Cognitive therapy
Encyclopedia
Cognitive behavioral therapy (CBT) is a psychotherapeutic
approach: a talking therapy
. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. The title is used in diverse ways to designate behavior 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 sometimes manualized, 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 an integration of behavior 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
; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored 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
.
. For example, Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers". The modern 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, 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 hospitalization. Low designed his techniques for use in his organization, Recovery International, which supports people recovering from mental illness. Although Recovery International was originally led by Low, 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 behavioral therapy became widely utilized, 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
. 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
, 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 behavior therapy as a constructive alternative. 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 and autism
.
Although the early behavioral approaches were successful in many of the neurotic disorders, they had little success in treating depression. Behaviorism 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 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. 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. Beck describes his therapeutic approach as originating in a realization he made while conducting free association
with patients in the context of classical psychoanalysis—he noted that patients had not been reporting certain thoughts at the fringe of consciousness, thoughts which often preceded intense emotional reactions; this realization led Beck to begin viewing emotional reactions as resulting from cognitions, rather than understanding emotion within the abstract psychoanalytic framework. Cognitive therapy rapidly became a favorite intervention technique 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 to this merging was the successful development of treatments for panic disorder
by David M. Clark in the UK and David H. Barlow in the US.
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. He later broadened the focus of behavioral treatment to incorporate cognitive aspects.
Arnold Lazarus, desiring to optimize therapy's effectiveness and effect durable treatment, cognitive and behavioral methods, developed a new form of therapy called multimodal therapy
, based on CBT, but also including 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.
, rational emotive behavior 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 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, mindfulness
and distraction techniques are also commonly included. Cognitive behavioral therapy is often also used in conjunction with mood stabilizing
medications to treat conditions like 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.
Going through cognitive behavioral therapy generally is not an overnight process for clients; a typical course consists of 12-16 hour-long sessions. Even after clients have learned to recognize 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. Cognitive Behavioral Therapy is problem focused and structured towards the client. It requires honesty and openness between the client and therapist, as a therapist develops strategies for managing problems and guiding the client to a better life.
Randomized controlled trial
s 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.
A new UK government initiative for tackling mental health
issues has recently been launched by the Care Services Improvement Partnership. This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE 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. Some areas have developed, or are trialing, other CCBT products notably the Serenity Programme developed in-house by the NHS and currently being trialed in North Wales (UK).
The more recent NICE guideline (2009) has recognised that there are likely to be a number of computerised CBT products that are useful to patients. They have therefore removed the endorsement of any specific product.
Today numerous sites offer computerised CBT. Many of them offer interactive communication with therapists. Live feedback has shown to improve the result of online CBT.
At Auckland University in New Zealand, a team led by Dr. Sally Merry have been developing a computerised CBT fantasy 'serious' game to help tackle depression amongst adolescences. The game is currently undergoing testing and the results are thought to be released in 2011. The game has a number of features to help combat depression, where the user takes on a role of a character who travels through a fantasy world, combating 'literal' negative thoughts and learning techniques to manage their depression.
concluded, "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists." However, cognitive behavioral therapy is unlikely to be effective in treating psychiatric problems caused solely by drug or alcohol abuse. It has been argued that the treatment of such patients should be directed at tackling their substance abuse problems (ideally aiming for complete abstinence) prior to the commencement of CBT.
—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 negatively 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
. CBT also looks at an individual's way of thinking and the way that he or she reacts to certain habits or behaviors. A specific phobia
, such as fear of spiders
, can often be treated with in vivo exposure and therapist modeling in one session. Obsessive compulsive disorder is typically treated with exposure with response prevention.
Social phobia
, also known as social anxiety
, 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 12-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.
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 theorized 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-generalization, magnification and minimization
. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.
Cognitive behavioral therapy 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 the antidepressant Nefazodone
alone) when a form of cognitive behavior 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.
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.
Recently some CBT practitioners have returned to more behavioral approaches to the treatment of depression such as behavioral activation
. A large-scale treatment study found behavioral activation to be more effective than cognitive therapy and on a par with medication for treating depression.
(CBT-I) has been found to be effective in reducing benzodiazepine
usage in the treatment of insomnia
. A large-scale trial utilizing CBT-I for chronic users of sedative hypnotics including nitrazepam
, temazepam
and zopiclone
found the addition of CBT-I 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 for insomnia with hypnotics compared with those patients receiving hypnotics alone. A marked reduction in total sedative hypnotic drug use was found in those receiving CBT-I, with 33% reporting no hypnotic drug use. Authors of the study suggested that CBT-I is potentially a flexible, practical, and cost-effective treatment for the treatment of insomnia and that CBT-I 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 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-I 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-I 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-I found that CBT-I 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 while CBT-I did have significant lasting benefits. The authors stated that CBT-I was superior to zopiclone
both in the short term and in the long term. A comparison of CBT-I and the hypnotic
drug zolpidem (Ambien) found similar results with CBT-I showing superiority and sustained benefits after long term follow up. Interestingly the addition of CBT-I and zolpidem offered no benefit over CBT-I alone.
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
.
However, in a 2010 article in Psychological Medicine entitled, "Cognitive behavioral therapy for the major psychiatric disorder: does it really work?",http://journals.cambridge.org/cogtherapy 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 in those found, the effect was small. CBT is also ineffective in preventing relapses in bipolar disorder.
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
. 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 post-traumatic stress disorder
and chronic maltreatment.
Cognitive and Behavioral Therapies for children and adolescents usually are short-term treatments (i.e., often between 6-20 sessions) that focus on teaching young people and their parents specific skills. CBT is different from many other therapy approaches by focusing on the ways that a person's cognitions (i.e., thoughts), emotions, and behaviors are connected and how they affect one another. Because emotions, thoughts, and behaviors are all linked, CBT approaches allow for therapists to intervene at different points in the cycle. Though approaches can differ somewhat, they have the following in common :
Such therapy can usually be obtained through speech and language therapists, trained in CBT. More recently, techniques offered by CBT are now available through computerized methods, including online approaches such as Speech Bloom, which is a study program for stuttering.
, which is used to treat post-traumatic stress disorder (PTSD) for veterans and sexual assault victims.
of the problem, an emphasis on measurement
(and measurable changes in cognition and behavior) and measurable goal-attainment.
Effective cognitive behavioral therapy is also dependent on a therapeutic alliance between the health care practitioner and the person seeking assistance. (See Therapeutic relationship
)
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."
Presenters at a psychotherapy conference at the University of East Anglia (UEA) in July 2008 criticized 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 University) issued a joint statement, which briefly stated:
At the same conference, professors Robert Elliott and Beth Freire presented their unpublished meta-analysis of more than 80 studies where person-centered psychotherapy
was shown to be as effective as other forms of psychotherapy, including CBT.
In a 2010 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 in those found, the effect was small. CBT is also ineffective in preventing relapses in bipolar disorder.
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
approach: a talking therapy
Talking therapies
Talking therapies is the generic name for the range of psychotherapies. It is a derivative of the talking cure, although less related to one therapy alone, it is a term that does cover psychoanalysis, cognitive behavioural therapy and counselling or counselling psychology approaches.- History...
. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. The title is used in diverse ways to designate behavior therapy
Behaviour therapy
Behaviour therapy, or behavior therapy is an approach to psychotherapy based on learning theory which aims to treat psychopathology through techniques designed to reinforce desired and eliminate undesired behaviours.-History:...
, cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
, and to refer to therapy based upon a combination of basic behavioral
Behaviorism
Behaviorism , also called the learning perspective , is a philosophy of psychology based on the proposition that all things that organisms do—including acting, thinking, and feeling—can and should be regarded as behaviors, and that psychological disorders are best treated by altering behavior...
and cognitive
Cognitive psychology
Cognitive psychology is a subdiscipline of psychology exploring internal mental processes.It is the study of how people perceive, remember, think, speak, and solve problems.Cognitive psychology differs from previous psychological approaches in two key ways....
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 sometimes manualized, 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
Self-help
Self-help, or self-improvement, is a self-guided improvement—economically, intellectually, or emotionally—often with a substantial psychological basis. There are many different self-help movements and each has its own focus, techniques, associated beliefs, proponents and in some cases, leaders...
applications. Some clinicians and researchers are more cognitive oriented (e.g. cognitive restructuring
Cognitive restructuring
Cognitive restructuring, sometimes used synonymously with Debating, is the process of learning to identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation....
), while others are more behaviorally oriented (in vivo exposure therapy
Exposure therapy
Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work...
). Other interventions combine both (e.g. imaginal exposure therapy).
CBT was primarily developed through an integration of behavior therapy with cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
. 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
Efficacy
Efficacy is the capacity to produce an effect. It has different specific meanings in different fields. In medicine, it is the ability of an intervention or drug to reproduce a desired effect in expert hands and under ideal circumstances.- Healthcare :...
; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments. In the United Kingdom, the National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
recommends CBT as the treatment of choice for a number of mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
difficulties, including post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
, OCD, bulimia nervosa
Bulimia nervosa
Bulimia nervosa is an eating disorder characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging and/or by laxative, diuretics or excessive exercise. Bulimia nervosa is...
, and clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
.
History
Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly StoicismStoicism
Stoicism is a school of Hellenistic philosophy founded in Athens by Zeno of Citium in the early . The Stoics taught that destructive emotions resulted from errors in judgment, and that a sage, or person of "moral and intellectual perfection," would not suffer such emotions.Stoics were concerned...
. For example, Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers". The modern 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, with Mary Cover Jones
Mary Cover Jones
Mary Cover Jones was born in Johnstown, Pennsylvania. Within psychology, a scientific field dominated throughout much of the 20th century by male scientists, Mary Cover Jones stands out as a pioneer of behavior therapy—Joseph Wolpe dubbed her "the mother of behavior therapy"...
' work on the unlearning of fears in children. In 1937 Abraham Low
Abraham Low
Abraham Low , was a Jewish-American neuropsychiatrist noted for his work establishing self-help programs for the mentally ill, and criticism of Freudian psychoanalysis. He was born February 28, 1891 in Baranów Sandomierski, Poland....
developed cognitive training techniques for patient aftercare
Managed care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
following psychiatric hospitalization. Low designed his techniques for use in his organization, Recovery International, which supports people recovering from mental illness. Although Recovery International was originally led by Low, 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 behavioral therapy became widely utilized, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviorist
Behaviorism
Behaviorism , also called the learning perspective , is a philosophy of psychology based on the proposition that all things that organisms do—including acting, thinking, and feeling—can and should be regarded as behaviors, and that psychological disorders are best treated by altering behavior...
learning theory of Ivan Pavlov
Ivan Pavlov
Ivan Petrovich Pavlov was a famous Russian physiologist. Although he made significant contributions to psychology, he was not in fact a psychologist himself but was a mathematician and actually had strong distaste for the field....
, John B. Watson
John B. Watson
John Broadus Watson was an American psychologist who established the psychological school of behaviorism. Watson promoted a change in psychology through his address Psychology as the Behaviorist Views it which was given at Columbia University in 1913...
and Clark L. Hull
Clark L. Hull
Clark Leonard Hull was an influential American psychologist who sought to explain learning and motivation by scientific laws of behavior. Born in Akron, New York, Hull obtained bachelor's and master's degrees from the University of Michigan, and in 1918 a PhD from the University of...
. In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe
Joseph Wolpe
Joseph Wolpe was born on April 20, 1915, in Johannesburg, South Africa, and died on December 4, 1997, from lung cancer. He is one of the most influential figures in behavior therapy....
, who applied the findings of animal experiments to his method of systematic desensitization
Systematic desensitization
Systematic desensitization is a type of behavioral therapy used in the field of psychology to help effectively overcome phobias and other anxiety disorders. More specifically, it is a type of Pavlovian therapy / classical conditioning therapy developed by a South African psychiatrist, Joseph Wolpe...
, the precursor to today's fear reduction techniques. British psychologist Hans Eysenck
Hans Eysenck
Hans Jürgen Eysenck was a German-British psychologist who spent most of his career in Britain, best remembered for his work on intelligence and personality, though he worked in a wide range of areas...
, inspired by the writings of Karl Popper
Karl Popper
Sir Karl Raimund Popper, CH FRS FBA was an Austro-British philosopher and a professor at the London School of Economics...
, criticized psychoanalysis in arguing that "if you get rid of the symptoms, you get rid of the neurosis", and presented behavior therapy as a constructive alternative. In the United States, psychologists were applying the radical behaviorism
Radical behaviorism
Radical behaviorism is a philosophy developed by B.F. Skinner that underlies the experimental analysis of behavior approach to psychology. The term radical behaviorism applies to a particular school that emerged during the reign of behaviorism...
of B. F. Skinner
B. F. Skinner
Burrhus Frederic Skinner was an American behaviorist, author, inventor, baseball enthusiast, social philosopher and poet...
to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior and autism
Autism
Autism is a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old. Autism affects information processing in the brain by altering how nerve cells and their...
.
Although the early behavioral approaches were successful in many of the neurotic disorders, they had little success in treating depression. Behaviorism was also losing in popularity due to the so-called "cognitive revolution
Cognitive revolution
The cognitive revolution is the name for an intellectual movement in the 1950s that began what are known collectively as the cognitive sciences. It began in the modern context of greater interdisciplinary communication and research...
". The therapeutic approaches of Albert Ellis and Aaron T. Beck
Aaron T. Beck
Aaron Temkin Beck is an American psychiatrist and a professor emeritus in the department of psychiatry at the University of Pennsylvania. He is widely regarded as the father of cognitive therapy, and his pioneering theories are widely used in the treatment of clinical depression...
gained popularity among behavior therapists, despite the earlier behaviorist rejection of "mentalistic
Mentalism (psychology)
In psychology, mentalism refers to those branches of study that concentrate on mental perception and thought processes, like cognitive psychology...
" 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
Psychoanalysis
Psychoanalysis is a psychological theory developed in the late 19th and early 20th centuries by Austrian neurologist Sigmund Freud. Psychoanalysis has expanded, been criticized and developed in different directions, mostly by some of Freud's former students, such as Alfred Adler and Carl Gustav...
. Aaron T. Beck, inspired by Albert Ellis, developed cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
in the 1960s. Beck describes his therapeutic approach as originating in a realization he made while conducting free association
Free association (psychology)
Free association is a technique used in psychoanalysis which was originally devised by Sigmund Freud out of the hypnotic method of his mentor and coworker, Josef Breuer....
with patients in the context of classical psychoanalysis—he noted that patients had not been reporting certain thoughts at the fringe of consciousness, thoughts which often preceded intense emotional reactions; this realization led Beck to begin viewing emotional reactions as resulting from cognitions, rather than understanding emotion within the abstract psychoanalytic framework. Cognitive therapy rapidly became a favorite intervention technique 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 to this merging was the successful development of treatments for panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
by David M. Clark in the UK and David H. Barlow in the US.
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. He later broadened the focus of behavioral treatment to incorporate cognitive aspects.
Arnold Lazarus, desiring to optimize therapy's effectiveness and effect durable treatment, cognitive and behavioral methods, developed a new form of therapy called multimodal therapy
Multimodal Therapy
Multimodal therapy is approach to psychotherapy founded by Arnold Lazarus. It is based on the idea that humans are biological beings that think, feel, act, sense, imagine, and interact; and that each of these "modalities" should be addressed in psychological treatment...
, based on CBT, but also including 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
CBT includes a variety of approaches and therapeutic systems; some of the most well known include cognitive therapyCognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
, rational emotive behavior therapy
Rational emotive behavior therapy
Rational emotive behavior therapy , previously called rational therapy and rational emotive therapy, is a comprehensive, active-directive, philosophically and empirically based psychotherapy which focuses on resolving emotional and behavioral problems and disturbances and enabling people to lead...
and multimodal therapy
Multimodal Therapy
Multimodal therapy is approach to psychotherapy founded by Arnold Lazarus. It is based on the idea that humans are biological beings that think, feel, act, sense, imagine, and interact; and that each of these "modalities" should be addressed in psychological treatment...
. 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 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, mindfulness
Mindfulness (psychology)
Modern clinical psychology and psychiatry since the 1970s have developed a number of therapeutic applications based on the concept of mindfulness in Buddhist meditation.-Definitions:...
and distraction techniques are also commonly included. Cognitive behavioral therapy is often also used in conjunction with mood stabilizing
Mood stabilizer
A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder.-Uses:...
medications to treat conditions like bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
. Its application in treating schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
along with medication and family therapy is recognized by the NICE
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
guidelines (see below) within the British NHS.
Going through cognitive behavioral therapy generally is not an overnight process for clients; a typical course consists of 12-16 hour-long sessions. Even after clients have learned to recognize 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. Cognitive Behavioral Therapy is problem focused and structured towards the client. It requires honesty and openness between the client and therapist, as a therapist develops strategies for managing problems and guiding the client to a better life.
Computerized
Computerized Cognitive Behavioral Therapy (CCBT) is described by the National Institute for Clinical Excellence (2006) as a "generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet or interactive voice response system", instead of face to face with a therapist. While it cannot replace face-to-face therapy, 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, computerized CBT can be an alternative option.Randomized controlled trial
Randomized controlled trial
A randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
s have proven its effectiveness, and in February 2006 the UK's National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
recommended that CCBT be made available for use within the NHS
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
across England and Wales, for patients presenting with mild to moderate depression, rather than immediately opting for antidepressant medication.
A new UK government initiative for tackling mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
issues has recently been launched by the Care Services Improvement Partnership. This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE has confirmed that by 31 March 2007 PCTs should have ST Solutions' "FearFighter" and Ultrasis
Ultrasis
Ultrasis Group Plc is a healthcare company based in the United Kingdom which develops computerised healthcare products based on Cognitive Behavioural Therapy .The company’s products cover stress, anxiety and depression problems....
' "Beating the Blues" CCBT products in place and the NICE Guidelines should be met. Some areas have developed, or are trialing, other CCBT products notably the Serenity Programme developed in-house by the NHS and currently being trialed in North Wales (UK).
The more recent NICE guideline (2009) has recognised that there are likely to be a number of computerised CBT products that are useful to patients. They have therefore removed the endorsement of any specific product.
Today numerous sites offer computerised CBT. Many of them offer interactive communication with therapists. Live feedback has shown to improve the result of online CBT.
At Auckland University in New Zealand, a team led by Dr. Sally Merry have been developing a computerised CBT fantasy 'serious' game to help tackle depression amongst adolescences. The game is currently undergoing testing and the results are thought to be released in 2011. The game has a number of features to help combat depression, where the user takes on a role of a character who travels through a fantasy world, combating 'literal' negative thoughts and learning techniques to manage their depression.
Specific applications
CBT has been applied within many clinical and non-clinical environments and has been successfully used as a treatment for many clinical disorders, personality conditions and behavioral problems. A systematic reviewSystematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
concluded, "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists." However, cognitive behavioral therapy is unlikely to be effective in treating psychiatric problems caused solely by drug or alcohol abuse. It has been argued that the treatment of such patients should be directed at tackling their substance abuse problems (ideally aiming for complete abstinence) prior to the commencement of CBT.
Anxiety disorders
A basic concept in CBT treatment of anxiety disorders is in vivo exposureExposure therapy
Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work...
—a gradual exposure to the actual, feared stimulus
Stimulus (physiology)
In physiology, a stimulus is a detectable change in the internal or external environment. The ability of an organism or organ to respond to external stimuli is called sensitivity....
. This treatment is based on the theory that the fear response has been classically conditioned
Classical conditioning
Classical conditioning is a form of conditioning that was first demonstrated by Ivan Pavlov...
and that avoidance negatively reinforces and maintains that fear. This "two-factor" model is often credited to O. Hobart Mowrer
Orval Hobart Mowrer
Orval Hobart Mowrer was an American born psychologist and professor of psychology at the University of Illinois from 1948 to 1975 known for his research on behaviour therapy. Mowrer practiced psychotherapy in Champaign-Urbana and at Galesburg State Research Hospital. In 1954 Mowrer held the...
. Through exposure to the stimulus, this conditioning can be unlearned; this is referred to as extinction
Extinction (psychology)
Extinction is the conditioning phenomenon in which a previously learned response to a cue is reduced when the cue is presented in the absence of the previously paired aversive or appetitive stimulus.-Fear conditioning:...
and habituation
Habituation
Habituation can be defined as a process or as a procedure. As a process it is defined as a decrease in an elicited behavior resulting from the repeated presentation of an eliciting stimulus...
. CBT also looks at an individual's way of thinking and the way that he or she reacts to certain habits or behaviors. A specific phobia
Specific phobia
A specific phobia is a generic term for any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations...
, such as fear of spiders
Arachnophobia
Arachnophobia or arachnephobia is a specific phobia, the fear of spiders and other arachnids such as scorpions. It is a manifestation of zoophobia, among the most common of all phobias. The reactions of arachnophobics often seem irrational to others...
, can often be treated with in vivo exposure and therapist modeling in one session. Obsessive compulsive disorder is typically treated with exposure with response prevention.
Social phobia
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
, also known as social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
, has often been treated with exposure coupled with cognitive restructuring
Cognitive restructuring
Cognitive restructuring, sometimes used synonymously with Debating, is the process of learning to identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation....
, 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 12-month follow up. Furthermore in patients who had discontinued benzodiazepines, it was found that they no longer met the diagnosis of general anxiety disorder
General anxiety disorder
Generalized anxiety disorder is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry...
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
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
benefits.
Mood disorders
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 schemaSchema (psychology)
A schema , in psychology and cognitive science, describes any of several concepts including:* An organized pattern of thought or behavior.* A structured cluster of pre-conceived ideas....
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
Beck's cognitive triad
Beck's cognitive triad is a triad of types of negative thought present in depression proposed by Aaron Beck in 1976. The triad forms part of his Cognitive Theory Of Depression.The triad involves negative thoughts about:# The self...
, made up of the negative schemata and cognitive biases of the person; Beck theorized 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-generalization, magnification and minimization
Minimisation (psychology)
Minimisation is a type of deception involving denial coupled with rationalisation in situations where complete denial is implausible. It is the opposite of exaggeration....
. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.
Cognitive behavioral therapy 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 the antidepressant Nefazodone
Nefazodone
Nefazodone is an antidepressant marketed by Bristol-Myers Squibb. Its sale was discontinued in 2003 in some countries due to the rare incidence of hepatotoxicity , which could lead to the need for a liver transplant, or even death. The incidence of severe liver damage is approximately 1 in every...
alone) when a form of cognitive behavior 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.
The American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy
Interpersonal psychotherapy
Interpersonal Psychotherapy is a time-limited psychotherapy that focuses on the interpersonal context and on building interpersonal skills. IPT is based on the belief that interpersonal factors may contribute heavily to psychological problems. It is commonly distinguished from other forms of...
had the best-documented efficacy for treatment of major depressive disorder.
Recently some CBT practitioners have returned to more behavioral approaches to the treatment of depression such as behavioral activation
Behavioral activation
Behavioral activation is a third generation behavior therapy for treating depression. It is one of many functional analytic psychotherapies which are based on a Skinnerian psychological model of behavior change, generally referred to as applied behavior analysis...
. A large-scale treatment study found behavioral activation to be more effective than cognitive therapy and on a par with medication for treating depression.
Insomnia
Cognitive Behavioral Therapy for InsomniaCognitive behavioral therapy for insomnia
Cognitive behavioral therapy for insomnia is a method for treating insomnia without medications.-Stimulus control:Stimulus control aims to associate the bed with sleeping and limit its association with stimulating behavior...
(CBT-I) has been found to be effective in reducing benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
usage in the treatment of insomnia
Insomnia
Insomnia is most often defined by an individual's report of sleeping difficulties. While the term is sometimes used in sleep literature to describe a disorder demonstrated by polysomnographic evidence of disturbed sleep, insomnia is often defined as a positive response to either of two questions:...
. A large-scale trial utilizing CBT-I for chronic users of sedative hypnotics including nitrazepam
Nitrazepam
Nitrazepam is a type of benzodiazepine drug and is marketed in English-speaking countries under the following brand names: Alodorm, Arem, Insoma, Mogadon, Nitrados, Nitrazadon, Ormodon, Paxadorm, Remnos, and Somnite...
, temazepam
Temazepam
Temazepam is an intermediate-acting 3-hydroxy benzodiazepine. It is mostly prescribed for the short-term treatment of sleeplessness in patients who have difficulty maintaining sleep...
and zopiclone
Zopiclone
Zopiclone is a non-benzodiazepine hypnotic agent used in the treatment of insomnia. In the United States, zopiclone is not commercially available, although its active stereoisomer, eszopiclone, is sold under the name Lunesta...
found the addition of CBT-I 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 for insomnia with hypnotics compared with those patients receiving hypnotics alone. A marked reduction in total sedative hypnotic drug use was found in those receiving CBT-I, with 33% reporting no hypnotic drug use. Authors of the study suggested that CBT-I is potentially a flexible, practical, and cost-effective treatment for the treatment of insomnia and that CBT-I 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 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
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
medications. A clinical trial in elderly people dependent on benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
hypnotics showed that the addition of CBT-I to a gradual benzodiazepine reduction program increased the success rate of discontinuing benzodiazepine hypnotic
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
drugs from 38% to 77% and at 12-month follow-up from 24% to 70%. The paper concluded that CBT-I is an effective tool for reducing hypnotic
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
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
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
drug zopiclone
Zopiclone
Zopiclone is a non-benzodiazepine hypnotic agent used in the treatment of insomnia. In the United States, zopiclone is not commercially available, although its active stereoisomer, eszopiclone, is sold under the name Lunesta...
against CBT-I found that CBT-I actually improved EEG
EEG
EEG commonly refers to electroencephalography, a measurement of the electrical activity of the brain.EEG may also refer to:* Emperor Entertainment Group, a Hong Kong-based entertainment company...
slow wave sleep as well as increased time spent asleep and found that the benefits were maintained at 6-month follow-up. Zopiclone
Zopiclone
Zopiclone is a non-benzodiazepine hypnotic agent used in the treatment of insomnia. In the United States, zopiclone is not commercially available, although its active stereoisomer, eszopiclone, is sold under the name Lunesta...
however worsened sleep by suppressing slow wave sleep. A lack of slow wave sleep is linked to impaired functioning and sleepiness. Zopiclone
Zopiclone
Zopiclone is a non-benzodiazepine hypnotic agent used in the treatment of insomnia. In the United States, zopiclone is not commercially available, although its active stereoisomer, eszopiclone, is sold under the name Lunesta...
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 while CBT-I did have significant lasting benefits. The authors stated that CBT-I was superior to zopiclone
Zopiclone
Zopiclone is a non-benzodiazepine hypnotic agent used in the treatment of insomnia. In the United States, zopiclone is not commercially available, although its active stereoisomer, eszopiclone, is sold under the name Lunesta...
both in the short term and in the long term. A comparison of CBT-I and the hypnotic
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
drug zolpidem (Ambien) found similar results with CBT-I showing superiority and sustained benefits after long term follow up. Interestingly the addition of CBT-I and zolpidem offered no benefit over CBT-I alone.
Severe mental disorders
Several meta-analyses have shown CBT effective in schizophreniaSchizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
and the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
includes CBT in its schizophrenia guideline as an evidence-based treatment. There is also some limited evidence of effectiveness for CBT in bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
and severe depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
.
However, in a 2010 article in Psychological Medicine entitled, "Cognitive behavioral therapy for the major psychiatric disorder: does it really work?",http://journals.cambridge.org/cogtherapy 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 in those found, the effect was small. CBT is also ineffective in preventing relapses in bipolar disorder.
Children and adolescents
The use of CBT has been extended to children and adolescents with positive results. CBT is one of the few empirically-supported psychosocial treatments for young people 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 PsychologyClinical psychology
Clinical psychology is an integration of science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development...
program in Chicago
Chicago
Chicago is the largest city in the US state of Illinois. With nearly 2.7 million residents, it is the most populous city in the Midwestern United States and the third most populous in the US, after New York City and Los Angeles...
. 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
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
. 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 post-traumatic stress disorder
Complex post-traumatic stress disorder
Complex post-traumatic stress disorder is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, i.e. the lack of a viable escape route for the...
and chronic maltreatment.
Cognitive and Behavioral Therapies for children and adolescents usually are short-term treatments (i.e., often between 6-20 sessions) that focus on teaching young people and their parents specific skills. CBT is different from many other therapy approaches by focusing on the ways that a person's cognitions (i.e., thoughts), emotions, and behaviors are connected and how they affect one another. Because emotions, thoughts, and behaviors are all linked, CBT approaches allow for therapists to intervene at different points in the cycle. Though approaches can differ somewhat, they have the following in common :
- The therapist and child or adolescent client develop goals for therapy together, often in close collaboration with parents, and track progress toward goals throughout the course of treatment.
- The therapist and client work together with a mutual understanding that the therapist has theoretical and technical expertise, but the client is the expert on him- or herself.
- The therapist seeks to help the client discover that he/she is powerful and capable of choosing positive thoughts and behaviors.
- Treatment is often short-term. Clients actively participate in treatment in and out of session. Homework assignments often are included in therapy. The skills that are taught in these therapies require practice.
- Treatment is goal-oriented to resolve present-day problems. Therapy involves working step-by-step to achieve goals.
Stuttering
Cognitive behavioral therapy is increasingly being used to help people who stutter or stammer, to overcome anxiety. CBT teaches people to analyze how unhelpful thoughts may be contributing to their anxieties, which can cause avoidance behaviors, and further stuttering. People can then learn to challenge such thoughts. It can also be used to help people who stutter change negative beliefs about themselves into positive ones.Such therapy can usually be obtained through speech and language therapists, trained in CBT. More recently, techniques offered by CBT are now available through computerized methods, including online approaches such as Speech Bloom, which is a study program for stuttering.
Complex trauma
Recent efforts have been made to develop models for using CBT with complex trauma. These models are still in their early stages but have strong promise. In particular programs based on the use of exposure therapy One example of a model being used is Cognitive Processing TherapyCognitive Processing Therapy
Cognitive processing therapy is an adaptation of the evidence-based therapy known as cognitive behavioral therapy used by clinicians to help consumers explore recovery from posttraumatic stress disorder and related conditions....
, which is used to treat post-traumatic stress disorder (PTSD) for veterans and sexual assault victims.
Post-stroke depression
"There is moderate evidence that cognitive behavioural therapy is ineffective as a treatment for poststroke depression."http://www.ebrsr.com/~ebrsr/uploads/F_Psychosocial_Issues_%28Full_Version%29.pdfResearch
Cognitive behavioral therapy most closely allies with the scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalizationOperationalization
In humanities, operationalization is the process of defining a fuzzy concept so as to make the concept clearly distinguishable or measurable and to understand it in terms of empirical observations...
of the problem, an emphasis on measurement
Measurement
Measurement is the process or the result of determining the ratio of a physical quantity, such as a length, time, temperature etc., to a unit of measurement, such as the metre, second or degree Celsius...
(and measurable changes in cognition and behavior) and measurable goal-attainment.
Effective cognitive behavioral therapy is also dependent on a therapeutic alliance between the health care practitioner and the person seeking assistance. (See Therapeutic relationship
Therapeutic relationship
The therapeutic relationship, also called the helping alliance, the therapeutic alliance, and the working alliance, refers to the relationship between a healthcare professional and a client...
)
Criticism
CBT has 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 unrecognized. Psychotherapist and professor Andrew SamuelsAndrew Samuels
Andrew Samuels is known internationally as an influential commentator on political and social themes from the standpoint of 'therapy thinking'. He has worked with politicians, political organizations, activist groups and members of the public in Europe, US, Brazil, Israel, Japan, Russia and South...
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."
Presenters at a psychotherapy conference at the University of East Anglia (UEA) in July 2008 criticized 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 University) 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 appear 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-centered psychotherapy
Person-centered psychotherapy
Person-centered therapy is also known as person-centered psychotherapy, person-centered counseling, client-centered therapy and Rogerian psychotherapy. PCT is a form of talk-psychotherapy developed by psychologist Carl Rogers in the 1940s and 1950s...
was shown to be as effective as other forms of psychotherapy, including CBT.
In a 2010 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 in those found, the effect was small. CBT is also ineffective in preventing relapses in bipolar disorder.
Further reading
- Albano, M., & Kearney C. (2000). When children refuse school: a cognitive behavioral therapy approach: Therapist guide. Psychological Corporation.
- Burns, D. (1999). Feeling Good: The New Mood Therapy (Revised Edition). Avon. ISBN 0-380-81033-6
- Burns, D. (1999). The Feeling Good Handbook. NY: Plume. ISBN 978-0-452-28132-5
- Bush, J., Vermont Department of Corrections (2002). A Manual for the Delivery of Cognitive Self-Change, Vermont Department of Corrections.
- Butler, G., Fennell, M., and Hackmann, A. (2008). Cognitive-Behavioral Therapy for Anxiety Disorders. New York: The Guilford Press. ISBN 978-1-60623-869-1
- Dattilio, F.M., and Freeman, A. (Eds.) (2007). Cognitive-Behavioral Strategies in Crisis Intervention (3rd ed.). New York: The Guilford Press. ISBN 978-1-60623-648-2
- Deblinger, E. and Heflin, A. (1996) . Treating sexually abused children and their non-offending parents: a cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.
- Ellis, A. (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy. Prometheus Books. ISBN 978-1-57392-879-3
- French, Abe. (2007). Thinking Matters Facilitator Manual.
- Leahy, R.L. and Holland, S.J. (2000). Treatment Plans and Interventions for Depression and Anxiety Disorders. New York: Guilford*Tanner, S. and Ball, J. (2001). Beating the Blues: A Self-help Approach to Overcoming Depression. ISBN 0-646-36622-X
- McCullough, J.P. (2003). Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press. ISBN 1-57230-965-2
- Willson, R. and Branch, R. (2006). Cognitive Behavioural Therapy for Dummies. ISBN 978-0-470-01838-5