16: Cognitive-Behavioral Therapy, Behavioral Therapy, and Cognitive Therapy

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CHAPTER 16 Cognitive-Behavioral Therapy, Behavioral Therapy, and Cognitive Therapy


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.


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

Distortion Description
All-or-nothing thinking Looking at things in absolute, black-and-white categories
Overgeneralization Viewing negative events as a never-ending pattern of defeat
Mental filter Dwelling on the negatives and ignoring the positives
Discounting the positives Insisting that accomplishments or positive qualities “don’t count”
Jumping to conclusions Mind reading (assuming that people are reacting negatively to you when there’s no evidence to support the assumptions)
  Fortune-telling (arbitrarily predicting that things will turn out badly)
Magnification or minimization Blowing things out of proportion or shrinking their importance inappropriately
Emotional reasoning Reasoning from how you feel (“I feel stupid, so I must really be stupid”)
“Should” statements Criticizing yourself (or others) with “shoulds” or “shouldn’ts,” “musts,” “oughts,” and “have-tos”
Labeling Identifying with shortcomings (“I’m a loser”)
Personalization and blame Blaming yourself for something you weren’t entirely responsible for

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


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

Treatment Condition/Disorder
Cognitive Depression
Behavioral Agoraphobia
  Social phobia
  Specific phobia
  Obsessive-compulsive disorder
  Oppositional behavior
  Marital dysfunction
  Female orgasmic dysfunction
  Male erectile dysfunction
  Developmental disabilities
Cognitive-behavioral Panic, with and without agoraphobia
  Generalized anxiety disorder
  Social phobia
  Irritable bowel syndrome
  Chronic pain

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

Basic Principles of Cognitive-Behavioral Therapy

As outlined in Table 16-3, contemporary CBT is a collaborative, structured, and goal-oriented intervention.1 Current forms of CBT target core components of a given disorder. For example, CBT interventions for panic disorder target catastrophic misinterpretations of somatic sensations of panic and their perceived consequences, while exposure procedures focus directly on the fear of somatic sensations. Likewise, CBT for social phobia focuses on the modification of fears of a negative evaluation by others and exposure treatments emphasize the completion of feared activities and interactions with others. For generalized anxiety disorder (GAD), CBT treatment focuses on the worry process itself, with the substitution of cognitive restructuring and problem solving for self-perpetuating worry patterns, and the use of imaginal exposure for worries and fears. In the case of depression, CBT targets negative thoughts about the self, the world, and the future, as well as incorporating behavioral activation to provide more opportunities for positive reinforcement. Symptom management strategies (e.g., breathing retraining or muscle relaxation) or social skills training (e.g., assertiveness training) are also valuable adjuncts to exposure and to cognitive restructuring interventions.

Table 16-3 Characteristic Features of Cognitive-Behavioral Therapy

Feature Description
CBT is short-term The length of therapy in CBT is largely dependent on the time needed to help the patient develop more adaptive patters of responding. However, CBT treatments generally involve approximately 8 to 20 sessions.
CBT is active CBT provides a context for learning adaptive behavior. It is the therapist’s role to provide the patient with the information, skills, and opportunity to develop more adaptive coping mechanisms. Thus, homework is a central feature of CBT.
CBT is structured CBT is agenda-driven such that portions of sessions are dedicated to specific goals. Specific techniques or concepts are taught during each session. However, each session should strike a balance between material introduced by the patient and the predetermined session agenda.
CBT is collaborative The therapeutic relationship is generally less of a focus in CBT. However, it is important that the therapist and patient have a good collaborative working relationship in order to reduce symptoms by developing alternative adaptive skills.

CBT, Cognitive-behavioral therapy.

The Basic Practice of Cognitive-Behavioral Therapy

CBT is typically targeted toward short-term treatment, often in the range of 12 to 20 sessions. Treatment begins with a thorough evaluation of the problem for which the patient is seeking treatment. This generally consists of a very detailed functional analysis of the patient’s symptoms and the contexts in which they occur. This assessment requires extensive history-taking, a diagnostic interview, analysis of current function (e.g., social, occupational, relational, and family), and assessment of social support. Although the assessment may require some consideration of past events, such information is generally gathered if it is directly relevant to the solution of here-and-now problems.

A key feature of CBT involves the establishment of a strong, collaborative working alliance with the patient. This is often initiated in the context of educating the patient about the nature of his or her disorder, explaining the CBT model of the etiology and maintenance of the disorder, and the intervention that is derived from the model. Educating the patient serves the function of normalizing aspects of the disorder; this can help to reduce self-blame. Psychoeducation (including information on the course of treatment) may also enhance patient motivation for change. The therapist and the patient also work together to develop clear, realistic treatment goals.

To gather information on the patient’s symptoms, the patient is taught early on how to monitor his or her thoughts and behaviors. This usually requires that the patient documents his or her symptoms, as well as the time, date, and the level of distress and the precursors and consequences of symptoms. Self-monitoring helps a patient become aware of the timing and occurrence of target symptoms, and provides additional information on opportunities for intervention. Self-monitoring procedures are vital to help a patient identify the content of his or her thoughts; once these thoughts have been identified, they can be challenged for their accuracy and utility. The accuracy of thoughts and beliefs is often examined in the context of behavioral experiments, where patients have the opportunity to test out predictions (e.g., “I will pass out,” “I will not be able to cope”).

CBT also emphasizes systematic monitoring of symptom change. This may take the form of asking a patient how he or she is feeling as compared to previous sessions. However, more standard CBT practice consists of having a patient complete objective measures of symptoms. Periodic assessment of symptoms provides an objective look at the nature of a patient’s symptoms relative to established norms, to which symptoms have improved, and to which symptoms require more attention. Essentially, objective assessment during CBT helps inform both the patient and the therapist about the efficacy of treatment and highlights further points that require emphasis during the treatment. Monitoring outcomes can also guide the clinician with regard to case formulation or consideration of alternative CBT interventions, if expected treatment goals are not achieved.

In many approaches to CBT, patient and therapist collaboratively set an agenda for topics to be discussed in each session. Particular attention is given to events that occurred since the previous session that are relevant to the patient’s goals for treatment. Part of the agenda for treatment sessions should focus on the anticipation of difficulties that may occur before the next treatment session. These problems should then be discussed in the context of problem-solving and the implementation of necessary cognitive and behavioral skills. This may require training in skills that readily facilitate the reduction of distress. Skills, such as training in diaphragmatic breathing and progressive muscle relaxation, can be particularly useful in this regard. Although the specific interventions used during CBT may vary, the decision on which interventions to use should be informed by cognitive and learning theories that view disorders as understandable within a framework of reciprocally connected behaviors, thoughts, and emotions that are activated and influenced by environmental and interpersonal events.

As indicated in Table 16-3, CBT is also an active treatment with an emphasis on home practice of interventions. Thus, review of homework is a major component of the CBT session. In reviewing the patient’s homework, emphasis should be placed on what the patient learned, and what the patient wants to continue doing during the coming week for homework. The homework assignment, which is collaboratively set, should follow naturally from the problem-solving process in the treatment session. The use of homework in CBT draws from the understanding of therapy as a learning experience in which the patient acquires new skills. At the end of each CBT treatment session, a patient should be provided with an opportunity to summarize useful interventions from the session. This should also consist of asking the patient for feedback on the session, and efforts to enhance memories of and the subsequent home application of useful interventions.39

Relapse prevention skills are central to CBT as well. By emphasizing a problem-solving approach in treatment, a patient is trained to recognize the early warning signs of relapse and is taught to be “his or her own therapist.” Even after termination, a patient often schedules “booster sessions” to review the skills learned in treatment. In addition, novel approaches to relapse prevention, as well as treatment of residual symptoms, emphasize the application of CBT to the promotion of well-being rather than simply the reduction of pathology.40,41

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