Cognitive Behavior Therapy (CBT)

Article Author:
Suma Chand
Article Editor:
Martin Huecker
Updated:
1/19/2019 3:32:34 PM
PubMed Link:
Cognitive Behavior Therapy (CBT)

Introduction

In the 1960s, Aaron Beck developed cognitive behavior therapy (CBT) or cognitive therapy. Since then, it has been extensively researched and found to be effective in a large number of outcome studies for some psychiatric disorders including depression, anxiety disorders, eating disorders, substance abuse, and personality disorders. It also has been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. CBT has been adapted and studied for children, adolescents, adults, couples, and families. Its efficacy also has been established in the treatment of non-psychiatric disorders such as irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, insomnia, migraines, and other chronic pain conditions.

Issues of Concern

Origins of Cognitive Behavior Therapy

The idea for developing this form of psychotherapy took root when Aaron Beck began to notice that his patients with depression often verbalized thoughts that were lacking in validity and noted characteristic "cognitive distortions" in their thinking. His empirical observations led him to start viewing depression not so much as a mood disorder but as a cognitive disorder. Based on his clinical observations and empirical findings Beck outlined a new cognitive theory of depression. He published Cognitive Therapy for Depression (Beck, Rush, Shaw, and Emery, 1979) after having published a study that evaluated and demonstrated the efficacy of cognitive therapy. The combination of a detailed treatment protocol manual with outcome research was an innovation in psychotherapy practice that had only previously been attempted by behavior therapists in treating discrete behavioral problems. By accomplishing the same feat with a more complex set of clinical interventions that included cognitive, emotional, and behavioral components, Beck pioneered a model for what psychologists many years later defined as an “empirically validated psychological treatment.”

Other clinicians and researchers became interested and began developing CBT treatment protocols and evaluating their efficacy. Specific treatment protocols were developed for some psychiatric disorders. As behavioral strategies were incorporated, the term cognitive therapy changed to cognitive behavior therapy. Today CBT is the most extensively researched of all psychotherapies with several evidence-based treatment protocols.

Cognitive Model

CBT is based on a straightforward, common sense model of the relationships among cognition, emotion, and behavior.

Three aspects of cognition are emphasized:

  1. Automatic thoughts 
  2. Cognitive distortions
  3. Underlying beliefs or schemas

Automatic Thoughts

An individual’s immediate, unpremeditated interpretations of events are referred to as automatic thoughts. Automatic thoughts shape both the individual’s emotions and their actions in response to events. For example, a friend may cross you in the hallway and not say hello to you. If you were to have an automatic thought of "he hates me," or "I have done something to anger him," it is likely to impact your mood and cause you to feel upset and also to behave in an avoidant manner when you see him next. On the other hand, if you had the automatic thought "he is in a hurry," you would not be too concerned, and you would not be avoidant when you were to see him next.

CBT is based on the observation that dysfunctional automatic thoughts that are exaggerated, distorted, mistaken or unrealistic in other ways play a major role in psychopathology.

Cognitive Distortions

Errors in logic are quite prevalent in patients with psychological disorders. They lead individuals to erroneous conclusions. Below are some cognitive distortions that are commonly seen in individuals with psychopathology:

  • Dichotomous thinking: Things are seen regarding two mutually exclusive categories with no shades of gray in between
  • Overgeneralization: Taking isolated cases and using them to make wide generalizations
  • Selective abstraction: Focusing exclusively on certain, usually negative or upsetting, aspects of something while ignoring the rest
  • Disqualifying the positive: Positive experiences that conflict with the individual’s negative views are discounted
  • Mind reading: Assuming the thoughts and intentions of others
  • Fortune telling: Predicting how things will turn out before they happen
  • Minimization: Positive characteristics or experiences are treated as real but insignificant
  • Catastrophizing: Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is really just uncomfortable
  • Emotional reasoning: Making decisions and arguments based on how you feel rather than objective reality
  • “Should” statements: Concentrating on what you think "should" or “ought to be” rather than the actual situation you are faced with or having rigid rules which you always apply no matter the circumstances
  • Personalization, blame, or attribution: Assuming you are completely or directly responsible for a negative outcome. When applied to others consistently, blame is the distortion

Underlying Beliefs

Underlying beliefs shape the perception and interpretation of events. Belief systems or schemas take shape as we go through life experiences. They are defined as templates or rules for information processing that underlie the most superficial layer of automatic thoughts. Beliefs are understood at two levels in CBT:

Core Beliefs

  • The central ideas about self and the world
  • The most fundamental level of belief
  • They are global, rigid, and overgeneralized

Examples of dysfunctional core beliefs: 

  • “I am unlovable.”
  • “I am inadequate.”
  • “The world is a hostile and dangerous place.” 

Intermediate Beliefs

  • Consist of assumptions, attitudes, and rules
  • Influenced in their development by the core beliefs

Examples of dysfunctional intermediate beliefs:

  • “To be accepted, I should always please others.”
  • “I should be excellent at everything I do to be considered adequate.”
  • “It is best to have as little as possible to do with people.”

Clinical Significance

Cognitive behavior therapy is a structured, didactic, and goal-oriented form of therapy. The approach is hands-on and practical wherein the therapist and patient work in a collaborative manner with the goal being that of modifying patterns of thinking and behavior to bring about a beneficial change in the patient's mood and way of living his/her life. It is used to help a wide range of problems, and appropriate treatment protocols are applied depending on the diagnosis and problems the patient is facing.

Most psychotherapists who practice CBT personalize and customize the therapy to the specific needs of each patient.

The first step is an assessment of the patient and the initiation of developing an individualized conceptualization of him/her. The conceptualization based on the CBT model is built from session to session and is shared with the patient at an appropriate time later in therapy. The approach to therapy is explained very early at the start of the therapy. The problems patient would like to work on in therapy, and goals for therapy are decided in the first or second session collaboratively. The prioritized problems are worked on first.

The structure of each session:

The session always starts with a brief update and check on mood. This is followed by a bridging from the previous session to establish continuity. The agenda of what will be talked about in the session is set up collaboratively, and the homework the patient had to do between the sessions is reviewed before plunging into talking about any problem. Issues on the agenda are talked about punctuated with feedback and summaries. The session ends with setting up further homework and a final summary.


References

A DILEMMA-FOCUSED INTERVENTION FOR DEPRESSION: A MULTICENTER, RANDOMIZED CONTROLLED TRIAL WITH A 3-MONTH FOLLOW-UP., Feixas G,Bados A,García-Grau E,Paz C,Montesano A,Compañ V,Salla M,Aguilera M,Trujillo A,Cañete J,Medeiros-Ferreira L,Soriano J,Ibarra M,Medina JC,Ortíz E,Lana F,, Depression and anxiety, 2016 Apr 22     [PubMed PMID: 27103215]
Drinking to cope with negative emotions moderates alcohol use disorder treatment response in patients with co-occurring anxiety disorder., Anker JJ,Kushner MG,Thuras P,Menk J,Unruh AS,, Drug and alcohol dependence, 2016 Feb 1     [PubMed PMID: 26718394]
Cognitive Behavioral Therapy for Anorexia Nervosa: An Update., Dalle Grave R,El Ghoch M,Sartirana M,Calugi S,, Current psychiatry reports, 2016 Jan     [PubMed PMID: 26689208]
Medication and psychotherapy in eating disorders: is there a gap between research and practice?, Cooper M,Kelland H,, Journal of eating disorders, 2015     [PubMed PMID: 26629344]
College Students' Perceptions of Depressed Mood: Exploring Accuracy and Associations., Geisner IM,Kirk JL,Mittmann AJ,Kilmer JR,Larimer ME,, Professional psychology, research and practice, 2015 Oct     [PubMed PMID: 26500389]
Mexican American women's perspectives on a culturally adapted cognitive-behavioral therapy guided self-help program for binge eating., Shea M,Cachelin FM,Gutierrez G,Wang S,Phimphasone P,, Psychological services, 2016 Feb     [PubMed PMID: 26462112]
Contemporary Cognitive Behavior Therapy: A Review of Theory, History, and Evidence., Thoma N,Pilecki B,McKay D,, Psychodynamic psychiatry, 2015 Sep     [PubMed PMID: 26301761]
Aging and the effects of emotion on cognition: Implications for psychological interventions for depression and anxiety., Knight BG,Durbin K,, PsyCh journal, 2015 Mar     [PubMed PMID: 26263526]
Multiple traces or Fuzzy Traces? Converging evidence for applications of modern cognitive theory to psychotherapy., Reyna VF,Landa Y,, The Behavioral and brain sciences, 2015     [PubMed PMID: 26050686]
Trajectories of change in youth anxiety during cognitive-behavior therapy., Peris TS,Compton SN,Kendall PC,Birmaher B,Sherrill J,March J,Gosch E,Ginsburg G,Rynn M,McCracken JT,Keeton CP,Sakolsky D,Suveg C,Aschenbrand S,Almirall D,Iyengar S,Walkup JT,Albano AM,Piacentini J,, Journal of consulting and clinical psychology, 2015 Apr     [PubMed PMID: 25486372]
Can cognitive behaviour therapy be beneficial for heart failure patients?, Lundgren J,Andersson G,Johansson P,, Current heart failure reports, 2015 Apr     [PubMed PMID: 25475179]
Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice., Carroll KM,, Annals of the New York Academy of Sciences, 2014 Oct     [PubMed PMID: 25204847]
Exploring mechanisms of change: the relationships between cognitions, symptoms, and quality of life over the course of group cognitive-behaviour therapy., Oei TP,McAlinden NM,Cruwys T,, Journal of affective disorders, 2014 Oct     [PubMed PMID: 25038294]
Randomized trial of telephone-delivered acceptance and commitment therapy versus cognitive behavioral therapy for smoking cessation: a pilot study., Bricker JB,Bush T,Zbikowski SM,Mercer LD,Heffner JL,, Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 2014 Nov     [PubMed PMID: 24935757]
A non-linear dynamical approach to belief revision in cognitive behavioral therapy., Kronemyer D,Bystritsky A,, Frontiers in computational neuroscience, 2014     [PubMed PMID: 24860491]
Reflections on the theory-practice gap in cognitive behavior therapy., Reese HE,Rosenfield E,Wilhelm S,, Behavior therapy, 2013 Dec     [PubMed PMID: 24094786]