What is Cognitive Behavior Therapy ?
CBT is a class of interventions and techniques with wide application and demonstrated efficacy in treating many psychological disorders. By a wide margin, CBT has more evidence from well-controlled research showing that it works for specified disorders than any other treatment. For example, according to a review article in 2001 (Chambless & Ollendick, 2001), approximately 80% of the treatments for specific disorders (for both adults and children) characterized as having research support fall within the CBT class. Hence, CBT predominates among
empirically supported treatments (ESTs)
for particular disorders, a fact that helps the CBT therapist advocate for the importance of his or her treatment with potential clients, referral sources, and third-party payers.
CBT also offers a conceptual model that can be applied to a wide range of psychopathology symptoms. The content of the thinking errors or the nature of the maladaptive behaviors may vary from disorder to disorder, but the basic framework is the same. Once you have a strong basis in CBT in a given problem, you can fairly readily learn CBT approaches to many other problems via the study of treatment manuals, workshop attendance, and other modalities of continuing education.
Consider someone suffering from a psychological disorder or general psychological distress. Whatever the core etiology, one might conceptualize the individual's experience with respect to three things: emotions, cognitions, and behavior. For example:
- Individuals suffering from psychopathology often experience distressing emotions, such as fear, sadness, and anger, with too much frequency or intensity, and without the ability successfully to regulate or manage the affect.
- Individuals suffering from psychopathology may appraise their environments and themselves in ways that are not helpful or accurate (i.e., engage in distorted cognitive processes).
- Individuals suffering from psychopathology may also engage in unhelpful behaviors, such as excessive avoidance, confrontation, etc.
These three experiential elements affect, and are affected by, each other, often leading to vicious cycles of maladaptive experience. For example, the emotion of anxiety can trigger anxious thoughts and, similarly, these thoughts of impending disaster can trigger more feelings of anxiety. Consequently, given that these constructs are all linked to one another, one can intervene at different points in the cycle, and the choice of where to intercede (and the techniques associated with that choice) differs between various cognitive behavior therapies. We introduce cognitive therapy and behavior therapy in more detail below.
The fundamental premise of cognitive therapy is that thoughts influence feelings, and that one's emotional response to any situation is a function of one's subjective construal of that situation. To illustrate, imagine you notice your heart racing and your face flushed, and find yourself sweating and struggling to catch your breath. What would you think? How would you feel? Imagine further that you notice all this while sitting on a park bench on a late summer evening, enjoying a cool breeze and the sounds of birds chirping. You might have thoughts or images of having a heart attack or other medical condition and of the necessity to contact a doctor. You might experience the emotions of anxiety or fear. But imagine, instead, that you notice the same physiological symptoms while running on a treadmill. What then would you think and how would you feel? Presumably you would attribute the symptoms to exercise and - however unpleasant you might find them - would not experience anxiety or fear. In short, different interpretations of the same symptoms could lead to entirely different emotions.
Proponents of a cognitive approach believe that pathological emotional states (e.g., as manifest in many psychological disorders) derive from distorted, biased, or illogical thinking processes or cognitive schemas. Two examples of many such processes are the tendency to engage in black-and-white thinking and to focus selectively on weakness or failure while discounting evidence of competence and success. People may, therefore, make unrealistic appraisals about events (e.g., catastrophic misinterpretations about benign bodily sensations) as well as their ability to cope with negative outcomes. Similarly, individuals may overestimate both the likelihood of a negative event occurring, and how terrible it would be if it were to occur.
In cognitive therapy, clients learn to:
- Distinguish between thoughts and feelings.
In casual conversation, we often use the words "think" and "feel" synonymously (e.g., "I feel like it would be a bad decision to buy that model" - That is a thought, not a feeling). In fact, we are sometimes not cognizant of the automatic thoughts that accompany feelings. For example, one might recount feeling particularly sad after receiving criticism from a boss without mention (or awareness) of the thought, "Now I'll never get the promotion and won't be able to afford to purchase a house." In cognitive therapy, clients first practice identifying, attending to, and distinguishing between thoughts and feelings.
- Become aware of the ways in which their thoughts influence their feelings in ways that are not helpful.
Clients in cognitive therapy track their own experiences associated with a shift in mood and link these processed to their behavioral responses. What were you thinking right before you noticed becoming sad? When you have the automatic thought, "I can't do anything right," how do you feel? When you experience these thoughts and feelings are you more likely to do something constructive or to give up? Which behavior increases the likelihood of success?
- Evaluate critically the veracity of their automatic thoughts and assumptions.
Clients in cognitive therapy are encouraged to challenge their automatic thoughts by considering alternative explanations and conducting informal behavioral experiments. The aim is not to adopt an unrealistically optimistic or positive outlook. Rather, one learns to consider good and bad, evidence pro and con, and arrive at more accurate and logical, less biased, and often more nuanced conclusions. For instance, imagine you (a) receive critical feedback from your boss, then (b) have the automatic thought, "I can't do anything right," and then (c) feel sad. You might learn to evaluate critically the actual content of the feedback, the circumstances of the feedback, and what evidence you have (pro and con) that you can't do anything right in order to evaluate the accuracy and utility of that initial automatic thought.
- Develop the skills to notice, interrupt, and intervene at the level of automatic thoughts "on-line," as they happen.
Ultimately, the goal of cognitive therapy is to develop the skills to modify habitual cognitive processes as they happen. As with any skill, it takes time and practice to gain the proficiency to implement cognitive therapy techniques in real time.
Particular behavioral accounts vary from disorder to disorder; however, common to behavioral interventions is the use of volitional behavior and experience to modify pathological emotions and cognitions.
By way of illustration, think back to that scenario in which you are sitting on a park bench relaxing when you notice your heart racing, face flushed, etc. That might be an objectively fearful, aversive experience. Imagine further that you associate that fearful, aversive experience with trying to relax on the park bench (a process one can think about in classical conditioning terms). The next day, you might get a nervous flutter of the heart thinking about going back to that park bench, but you promised your children you would take them to the park and set off to do so. Imagine further that your anxiety rises when the bench comes into view, and fearing another experience of such arousal, you turn around and take your children for ice cream instead. You might experience a great deal of relief, but this action might have unintended consequences. Not only have you failed to learn that the bench is safe and that you can cope with anxiety, your avoidance is negatively reinforced by that relief. One might expect that it will be harder to go back to the bench next time. Behavioral treatments would involve going to that bench repeatedly and for prolonged periods of time without escaping the anxiety (physically or mentally), until the bench is no longer associated with anxiety - i.e., a process of extinction.
Behavioral treatments for depression, in contrast, capitalize less on the classical conditioning process of extinction, and more on reinforcement. From a behavioral perspective, depression is thought to result from an absence of environmental reinforcers, and treatment involves increasing involvement in activities that the depressive individuals previously found enjoyable before they became depressed and in engaging in tasks that provide a sense of mastery and competence.
Although behavioral conceptualizations differ from disorder to disorder, a common thread is that behavioral therapists encourage clients to engage in adaptive behaviors and not to allow pathological internal experiences to dictate the ways in which they act. In sum, behavioral interventions are based on the following principles:
- Classical conditioning
Unhelpful or pathological emotional responses to neutral or benign stimuli are often learned by association. Those responses can be modified by repeated and prolonged exposure to the neutral stimuli without physical or mental avoidance, a process known as extinction.
- Operant conditioning
Behavior is influenced by its consequences. We are more likely to engage in behaviors for which we receive positive or negative reinforcement, and less likely to engage in behaviors for which we are punished. Interventions that are based on principles of operant conditioning encourage clients not to avoid situations that lead to negative affect, and to increase positive behaviors that lead to adaptive and helpful reinforcement.
Features common to CBT
Despite the differences between cognitive and behavioral approaches, these therapies share a great deal in common and CBT therapists tend to draw from both approaches. Common features of both approaches are:
- In CBT, the therapist and client work together, in the spirit of collaborative empiricism, to explore, test, and modify maladaptive patterns of behavior and thought. It is of critical import that the client understands and accepts the treatment rationale in general and also for particular exercises. To that end, the therapist seeks to be open and honest, with the explicit mutual understanding that the therapist has theoretical and technical expertise, but the client is expert on himself or herself.
- CBT is often short-term, is skills-based and involves active client participation, in and out of session. As with learning a new language, one cannot show up in class for an hour every week and expect to develop facility; one must rather practice continually. Overall, clients learn problem solving skills through application of CBT techniques to real-life problems in their daily lives.
- Unless presented with a compelling reason otherwise, the CBT practitioner is present focused, seeking to understand the functional role of the client's behavior and experience in their current life. This focus might mean, for instance, that the therapist evaluates the ways that idiosyncratic safety or avoidance behaviors maintain anxiety in their ongoing daily life, but does not necessarily explore the developmental origins of the anxiety. Given a difficult history of circumstances in a client's life, the CBT therapist's inclination would be to help the client consider what they can do now to resolve their present difficulties. Typically, this involves working step-by-step to achieve operationalized proximal goals with an eye toward ultimate distal goals. This focus on the client's present does not mean that CBT therapist never consider developmental histories; often it is helpful for the therapist and the client to have some sense of how their idiosyncratic experiences emerged. It does mean that the client's history is not likely to be a major focus of treatment.
- CBT therapists often seek to help the client discover that they can tolerate negative affect, that emotions are not dangerous, and that the client has the efficacy to choose their behavior regardless of they feel.
- In addition, symptom relief is an explicit aim, and the CBT practitioner's role is to facilitate the fastest attainment of maximal and enduring improvement, as evidenced by self-report and behavioral indices, subjective and objective. The emphasis on tracking and assessing treatment outcome during therapy is consistent with the use of the empirical literature to inform treatment choice.
- Finally, throughout treatment, the CBT therapist develops hypotheses about the client's experience, but remains cognizant of how tendencies such as confirmation bias may influence their own objectivity in evaluating those hypotheses as well as treatment progress.
Given the emphasis in empiricism and the necessity of continued investigation into effective treatment, cognitive-behavioral approaches to treatment are continually evolving to respond to new developments in research and clinical practice. The elements described here are the basic building blocks for most cognitive and behavioral interventions. Mastery of these concepts facilitates the ability to learn newer strategies as they emerge in the literature.
For further resources and recommended readings about utilizing CBT in clinical practice, see recommended readings.