Cognitive-Behavioral Therapy

Cognitive-behavioral therapy derives from the research protocols of hundreds of active scholars focused on a wide array of specific clinical problems. They cumulatively conclude that dysfunctional human behavior is caused or at least accompanied by irrational thinking and behavioral skill deficits; thus treatments focused on producing more reasonable thought patterns and personal-social coping skills provide the most efficient solution.

To be sure, the etiology of all human disturbances may someday be traced to biological defects, but currently such views are long on theory and short on data. Moreover, even when a pharmacological intervention may be warranted, the incremental benefits of cognitive-behavioral therapy are generally conceded.

At the core of cognitive-behavioral therapy lies the concept that people’s interpretations of experiences are beliefs rather than facts, and as such, they may be accurate, rational, or irrational to varying degrees. The focus of cognitive-behavioral treatment rests on identifying and directly altering cognitions and behaviors that maintain a pattern of distress, rather than on probing into early developmental factors that may have set the stage for these cognitions and behaviors. Thus, cognitive-behavioral therapies clearly differ from the traditional psychodynamic and insight-driven psychotherapies that preceded them.

More specifically, cognitive behavior therapists posit: (a) an internal cognitive process, or “thinking,” directly influences behavior; (b) this cognitive activity may be monitored and altered; and (c) desired behavior change may be mediated through a process of cognitive change. Thus external situations do not ultimately determine individuals’ emotions or behavior, but rather their interpretations of those situations dictate their feelings and actions. An identical event may trigger disparate views among a group of individuals, leading to dramatically different emotions and behavior. For example, two students may receive the same low score on an exam. One student interprets this event as a sign that he or she is insufficiently bright and feels a sense of failure, perhaps even contemplates a career change. The other student attributes the low grade to an unfair level of test difficulty, and feels only resentment toward the instructor. Thus, depending on how an event is interpreted and evaluated, the same external experience may lead to a wide range of eventual emotions and behaviors.

Cognitive-behavioral therapy encompasses a wide array of techniques and strategies. Cognitive-behavioral therapists argue that individuals respond to cognitive representations of environmental events rather than to the events themselves, so their interventions focus on the intricate yet functional interrelationships among cognitions, emotions, and behaviors. Although cognitive-behavioral therapy is empirically grounded and based on a manual of effective interventions, it is not a rigid approach to psychotherapy. When optimally employed, cognitive-behavioral therapy is a pragmatic and flexible process that may be tailored to the presenting needs of each client. From its origins in behavior therapy and cognitive learning science, cognitive-behavioral therapy continues to emerge as an efficient set of tools for aiding clients as they address the specific challenges of everyday life.

Historical and Theoretical Underpinnings of Cognitive-Behavioral Therapy

The origins of cognitive-behavioral therapy can be traced to movements in the 1950s and 1960s within the existing fields of cognitive psychology and behavioral science. Growing dissatisfaction with traditional psychoanalysis and a heightened interest in learning theory led to a notable rise in behaviorally oriented therapies during the 1950s. Fortified by an arsenal of empirical findings, behavior therapy became an established mode of treatment that included techniques based on classical, operant, and observational learning.

However, by the late 1960s, discontent with strict tenets of behaviorism began to appear, even among those with behavioral proclivities. Initial attempts to include “thinking” behaviors aped the existing paradigms for modifying observable behaviors: Coverant (a contraction of covert operant) control, covert sensitization, and covert modeling, for example, all focused on increasing or decreasing specific thoughts, images, and feelings deemed desirable or problematic. When Albert Ellis, Donald Meichenbaum, and Aaron T. Beck all began writing about the treatment of chronically and severely distressed individuals through cognitive approaches, the tide turned from behaviorism to cognitive therapies. Researchers demonstrated the effectiveness of cognitive therapy through tightly controlled outcome studies using random assignment and placebo controls. Soon cognitive explanations for learning-based phenomena began to be blended with the once-dominant paradigm of behaviorism, and cognitive-behavioral theories were born.

Researchers in the 1970s and 1980s began to develop specific cognitive-behavioral protocols that included strategies from forms of both cognitive and behavioral treatments. During this period, cognitive-behavioral therapy (CBT) began to be used more frequently as a manner of structured treatment for a variety of client concerns. Examples of typical CBT protocols included manualized approaches to panic control, depression, anxiety, and specific phobias. Researchers and clinicians alike began reporting that cognitive factors could be viewed as a form of behavior and, therefore, could be manipulated using previously established conventional behavior therapies. For example, behavioral techniques such as modeling, reinforcement, and problem solving were reconceptualized as tools for implementing various cognitive strategies; they were also used to explore the viability of inferences. Additionally, the cognitive-behavioral therapies involved learning experiences that were designed to change cognitions in order for behavior to become more appropriate, and, eventually, facilitate social or emotional functioning. Mounting evidence continues to support the effectiveness of cognitive-behavioral therapy for certain psychological problems.

Basic Features of Cognitive-Behavioral Therapy

Although a variety of different models and interventions have been developed under the rubric of cognitive-behavioral therapy, all share certain features that are common to CBT.

Empirical Grounding

Cognitive-behavioral therapy grew out of a precedent set by radical behaviorism that established the strong empirical verification of all clinical procedures. Consequently, an empirical, hypothesis-testing approach is a trademark of modern cognitive-behavioral therapy. Literally hundreds of controlled clinical trials have been performed using CBT to address a wide range of problems, with the continued evaluation of specific, standardized cognitive-behavioral protocols a salient goal in the field.

Problem Focused and Goal Oriented

In simplest form, the cognitive-behavioral case conceptualization of client concerns envisions people seeking treatment for problems they want to solve and goals they hope to attain. The cognitive-behavioral therapist works with a client to identify these problems, prioritize which ones to address in therapy, and together develop a concrete means of measuring regular progress. The process of treatment is designed to alleviate the identified problem and to assist clients in accomplishing the goals they seek. For example, a primary treatment goal for an individual suffering from panic disorder might be eliminating the symptoms of panic; secondary goals may address modifying the client’s dysfunctional beliefs and thoughts so that episodes of panic will not emerge if multiple stressors accumulate in the future.

Time Limited

Cognitive-behavioral treatments are typically brief, ranging in duration from 6 to approximately 30 sessions. However, treatment rarely exceeds 7 or 8 months in total. Treatment approaches are often based on established CBT manuals that identify specific goals for each session while recommending various techniques to accomplish these goals. The time-limited approach of cognitive-behavioral therapy has contributed to its popularity, because third-party and managed care providers place challenging limits on billing for therapy yet require a solid justification for payment in brief psychotherapy treatment.

Collaborative

Cognitive-behavioral therapists actively collaborate with their clients, helping them solve acute problems and identify effective strategies for coping with challenges. The therapist and client communicate in a direct, straightforward manner to develop treatment goals and strategies. Discussion of problems takes place in a transparent style that highlights any conceptual steps underlying the tactics employed. Clients play an active role and contribute to the treatment process throughout the course of cognitive-behavioral therapy.

Action Oriented

Cognitive-behavioral therapies require clients to behave in new ways in order to alter maladaptive patterns of interpreting and interacting with their environments. Novel interventions and activities are developed and performed by the client both in session and beyond in an attempt to address and eventually modify dysfunctional distortions, behaviors, and beliefs.

Structured Homework Assignments

Consistent with the active, teaching role of the therapist, homework is an important component of cognitive-behavioral treatments. Homework may include such activities as practicing specific techniques (e.g., relaxation or breathing), conducting personal experiments, rehearsing behavioral skills, or completing cognitive journals and assessments. Homework is viewed as a structured mechanism for both learning and rehearsing new skills and behaviors that require consistent practice for mastery. Homework is a cornerstone of the action-oriented approach epitomized by many cognitive-behavioral interventions.

Directive Role of Therapist

Under CBT protocols, the therapist provides active, direct assistance to clients who must confront problems they feel unable to address on their own. Irrational thoughts and cognitions are confronted by an active cognitive-behavioral therapist, who often argues the logic of these beliefs through various exercises aimed at fostering change. A therapist may also employ active modeling, role-playing, and other corrective interpretation strategies when working with a particular client. Although the process of cognitive-behavioral therapy is ultimately collaborative in nature, the therapist plays an active and directive role in many exchanges that take place in session.

Emphasis on the Present

Unlike its psychotherapeutic predecessors, cognitive-behavioral therapy is primarily focused on a client’s present-day concerns rather than mining through what has since passed. Although an understanding of the pathogenesis of problems may be helpful when considering optimal solutions to present-day concerns, the cognitive-behavioral therapist does not dwell on early etiological assertions of how problems may have developed in childhood. The CBT protocol most often addresses the cognitions and subsequent behaviors that are contributing to the client’s present dysfunction, rather than the pursuit of developmental insight.

Overview of Cognitive-Behavioral Therapies

Rational-Emotive Therapy

Ellis developed rational-emotive therapy in the 1950s in reaction to various aspects of traditional psychoanalysis. He proposed that irrational beliefs regarding the self and the world were cause for much suffering, including the expressions of psychopathology. Ellis identified cognitive processing errors that he described as irrational thoughts (e.g., “awfulizing,” believing “I must be perfect,” and jumping to conclusions). Rational-emotive therapy focuses on behavioral change, yet emphasizes cognitive persuasion and actively disputing irrational beliefs. An important contribution follows from the ABC model, wherein emotional consequences are thought to be caused by beliefs about unsettling events, not by the events themselves. These emotional consequences (C) are targeted for change by disputing the beliefs (B) about the situation (A). Ellis later moved away from a strictly cognitive approach, and his rational-emotive therapy evolved into rational emotive behavior therapy (REBT). Nonetheless, the central intervention of Ellis’s work remains the identification and disputation of irrational thoughts that are deemed responsible for an identified emotional upset. Therapy involves actively persuading the client to adopt more rational cognitions through modeling of appropriate thoughts, monitoring the content of existing thoughts, and developing an awareness of the frequency of irrational thoughts and their subsequent impact on emotions and behavior.

Cognitive Therapy

Aaron Beck has played a central role in the development of cognitive-behavioral therapy. Second only to Sigmund Freud in the number of citations to his work in the psychiatric literature, Beck published a cognitive theory of depression in the 1960s that has since grown to address anxiety, phobias, personality disorders, sub-stance abuse, suicide, bipolar disorder, and other specific psychological problems. Beck identified a collection of faulty mental processing mechanisms to which humans are susceptible. These cognitive distortions include all-or-nothing thinking, overgeneralization, negative prediction, arbitrary inference, and selective negative focusing. In working with clinical patients, Beck noted that depressed individuals experienced a set of negative thoughts about themselves, about the world around them, and regarding the future. He labeled this negative pattern the cognitive triad. Beck described these damaging thoughts as both omnipresent and automatic; so much so that the patient is unaware of his or her biased cognitive processing. Beck sought to elicit a client’s automatic thoughts through focused questioning and actively challenging dysfunctional attitudes. Beck also described schematic representations and beliefs that further create individuals’ characteristic interpretation of everyday events. In sum, Beck asserted that depression and other psychopathology is caused by automatic and negative thoughts, such as devaluing the self or viewing the future in a reliably pessimistic way.

Social Learning Theory

Albert Bandura was originally a behaviorist, but is most known for asserting the view that humans learn to fulfill their needs through active observation and evaluation of events, including social behavior. He alleged that individuals develop cognitive expectancies about what will happen in their environment, as well as beliefs about their own abilities to effectively perform tasks. Bandura’s social learning theory purports that external conditions, in conjunction with individuals’ thoughts about the situations, determine individuals’ behaviors and emotions. Bandura developed the principle of reciprocal determinism, which suggests that individuals not only are shaped by their environment but also act upon and impact the environment with an influence that is far from unidirectional. Additionally, social learning theory states that perceived reinforcers may be more reinforcing than actual reinforcers. Likewise, in social learning theory, direct reinforcement for performing a behavior is unnecessary for the behavior to occur, as observation of a modeled performance that incurs a positively evaluated reward is sufficient to create the behavior. Thus, in Bandura’s social learning theory, cognitive processes are responsible for mediating the relationship between behavioral reinforcers and personal response.

Stress Inoculation Training

Stress inoculation training (SIT) was popularized by Meichenbaum as a psychotherapeutic analogy to vaccination against a disease. SIT utilizes many of the specific cognitive-behavioral therapies previously described. It prepares clients for dealing with demanding future events by providing instruction in applying coping skills at gradually increasing levels of stress. Augmenting clients’ repertoire of coping responses to milder stressors is intended to build their skills and confidence when handling more severe levels of stress. The three phases of SIT involve education about the clinical problem, coping skills training, and exposure to simulated stressors. Clients are initially exposed to low levels of stressful situations through imagery techniques, and gradually practice coping skills with the stressful events encountered in daily life.

Problem-Solving Therapy and Decision-Making Counseling

Problem-solving therapy rests upon the assumption that symptoms of psychopathology are inversely related to effective problem solving, and that training in problem-solving techniques may ameliorate many maladaptive behaviors. Thomas D’Zurilla and Marvin Goldfried outlined a model of efficient problem solving that relies upon teaching clients to specify and define the problems in their lives, to generate possible solutions, and to implement those solutions judged best. Clients are trained to self-monitor their cognitive processes and to evaluate their choices and behaviors. One key component of problem solving involves the process of decision making. Decision-making counseling targets a number of tools for the collaborative generating of alternatives, gauging their relative utility, estimating probabilities of likely effects, and so forth. The literatures of problem solving and decision making overlap considerably, and some authors use the terms interchangeably. They may perhaps be distinguished in that problem solving focuses on discovering the single solution, whereas decision making weighs the trade-offs of competing alternatives.

Overall, the literature of problem-solving therapy asserts that at least one source of individual distress is a deficiency in ordinary problem-solving skills. Fundamentally, some form of problem solving is involved in any approach to psychotherapy.

Cognitive-Behavioral Therapy Strategies and Techniques

Psychoeducation

Individuals who receive cognitive-behavioral counseling are typically provided with educational information to facilitate the process of working on their presenting problems. Psychoeducation involves teaching individuals the key tenets of cognitive-behavioral therapy, from defining and identifying negative thoughts to understanding the impact these cognitions have on emotions and behavior. Although psychoeducation takes place throughout the process of counseling, it is used most extensively during early sessions and may be supplemented with bibliotherapy (reading materials), videos, and other educational resources. For example, in treating an individual suffering from an eating disorder, psychoeducation would likely entail exposure not only to the CBT model, but also to supplemental information addressing proper nutrition, healthy diet, and the possible medical complications associated with restricting, binging, or purging. In addressing issues of panic or anxiety dysregulation, the therapist must explain to the client the normal, biological elements involved in the stress process. The content of cognitive-behavioral psychoeducation may take many forms depending on the client’s presenting concerns, but understanding the process of change is integral to the success of CBT.

Cognitive Restructuring

At its core, the methodology of cognitive-behavioral therapy involves identifying and changing maladaptive cognitive processes as they relate to problematic emotions and behavior. Cognitive restructuring entails teaching clients to become aware of their automatic negative thoughts, to evaluate the extent to which these thoughts are accurate or rational, and to replace irrational thoughts with more reasonable interpretations, evaluations, and assumptions. Clients are encouraged to systematically seek out and test the evidence upon which they base their predictions and views. Initially, the therapist may actively question the client’s beliefs in an attempt to uncover automatic thought processes. Various forms of self-monitoring are also utilized to aid clients in identifying, disputing, and acting against their own negative thoughts that lead to problems with depression, anxiety, anger, and other distressing psychological symptoms. Several strategies for challenging irrational thinking include examining previous experiences, exploring objective data, shifting perspectives and role playing, combating catastrophic or biased thinking, and becoming educated about relevant facts. The therapist may provide examples of more adaptive cognitive patterns while reinforcing the client’s constructive efforts to develop new sets of rational schema. Cognitive restructuring is a collection of techniques that attempt to loosen and modify a client’s biased perceptions in favor of more functional and constructive ways of viewing the self, the world, and the future.

Social and Communication Skills Training

Depending on the areas of identified deficit, cognitive-behavioral therapy may involve teaching clients specific strategies for increasing the efficiency of their social and relational behaviors. Modeling, practice, and performance of new skills, videotaping, and group exposure may be used to facilitate social skills training. For example, eye contact may be practiced and targeted for improvement, along with other assertiveness skills. Interpersonal conflicts may be role-played, and methods of approaching confrontation or boundary setting may be brainstormed and discussed collaboratively. Training in social and communication skills is generally considered an indispensable part of cognitive-behavioral therapy for treating social anxiety and marital distress. These strategies have also been employed when addressing depression, discontent, and conflict in a variety of interpersonal systems.

Behavior Rehearsal

Introduced by Arnold A. Lazarus in 1966, the term behavior rehearsal identified a specific procedure that sought to replace deficient or ineffective social and interpersonal responses with more adaptive behavioral patterns. The cognitive-behavioral therapist might play the role of some person(s) with whom the client is inhibited, under the assumption that through role-playing progress is made toward dealing with actual people and events. The therapist may also train the client to become knowledgeable about other stressful situations or fear-provoking objects, to plan coping skills and alternate behaviors, and to rehearse these new modes of expression. Lazarus equated being rehearsed with being prepared, both of which were associated with successful spontaneous effects and the genesis of change.

Imagery Rehearsal

Imagery rehearsal therapy is conceptualized as a therapeutic process that employs the human imagery system in an effort to change and rehearse new outcomes. The use of mental reproductions in an attempt to generate change is a current topic in cognitive-behavioral therapy. Imagery treatments are used in CBT to mentally rehearse behavioral alternatives that contribute to burgeoning coping skills. For instance, positive imagery may be practiced to aid with relaxation or anxiety-reduction techniques. The rehearsal of imagery also shows preliminary promise for the treatment of trauma symptoms and chronic nightmares in a variety of populations. Aspects of imagery rehearsal therapy include practicing imagery skills, selecting images for change, and manipulating or rearranging the visualization in an attempt to change the frightening thoughts into a preferred context. These new images are then rehearsed in a structured effort to enhance control of bothersome mental scenes.

Relaxation

Relaxation strategies are commonly used with disorders having a basis of arousal or anxiety, but training in relaxation also serves as an adjunct to facilitate other forms of cognitive-behavioral therapy. In the 1930s, Edmund Jacobson developed a method of deep relaxation that depended upon a series of muscular tension and release exercises. This technique, known as progressive muscle relaxation (PMR), involves moving through the major muscle groups of the body in a sequence of directed tension and relaxation. The client is instructed to notice the difference between tautness and release, and to develop awareness of the sensations of relaxation. Other common forms of relaxation training include breathing retraining, meditation, and guided imagery. Various approaches to relaxation may be combined in a simultaneous or sequential approach. The overarching goal of relaxation training is for the individual to enhance his or her awareness of unnecessary tension in the body, and to develop an ability to release it.

Flooding

The process of flooding involves prolonged exposure to stimuli that evoke strong levels of anxiety or fear. This technique differs from other forms of exposure-based anxiety reduction in that flooding begins with intense exposure to highly feared situations, where other procedures allow for gradual contact. Flooding entails systematic, prolonged, and repeated exposure to fear-evoking stimuli until the anxiety and fear associated with the situation have been reduced. Flooding may take place in vivo, where exposure is to an actual, tangible stimulus, or a mental representation may be used in a second technique called imaginal flooding. The latter intervention is employed when it is neither feasible nor practical to conduct in vivo flooding (e.g., a therapist may have great difficulties accessing the feared situation). Flooding has typically been conceptualized as a procedure for eliminating fear, anxiety, phobias, and panic. High levels of discomfort are invariably induced in the client, yet many therapists view extended exposure to feared yet harmless stimuli as important and even essential conditions for extinction of the fear response.

Systematic Desensitizatlon

Systematic desensitization is another exposure therapy that emphasizes less intense and more gradual contact with distressing stimuli. Developed by Joseph Wolpe, systematic desensitization aims to maintain clients in a nonanxious state during the process of graduated exposure. Wolpe adopted and streamlined the technique used in progressive muscle relaxation as a method of counterconditioning, what he termed neurotic anxiety response habits. The client collaborates with the therapist to develop a hierarchy of anxiety-producing situations. Then, the client is induced into a deeply relaxed state and presented with a series of gradually escalating anxiety-provoking images from the hierarchy. This hierarchy might include items such as hearing that someone vomited, watching a movie where a character vomits, seeing someone vomit in real life, feeling nauseated and needing to vomit oneself, and so on. These graded visualizations are then paired with relaxation procedures, and discomfort is addressed with self-calming. When certain thresholds of anxiety are experienced during the intervention, images are terminated and relaxed states reproduced. With continued systematic exposure, the client’s levels of fear and anxiety are said to progressively weaken until the client no longer experiences anxiety in response to the once aversive circumstances.

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