In the 1930s to the 1960s, the field of psychosomatic medicine dominated the application of psychological theory and intervention to health-related problems. Psychosomatic medicine practitioners, guided by psychoanalytic or psychodynamic theory, conceptualized and treated patients with various stress-related diseases or whose behavior contributed to their illnesses. At the same time, basic research on learning principles flourished in psychology laboratories, which led to behavior change strategies that were applied to humans. In addition, psychodynamic theory and therapy evolved by increasingly emphasizing the rational, conscious aspects of people (the “ego”). Furthermore, by the 1970s, health practitioners realized the limitations of the biomedical model for people with chronic pain and other chronic conditions, people whose lifestyle caused their illness, or people with physical symptoms related to stress. Both patients and providers sought interventions for these problems that were briefer, more effective, and more acceptable to a wide variety of people than were currently available. Thus, by the late 1970s, behavior therapy, and subsequently cognitive-behavioral therapy (CBT), replaced psychosomatic medicine as the dominant model of theory and intervention among health psychologists, many of whom aligned with the new field of behavioral medicine.
Theoretical Foundations of Cognitive-Behavioral Therapy
Cognitive-behavioral therapy has its theoretical foundations in classical conditioning, operant conditioning, social learning, and research on cognitive processes. Generally, classical and operant conditioning view behavior as a response to environmental stimuli and consequences. At its simplest, classical conditioning occurs when a neutral environmental stimulus is repeatedly paired with a biologically relevant stimulus that automatically elicits an unlearned, biological response, resulting in the neutral stimulus acquiring the ability to elicit the biological response. Operant conditioning occurs when environmental consequences increase or decrease the frequency of previous behavior and when antecedent stimuli signal the likelihood of those consequences. These two types of learning were studied initially in animals, and the application of their principles to improve human functioning—behavior therapy—emphasized that behavior change follows from changes in the environment. Thus, a primary focus of behavior therapy is a systematic examination and modification of the environment to alter a person’s behavior in a desired direction.
The rise of social learning theory in the 1960s, which emphasized modeling or observation and verbal instruction, shifted the research focus from animals to humans and introduced cognition into learning theory. Various cognitive models of human behavior subsequently flourished, and cognitive research established the value of beliefs, appraisals, and attributions as intervening variables between environmental stimuli and behavioral responses. CBT strategies derived, in part, from these cognitive models and from other influences (e.g., covert conditioning, ego psychology). Cognitive strategies emphasize that changes in behavior, symptoms, and moods follow cognitive change.
Basic Principles of Cognitive-Behavioral Therapy
Several principles distinguish CBT from other forms of psychotherapy. First, CBT views problematic behavior as fundamentally learned via interaction with the environment; therefore, undesired behavior can be unlearned, and desired behavior, such as new skills, can be learned. Although factors other than a person’s learning history are acknowledged (e.g., genetics or socioeconomic forces), CBT maintains the rather optimistic attitude that behavior is generally malleable by creating changes in learning experiences. Second, CBT is guided by the principle of parsimony to prioritize its explanations of problems, its clinical targets, and its interventions. According to this principle, the most straightforward and least inferential explanations, problems, and treatments are considered first, whereas more complex or inferential explanations and treatments are considered only if initial approaches prove insufficient. Thus, CBT typically avoids explanations that are difficult to verify (e.g., involving unconscious psychodynamic processes), targets of change that are broad or pervasive (e.g., personality), and interventions that are indirect or overly general (e.g., interpretations). Third, CBT bases it approach on the cumulative body of scientific psychological knowledge as opposed to other sources of knowledge such as personal intuition, clinical experience, persuasive leaders, or tradition. This scientific attitude also is manifest in clinical work with individual cases. In administering CBT, one first generates hypotheses about the factors influencing the problem behavior and then tests these hypotheses by using targeted interventions, followed by an assessment of change. In this way, hypotheses about behavior can be supported if change occurs as expected or refuted if change does not occur, which leads to alternative hypotheses and interventions.
Specific Therapeutic Strategies
There is a plethora of CBT approaches for health-related problems, and many of these strategies have direct links to the various theories noted previously. Classical conditioning has given rise to procedures designed to alter the responses of the body. For example, exposure-based strategies (e.g., systematic desensitization, flooding, and response prevention) present clients with stimuli that elicit negative emotions or bodily reactions in order to extinguish or habituate these reactions. Operant theory has given rise to stimulus control, in which the eliciting stimuli for behavior are changed, and to contingency management, in which environmental consequences are altered. Other popular CBT strategies are various arousal reduction techniques, particularly relaxation training and related approaches (biofeedback, meditation, breathing retraining). Social learning theory has encouraged interventions in which clients learn complex behaviors, particularly interpersonal behavior, including assertiveness training, which incorporates modeling, role playing, practice, and feedback. Cognitive therapy approaches take advantage of the powerful capacity of cognitive processes. Thus, education and information provision are used to increase predictability and control in stressful situations. Mental control techniques such as thought stopping, distraction, or imagery are also used to control emotions. More importantly, however, cognitive therapy generally views most dysfunctional behavior, moods, and symptoms as resulting from beliefs or thinking patterns that are inflexible, erroneous, overly narrow, or otherwise distorted. Cognitive restructuring identifies the underlying beliefs that support the dysfunctional behavior and attempts to change those beliefs by using logical analysis, rational persuasion, and clinical experimentation.
In CBT practice, therapist and client collaborate to change the clients environment, help the client learn new skills, and modify the client s thinking patterns. Sessions tend to be structured and didactic, various techniques are taught and practiced, homework between sessions is routinely prescribed, and changes in the target problem are tracked over time. There is an emphasis on self-management or self-control procedures, in which clients are encouraged to make changes and apply the skills in their daily lives. This focused and direct intervention approach typically is shorter in duration than most other psychotherapeutic approaches, and much research has demonstrated its efficacy with many health-related problems.
Applications to Health Psychology Problems
Numerous problems encountered by health psychologists have been conceptualized in cognitive-behavioral terms and effectively treated using CBT strategies. For some clinical problems, a single strategy is useful. For example, by changing environmental contingencies, some unhealthy behaviors (medication non-adherence, excessive sun exposure) can be reduced, and some adaptive behaviors (e.g., exercise, nutritious eating) can be increased. Problems that have strong negative emotional components (e.g., panic disorder and its medically relevant variants, blood and needle phobia, conditioned nausea and vomiting, and posttraumatic stress) can be redressed with conditioning or exposure-based interventions. Relaxation strategies are efficacious for many psychophysiologic or stress-related health problems such as hypertension, irritable bowel syndrome, and headaches. Education or information provision helps to prepare children for stressful medical procedures such as anesthesia induction.
Yet, most health psychology problems are multifaceted and require several CBT intervention strategies and a greater focus on cognitive change. For example, addictive behaviors, including smoking, alcohol abuse or dependence, and obesity-related behaviors (diet and exercise) are complex, and CBT treatment protocols usually incorporate several strategies, including stimulus control and contingency management, cognitive restructuring, problem solving, and relapse prevention. An empirically supported approach to chronic pain is coping skills training, which includes education in pain mechanisms, relaxation training, self-reinforcement via pleasant activity scheduling, substituting positive self-statements for negative thoughts, and problem solving. Depression, which is relatively common in medical patients, is often treated not only with cognitive therapy, but also by behavioral activation, increasing pleasant activities, and even modeling and assertiveness training. A leading CBT approach to decreasing hostility in people at risk for coronary events prescribes 17 strategies including rational analysis, relaxation, distraction, thought stopping, assertiveness, intimacy development, humor, and forgiveness exercises. Although all of these clinical problems could be conceptualized in a more complex fashion (e.g., in psychodynamic terms), CBT focuses on relearning in the most direct and efficient manner possible. This “skills” approach is particularly attractive to many medical patients, who may avoid more traditional psychological explanations and approaches.
The Future of Cognitive-Behavioral Therapy
CBT is not static, but continues to evolve, both conceptually and pragmatically. For example, there is increasing agreement that a limited number of common mechanisms or change factors likely underlie the myriad of CBT technical procedures. Leading candidates include exposure to avoided stimuli, increases in self-efficacy, and coping skills. Further, as limitations of CBT are recognized and alternative approaches are validated, the repertoire of acceptable interventions broadens.
For example, biological factors are increasingly recognized as vital to addictive behaviors, and pharmacologic treatments are being integrated into CBT models to yield “biobehavioral” interventions. Practitioners of CBT are increasingly viewing emotional factors as potentially useful and adaptive components of behavior change, and techniques such as emotional disclosure and emotional processing are making inroads into CBT. It is expected that CBT will continue to evolve into an integrated, empirically supported set of interventions that, ideally, are matched to particular clients and specific problems.
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