Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures. The name refers to behavior therapy, cognitive therapy, and to therapy based upon a combination of basic behavioral and cognitive principles and research. Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought. CBT is "problem focused" (undertaken for specific problems) and "action oriented" (therapist tries to assist the client in selecting specific strategies to help address those problems).
CBT was primarily developed through an integration of behavior therapy (the term "behavior modification" appears to have been first used by Edward Thorndike) with cognitive psychology research, first by Donald Meichenbaum and several other authors with the label of cognitive behavior modification in the late 1970s. This tradition thereafter merged with earlier work of a few clinicians, labeled as Cognitive Therapy (CT), developed by Aaron Beck, and Rational Emotive Therapy (RET) developed by Albert Ellis. While rooted in rather different theories, these two traditions have been characterised by a constant reference to experimental research to test hypotheses, both at clinical and basic level. Common features of CBT procedures are the focus on the "here and now", a directive or guidance role of the therapist, a structuring of the psychotherapy sessions and path, and on alleviating both symptoms and patients' vulnerability.
Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in affect and behavior, but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself. Therapists or computer-based programs use CBT techniques to help individuals challenge their patterns and beliefs and replace "errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior"  or to take a more open, mindful, and aware posture toward them so as to diminish their impact. Mainstream CBT helps individuals replace "maladaptive… coping skills, cognitions, emotions and behaviors with more adaptive ones", by challenging an individual's way of thinking and the way that he/she reacts to certain habits or behaviors, but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.
The reconceptualization phase makes up much of the "cognitive" portion of CBT. A summary of modern CBT approaches is given by Hofmann.
There are different protocols for delivering cognitive behavioral therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting". Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivoexposure therapy). Interventions such as imaginal exposure therapy combine both approaches.
CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioral problems. A systematic review of CBT in depression and anxiety disorders concluded that "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."
Martinez-Devesa et al (2010) found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Turner et al (2007) found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care, and Smedslund et al (2007) found that it was not helpful in treating men who abuse their intimate partners.
In the case of metastatic breast cancer, Edwards et al (2008) maintained that the current body of evidence is not sufficient to rule out the possibility that psychological interventions may cause harm to women with this advanced neoplasm.
CBT has been shown to be efficacious in the treatment of adult anxiety disorders.
A basic concept in some CBT treatments used in anxiety disorders is in vivoexposure, a term describing a technique where the patient is gradually exposed to the actual, feared stimulus. The treatment is based on the theory that the fear response has been classically conditioned, and that avoidance of it negatively reinforces and maintains the fear. This "two-factor" model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this harmful conditioning can be "unlearned" (referred to as extinction and habituation).
Schizophrenia, psychosis and mood disorders
Cognitive behavioral therapy has been shown as an effective treatment for clinical depression. 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. One etiological theory of depression is Aaron T. 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 schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations.
Beck also described a negative cognitive triad, made up of the negative schemata and cognitive biases of the person, theorizing 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. Beck further 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.
In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses. Several meta-analyses have shown CBT to be effective in schizophrenia, 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.
A 2010 meta-analysis found that no trial employing both blinding and psychological placebo has shown CBT to be effective in either schizophrenia or bipolar disorder, and that the effect size of CBT was small in major depressive disorder. They also found a lack of evidence to conclude that CBT was effective in preventing relapses in bipolar disorder. Evidence that severe depression is mitigated by CBT is also lacking, with anti-depressant medications still viewed as significantly more effective than CBT, although success with CBT for depression was observed beginning in the 1990s.
According to Cox, Abramson, Devine, and Hollon (2012), cognitive behavioral therapy can also be used to reduce prejudice towards others. This other-directed prejudice can cause depression in the "others," or in the self when a person becomes part of a group he or she previously had prejudice towards (i.e. deprejudice). "Devine and colleagues (2012) developed a successful Prejudice Perpetrator intervention with many conceptual parallels to CBT. Like CBT, their intervention taught Sources to be aware of their automative thoughts and to intentionally deploy a variety of cognitive techniques against automatic stereotyping."
Cognitive Behavioral Therapy with older adults
CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age. Some of the challenges to CBT because of age include the following:
The Cohort Effect
The times that each generation lives through partially shape its thought processes as well as values, so a 70-year-old may react to the therapy very differently from a 30-year-old, because of the different culture in which they were brought up. A tie-in to this effect is that each generation has to interact with one another, and the differing values clashing with one another may make the therapy more difficult.
By the time one reaches old age, the person has a definitive idea of her or his role in life and is invested in that role. This social role can dominate who the person thinks he or she is and may make it difficult to adapt to the changes required in CBT.
Mentality toward Aging
If the older individual sees aging itself as a negative this can exacerbate whatever malady the therapy is trying to help (depression and anxiety for example). Negative stereotypes and prejudice against the elderly cause depression as the stereotypes become self-relevant.
Processing Speed Decreases
As we age, we take longer to learn new information, and as a result may take more time to learn and retain the cognitive therapy. Therefore, therapists should slow down the pacing of the therapy and use any tools both written and verbal that will improve the retention of the cognitive behavioral therapy.
Methods of access
A typical CBT programme would consist of face-to-face sessions between patient and therapist, made up of 6-18 sessions of around an hour each with a gap of a 1–3 weeks between sessions. This initial programme might be followed by some booster sessions, for instance after one month and three months. CBT has also been found to be effective if patient and therapist type in real time to each other over computer links.
Cognitive behavioral therapy is most closely allied with the scientist–practitioner model in which clinical practice and research is informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and in the attainment of goals. These are often met through "homework" assignments in which the patient and the therapist work together to craft an assignment to complete before the next session. The completion of these assignments – which can be as simple as a person suffering from depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change. The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment. Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance. Unlike many other forms of psychotherapy, the patient is very involved in CBT. For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first. The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.
Computerized Cognitive Behavioral Therapy (CCBT) has been described by NICE 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 human therapist. CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist.
CCBT completion rates and treatment efficacy have been found in some studies to be higher when use of CCBT is prescribed and supported, than when use is in a self-help form without medical professional involvement.
In February 2006 NICE 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, and CCBT is made available by some health systems. The 2009 NICE guideline recognized that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product.
A relatively new avenue of research is the combination of artificial intelligence and CCBT. It has been proposed to use modern technology to create CCBT that simulates face-to-face therapy. This might be achieved in cognitive behaviour therapy for a specific disorders using the comprehensive domain knowledge of CBT. One area where this has been attempted, is the specific domain area of social anxiety in those who stutter.
Reading self-help materials
Enabling patients to read self-help CBT guides has been shown to be effective by some studies. However one study found a negative effect in patients who tended to ruminate, and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional).
Group educational course
Patient participation in group courses has been shown to be effective.
Brief Cognitive Behavioral Therapy
Brief Cognitive Behavioral Therapy (BCBT) is a form of Cognitive Behavioral Therapy (CBT) which has been developed for situations in which there are time constraints on the therapy sessions. BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed on soldiers overseas in active duty by David M. Rudd to prevent suicide.
Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care, nor was it helpful in treating men who abuse their intimate partners.
Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression. However, psychodynamic therapy may provide better long-term outcomes.
Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children, as well as insomnia. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety and insomnia.
Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners. However evidence supports the effectiveness of CBT for anxiety and depression.
Mounting evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.
The basic concept of CBT that negative cognitions are the cause of Major Depressive Disorder (MDD) is the only instance in all of medicine and psychiatry where a symptom of an illness is also construed to be the cause in spite of this proposition as yet to be unproved.
A number of methodological issues have been raised with the clinical studies on the effectiveness of CBT.
A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.
The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in. Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.
The element of hope and expectation on the part of the patients to get better in non-blinded trials will bias the results in favor of CBT. The informed consent procedure required to enter a psychotherapy trial biases the subjects who enter to those that are favorably inclined to the psychotherapy. Taken together, trials using psychotherapy do not meet the qualifications of high quality evidence.
Use in prevention of mental illness
For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes. In another study 3% of the group receiving the CBT intervention developed GAD by 12 months postintervention compared with 14% in the control group. Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT. Use of CBT was found to significantly reduce social anxiety prevalence.
For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older. Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles. A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.
For schizophrenia, one study of preventative CBT showed a positive effect and another showed neutral effect.
Behavior therapy roots
Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Aaron T. 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. Behaviorally-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones' work on the unlearning of fears in children. In 1937, American psychiatrist Abraham Low developed cognitive training techniques for patient aftercare following psychiatric hospitalization.
It was during the period 1950 to 1970 that behavioral therapy became widely utilized by 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",[page needed] 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 on 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 of these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Albert Ellis' 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).[page needed] 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. He named these cognitions "automatic thoughts" because he believed that people were not necessarily aware that the cognitions existed, but that they could identify these types of thoughts when questioned closely. Beck believed that pushing his clients to identify these automatic thoughts was integral to overcoming a particular difficulty.
In initial studies, cognitive therapy 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.
Society and culture
The UK's National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense as part of an initiative called Improving Access to Psychological Therapies (IAPT).NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed. Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels 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 ... Everyone has been seduced by CBT's apparent cheapness." The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT's policies were undermining traditional psychotherapy and criticized proposals that would limit some approved therapies to CBT, claiming that they restricted patients to "a watered down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff".
NICE also recommends offering CBT to all people with schizophrenia.
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