Cognitive therapy is a psychosocial (both psychological and social) therapy that assumes that faulty thought patterns (called cognitive patterns) cause maladaptive behavior and emotional responses. The treatment focuses on changing thoughts in order to solve psychological and personality problems. Behavior therapy is also a goal-oriented, therapeutic approach, and it treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training. Cognitive-behavioral therapy (CBT) integrates features of behavior modification into the traditional cognitive restructuring approach.
Cognitive-behavioral therapy attempts to change clients' unhealthy behavior through cognitive restructuring (examining assumptions behind the thought patterns) and through the use of behavior therapy techniques.
Cognitive-behavioral therapy is a treatment option for a number of mental disorders, including depression, dissociative identity disorder , eating disorders, generalized anxiety disorder , hypochondriasis , insomnia , obsessive-compulsive disorder , and panic disorder without agoraphobia .
Cognitive-behavioral therapy may not be appropriate for all patients. Patients with significant cognitive impairments (patients with traumatic brain injury or organic brain disease, for example) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.
Origins of the two approaches
Psychologist Aaron Beck developed cognitive therapy in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted view of the situation. Cognitive therapy strives to change these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.
Behavior therapy focuses on observable behavior and its modification in the present, in sharp contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past. Behavior therapy was developed during the 1950s by researchers and therapists who were critical of the prevailing psychodynamic treatment methods. The therapy drew on a variety of theories and research, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), the work of American B. F. Skinner (1904-1990), and the work of psychiatrist Joesph Wolpe (1915-1997). Pavlov became famous for experiments in which dogs were trained to salivate at the sound of a bell, and Skinner pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. Wolpe is probably best known for his work in the areas of desensitization and assertiveness training . By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Since the 1980s, many therapists have begun to use cognitive-behavioral therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.
The combined approach
In cognitive-behavioral therapy, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, that are flawed and are having a negative impact on the patient's behavior and functioning.
For example, a patient suffering from depression may develop a social phobia because he is convinced that he is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends who care for him and enjoy his company. By showing the patient that others value him, the therapist exposes the irrationality of the patient's assumption and also provides a new model of thought for the patient to change his previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations in order to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.
Cognitive-behavioral therapy is usually administered in an outpatient setting (clinic or doctor's office) by a specially trained therapist. Therapy may be in either individual or group sessions. Therapists are psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. trained in psychiatry).
Therapists use several different techniques in the course of cognitive-behavioral therapy to help patients examine and change thoughts and behaviors. These include:
- Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
- Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to cope successfully with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to manage it.
- Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
- Writing in a journal. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behaviors that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
- Homework. In order to encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling, review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
- Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.
- Systematic positive reinforcement. Human behavior is routinely motivated and rewarded by positive reinforcement , and a more specialized version of this phenomenon (systematic positive reinforcement) is used by behavior-oriented therapists. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of tokens that may be accumulated and later exchanged for certain privileges. Just as providing reinforcement strengthens behaviors, withholding it weakens them. Eradicating undesirable behavior by deliberately withholding reinforcement is another popular treatment method called extinction. For example, a child who habitually shouts to attract attention may be ignored unless he or she speaks in a conversational tone.
- Aversive conditioning. This technique employs the principles of classical conditioning to lessen the appeal of a behavior that is difficult to change because it is either very habitual or temporarily rewarding. The client is exposed to an unpleasant stimulus while engaged in or thinking about the behavior in question. Eventually the behavior itself becomes associated with unpleasant rather than pleasant feelings. One treatment method used with alcoholics is the administration of a nausea-inducing drug together with an alcoholic beverage to produce an aversion to the taste and smell of alcohol by having it become associated with nausea. In counterconditioning, a maladaptive response is weakened by the strengthening of a response that is incompatible with it. A well-known type of counterconditioning is systematic desensitization , which counteracts the anxiety connected with a particular behavior or situation by inducing a relaxed response to it instead. This method is often used in the treatment of people who are afraid of flying.
Because cognitive-behavioral therapy is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in CBT should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist's professional credentials, his/her approach to treatment, and other relevant issues.
In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.
Because cognitive-behavioral therapy is employed for such a broad spectrum of illnesses, and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. However, several studies have indicated that CBT:
- may reduce the rate of rehospitalization and improve social and occupational functioning for bipolar disorder patients, when combined with pharmacotherapy (treatment with medication)
- is an effective treatment for patients with bulimia nervosa
- can help generalized anxiety patients manage their worry, when combined with relaxation exercises
- is helpful in treating hypochondriasis
- may be effective for treating depression, especially when combined with pharmacotherapy, and may also prevent depression in at-risk children
- is one of the first-line treatments for obsessive-compulsive disorder
- that focuses on education and provides some exposure and coping skills is effective for treating panic disorder without agoraphobia
- is effective for helping to treat insomnia, and its effects may be sustained longer than the effects of medications alone
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Craighead, Linda W. Cognitive and Behavioral Interventions: An Empirical Approach to Mental Health Problems. Boston: Allyn and Bacon, 1994.
Nathan, Peter E., and Jack M. Gorman. A Guide to Treatments that Work. 2nd edition. New York: Oxford University Press, 2002.
Weishaar, Marjorie. "Cognitive Therapy." In Encyclopedia of Mental Health, edited by Howard S. Friedman. San Diego, CA: Academic Press, 1998.
Wolpe, Joseph. The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, 1996.
Paula Ford-Martin, M.A.