an important element of the strong relapse prevention effects associated with cognitive therapy.³³

Although cognitive therapy was initially developed to focus on challenging depressive distortions, basic maladaptive assumptions are also observed in a wide range of other conditions, with the development of cognitive therapy approaches ranging from panic disorder,³⁴ posttraumatic stress disorder (PTSD),³⁵ social phobia,³⁶ and hypochondriasis,²⁵ to personality disorders²⁴ and the prevention of suicide.³⁷

PUTTING BEHAVIORAL THERAPY AND COGNITIVE THERAPY TOGETHER

As a functional unification of cognitive and behavioral interventions, CBT relies heavily on functional analysis of interrelated chains of thoughts, emotions, and behavior. Thus, the principles that underlie CBT are easily exportable to a wide range of behavioral deficits. As outlined in Table 16-2,³⁸ cognitive therapy, behavioral therapy, and their combination have garnered empirical support for the treatment of a wide range of disorders. CBT has become increasingly specialized in the last decade, and advances in the conceptualization of various disorders have brought a refinement of CBT interventions to target core features and dominant behavior patterns that characterize various disorders.

Table 16-2 Examples of Well-Established Cognitive, Behavioral, and Cognitive-Behavioral Treatments for Specific Disorders

Adapted from Chambless DL, Baker MJ, Baucom DH, et al: Update on empirically validated therapies: II, Clin Psychol 51:3-16, 1998.