| Cognitive behavioral therapy | |
|---|---|
The
diagram depicts how emotions, thoughts, and behaviors all influence
each other. The triangle in the middle represents CBT's tenet that all
humans' core beliefs can be summed up in three categories: self, others,
future.
| |
| MeSH | D015928 |
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing unhelpful cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its use has been expanded to include treatment of a number of mental health conditions, including anxiety.
The CBT model is based on the combination of the basic principles from behavioral and cognitive psychology. It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and decrease symptoms of the disorder. CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of psychological disorders, and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.
When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression and anxiety, posttraumatic stress disorder (PTSD), tics, substance abuse, eating disorders and borderline personality disorder. It is often recommended in combination with medications for treating other conditions, such as severe obsessive compulsive disorder (OCD) and major depressive disorder, opioid use disorder, bipolar disorder and psychotic disorders. In addition, CBT is recommended as the first line of treatment for majority of psychological disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice, and CBT and IPT are the only psychosocial interventions that psychiatry residents are mandated to be trained in.
Description
Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in behavior and affect, but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself.
The goal of cognitive behavioral therapy is not to diagnose a person
with a particular disease, but to look at the person as a whole and
decide what can be altered.
Cognitive distortions
Therapists
or computer-based programs use CBT techniques to help people challenge
their patterns and beliefs and replace errors in thinking, known as cognitive distortions, such as "overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior". Cognitive distortions can be either a pseudo-discrimination belief or an over-generalization of something.
CBT techniques may also be used to help individuals take a more open,
mindful, and aware posture toward cognitive distortions so as to
diminish their impact.
Skills
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 they react 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.
Phases in therapy
CBT can be seen as having six phases:
- Assessment or psychological assessment;
- Reconceptualization;
- Skills acquisition;
- Skills consolidation and application training;
- Generalization and maintenance;
- Post-treatment assessment follow-up.
These steps are based on a system created by Kanfer and Saslow.
After identifying the behaviors that need changing, whether they be in
excess or deficit, and treatment has occurred, the psychologist must
identify whether or not the intervention succeeded. For example, "If the
goal was to decrease the behavior, then there should be a decrease
relative to the baseline. If the critical behavior remains at or above
the baseline, then the intervention has failed."
The steps in the assessment phase include:
- Step 1: Identify critical behaviors
- Step 2: Determine whether critical behaviors are excesses or deficits
- Step 3: Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline)
- Step 4: If excess, attempt to decrease frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors.
The re-conceptualization phase makes up much of the "cognitive" portion of CBT. A summary of modern CBT approaches is given by Hofmann.
Delivery protocols
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 vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.
Related techniques
CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.
Some practitioners promote a form of mindful cognitive therapy which
includes a greater emphasis on self-awareness as part of the therapeutic
process.
Medical uses
In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders, body dysmorphic disorder, depression, eating disorders, chronic low back pain, personality disorders, psychosis, schizophrenia, substance use disorders, in the adjustment, depression, and anxiety associated with fibromyalgia, and with post-spinal cord injuries.
In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive–compulsive disorder (OCD), and posttraumatic stress disorder, as well as tic disorders, trichotillomania, and other repetitive behavior disorders.
CBT-SP, an adaptation of CBT for suicide prevention (SP), was
specifically designed for treating youths who are severely depressed and
who have recently attempted suicide within the past 90 days, and was
found to be effective, feasible, and acceptable. CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age). CBT has also been applied to a variety of childhood disorders, including depressive disorders and various anxiety disorders.
CBT combined with hypnosis and distraction reduces self-reported pain in children.
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 youths under their care, nor was it helpful in treating people who abuse their intimate partners.
According to a 2004 review by INSERM
of three methods, cognitive behavioral therapy was either "proven" or
"presumed" to be an effective therapy on several specific mental disorders. According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.
Some meta-analyses find CBT more effective than psychodynamic
therapy and equal to other therapies in treating anxiety and depression.
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. Sparx is a video game to help young persons, using the CBT method to teach them how to resolve their own issues.
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. Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT).
ACT uses mindfulness and acceptance interventions and has been found to
have a greater longevity in therapeutic outcomes. In a study with
anxiety, CBT and ACT improved similarly across all outcomes from pre-to
post-treatment. However, during a 12-month follow-up, ACT proved to be
more effective, showing that it is a highly viable lasting treatment
model for anxiety disorders.
Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.
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."
Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD); hypochondriasis; coping with the impact of multiple sclerosis; sleep disturbances related to aging; dysmenorrhea; and bipolar disorder,
but more study is needed and results should be interpreted with
caution. CBT can have a therapeutic effects on easing symptoms of
anxiety and depression in people with Alzheimer's disease. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter, but not in reducing stuttering frequency.
In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management.
There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. CBT has been shown to be moderately effective for treating chronic fatigue syndrome.
In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive–compulsive disorder (OCD), bulimia nervosa, and clinical depression.
Anxiety disorders
CBT has been shown to be effective in the treatment of adults with anxiety disorders.
A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure.
The term refers to the direct confrontation of feared objects,
activities, or situations by a patient. For example, a woman with PTSD
who fears the location where she was assaulted may be assisted by her
therapist in going to that location and directly confronting those
fears.
Likewise, a person with social anxiety disorder who fears public
speaking may be instructed to directly confront those fears by giving a
speech. 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). Studies have provided evidence that when examining animals and humans that glucocorticoids
may possibly lead to a more successful extinction learning during
exposure therapy. For instance, glucocorticoids can prevent aversive
learning episodes from being retrieved and heighten reinforcement of
memory traces creating a non-fearful reaction in feared situations. A
combination of glucocorticoids and exposure therapy may be a better
improved treatment for treating patients with anxiety disorders.
A 2015 Cochrane review also found that CBT might be helpful for
patients with non-cardiac chest pain, and may reduce frequency of chest
pain episodes.
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.
The cognitive triad is made up of the depressed individual's negative
evaluations of themselves, the world, and the future. Beck suggested
that these negative evaluations derive from the negative schemata and
cognitive biases of the person. According to this theory, depressed
people 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. 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 suggested that CBT is effective in schizophrenia,
and the American Psychiatric Association includes CBT in its
schizophrenia guideline as an evidence-based treatment. There is also
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 placebos
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, Lyn Yvonne Abramson, Patricia 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." A 2012 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia.
| Summary | |
|---|---|
| For people with schizophrenia trial-based evidence suggests no clear and convincing advantage for cognitive behavioral therapy over other – and sometime much less sophisticated – therapies. | |
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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.
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 generalized anxiety disorder 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
behavioral intervention delivered by a psychoeducational method, saw a
38% reduction in risk of major depression.
For people at risk of psychosis, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT.
Gambling addiction
CBT is also used for gambling addiction. The percentage of people who problem gamble is 1–3% around the world.
Cognitive behavioral therapy develops skills for relapse prevention and
someone can learn to control their mind and manage high-risk cases.
Smoking cessation
CBT
looks at the habit of smoking cigarettes as a learned behavior, which
later evolves into a coping strategy to handle daily stressors. Because
smoking is often easily accessible, and quickly allows the user to feel
good, it can take precedence over other coping strategies, and
eventually work its way into everyday life during non-stressful events
as well. CBT aims to target the function of the behavior, as it can vary
between individuals, and works to inject other coping mechanisms in
place of smoking. CBT also aims to support individuals suffering from
strong cravings, which are a major reported reason for relapse during
treatment.
In a 2008 controlled study out of Stanford University School of
Medicine, CBT was proven as an effective tool for most participants. The
results of 304 random adult participants were tracked over the course
of one year. During this program, some participants were provided
medication, CBT, 24 hour phone support, or some combination of the three
methods. At 20 weeks, the participants who received CBT had a 45%
abstinence rate, versus non-CBT participants, who had a 29% abstinence
rate. Overall, the study concluded that emphasizing cognitive and
behavioral strategies to support smoking cessation can help individuals
build tools for long term smoking abstinence.
Mental health history can affect the outcomes of treatment. It
should be noted that individuals with a history of depressive disorders
had a lower rate of success when using CBT alone to combat smoking
addiction.
Eating disorders
Though
many forms of treatment can support individuals with eating disorders,
CBT is proven to be a more effective treatment than medications and
interpersonal psychotherapy alone.
CBT aims to combat major causes of distress such as negative cognitions
surrounding body weight, shape and size. CBT therapists also work with
individuals to regulate strong emotions and thoughts that lead to
dangerous compensatory behaviors. CBT is the first line of treatment for
Bulimia Nervosa, and Eating Disorder Non-Specific.
Internet addiction
Research
has identified Internet addiction as a new clinical disorder
that causes relational, occupational, and social problems.
Cognitive behavioral therapy (CBT) has been suggested as the
treatment of choice for Internet addiction, and addiction recovery in
general has used CBT as part of treatment planning.
History
Philosophical roots
Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Stoic philosophers, particularly Epictetus,
believed logic could be used to identify and discard false beliefs that
lead to destructive emotions, which has influenced the way modern
cognitive-behavioral therapists identify cognitive distortions that
contribute to depression and anxiety. 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". Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis. A key philosophical figure who also influenced the development of CBT was John Stuart Mill.
Behavior therapy roots
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. Groundbreaking work of
behaviorism began with John B. Watson and Rosalie Rayner's studies of conditioning in 1920. Behaviorally-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones' work dedicated to the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s. It was the work of Wolpe and Watson, which was based on Ivan Pavlov's work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioral therapy techniques based on classical conditioning. One of Eysenck's colleagues, Glenn Wilson showed that classical fear conditioning in humans could be controlled by verbally induced cognitive expectations, thus opening a field of research that supports the rationale of cognitive behaviorial therapy.
During the 1950s and 1960s, 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, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization,
applied behavioral research to the treatment of neurotic disorders.
Wolpe's therapeutic efforts were precursors to today's fear reduction
techniques. British psychologist Hans Eysenck presented behavior therapy as a constructive alternative.
At the same time of Eysenck's work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning. Skinner's work was referred to as radical behaviorism and avoided anything related to cognition. However, Julian Rotter, in 1954, and Albert Bandura, in 1969, contributed behavior therapy with their respective work on social learning theory, by demonstrating the effects of cognition on learning and behavior modification.
The emphasis on behavioral factors constituted the "first wave" of CBT.
Cognitive therapy roots
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One of the first therapists to address cognition in psychotherapy was Alfred Adler with his notion of basic mistakes and how they contributed to creation of unhealthy or useless behavioral and life goals. Adler's work influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy, known today as rational emotive behavior therapy, or REBT.
Around the same time that rational emotive therapy, as it was known then, was being developed, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorized, and that certain types of thinking may be the culprits of emotional distress. It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts "automatic thoughts".
It was these two therapies, rational emotive therapy and
cognitive therapy, that started the "second wave" of CBT, which was the
emphasis on cognitive factors.
Behavior and cognitive therapies merge - "third wave" CBT
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.
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.
Over time, cognitive behavior therapy became to be known not only
as a therapy, but as an umbrella term for all cognitive-based
psychotherapies. These therapies include, but are not limited to, rational emotive therapy (REBT), cognitive therapy, acceptance and commitment therapy, dialectical behavior therapy, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy. All of these therapies are a blending of cognitive- and behavior-based elements.
This blending of theoretical and technical foundations from both
behavior and cognitive therapies constituted the "third wave" of CBT. The most prominent therapies of this third wave are dialectical behavior therapy and acceptance and commitment therapy.
Methods of access
Therapist
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 or Internet-delivered
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. It is also known as internet-delivered cognitive behavioral therapy or ICBT.
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.
In this context, it is important not to confuse CBT with
'computer-based training', which nowadays is more commonly referred to
as e-Learning.
CCBT has been found in meta-studies to be cost-effective and often cheaper than usual care, including for anxiety. Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods.
A review of current CCBT research in the treatment of OCD in children
found this interface to hold great potential for future treatment of OCD
in youths and adolescent populations. Additionally, most internet interventions for posttraumatic stress disorder
use CCBT. CCBT is also predisposed to treating mood disorders amongst
non-heterosexual populations, who may avoid face-to-face therapy from
fear of stigma. However presently CCBT programs seldom cater to these
populations.
A key issue in CCBT use is low uptake and completion rates, even when it has been clearly made available and explained.
CCBT completion rates and treatment efficacy have been found in some
studies to be higher when use of CCBT is supported personally, with
supporters not limited only to therapists, than when use is in a
self-help form alone.
Another approach to improving uptake and completion rate, as well as
treatment outcome, is to design software that supports the formation of a
strong therapeutic alliance between the user and the technology.
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 behavior therapy for a specific disorder
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.
Smartphone app-delivered
Another new method of access is the use of mobile app
or smartphone applications to deliver self-help or guided CBT.
Technology companies are developing mobile-based artificial intelligence
chatbot applications in delivering CBT as an early intervention to support mental health, to build Psychological resilience and to promote emotional well-being. Artificial intelligence
(AI) text-based conversational application delivered securely and
privately over smartphone devices have the ability to scale globally and
offer contextual and always-available support. Active research is
underway including real world data studies
that measure effectiveness and engagement of text-based smartphone
chatbot apps for delivery of CBT using a text-based conversational
interface.
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.
In a meta-analysis reviewing evidence-based treatment of OCD in
children, individual CBT was found to be more efficacious than group
CBT.
Types
BCBT
Brief
cognitive behavioral therapy (BCBT) is a form of 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.
Breakdown of treatment:
- Orientation
- Commitment to treatment
- Crisis response and safety planning
- Means restriction
- Survival kit
- Reasons for living card
- Model of suicidality
- Treatment journal
- Lessons learned
- Skill focus
- Skill development worksheets
- Coping cards
- Demonstration
- Practice
- Skill refinement
- Relapse prevention
- Skill generalization
- Skill refinement
Cognitive emotional behavioral therapy
Cognitive emotional behavioral therapy (CEBT) is a form of CBT
developed initially for individuals with eating disorders but now used
with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. It combines aspects of CBT and dialectical behavioral therapy
and aims to improve understanding and tolerance of emotions in order to
facilitate the therapeutic process. It is frequently used as a
"pretreatment" to prepare and better equip individuals for longer-term
therapy.
Structured cognitive behavioral training
Structured cognitive behavioral training (SCBT) is a cognitive-based
process with core philosophies that draw heavily from CBT. Like CBT,
SCBT asserts that behavior is inextricably related to beliefs, thoughts
and emotions. SCBT also builds on core CBT philosophy by incorporating
other well-known modalities in the fields of behavioral health and psychology: most notably, Albert Ellis's rational emotive behavior therapy.
SCBT differs from CBT in two distinct ways. First, SCBT is delivered in
a highly regimented format. Second, SCBT is a predetermined and finite
training process that becomes personalized by the input of the
participant. SCBT is designed with the intention to bring a participant
to a specific result in a specific period of time. SCBT has been used to
challenge addictive behavior, particularly with substances such as
tobacco, alcohol and food, and to manage diabetes and subdue stress and anxiety. SCBT has also been used in the field of criminal psychology in the effort to reduce recidivism.
Moral reconation therapy
Moral reconation therapy, a type of CBT used to help felons overcome antisocial personality disorder (ASPD), slightly decreases the risk of further offending.
It is generally implemented in a group format because of the risk of
offenders with ASPD being given one-on-one therapy reinforces
narcissistic behavioral characteristics, and can be used in correctional
or outpatient settings. Groups usually meet weekly for two to six
months.
Stress inoculation training
This
type of therapy uses a blend of cognitive, behavioral and some
humanistic training techniques to target the stressors of the client.
This usually is used to help clients better cope with their stress or
anxiety after stressful events.
This is a three-phase process that trains the client to use skills that
they already have to better adapt to their current stressors. The first
phase is an interview phase that includes psychological testing, client
self-monitoring, and a variety of reading materials. This allows the
therapist to individually tailor the training process to the client.
Clients learn how to categorize problems into emotion-focused or
problem-focused, so that they can better treat their negative
situations. This phase ultimately prepares the client to eventually
confront and reflect upon their current reactions to stressors, before
looking at ways to change their reactions and emotions in relation to
their stressors. The focus is conceptualization.
The second phase emphasizes the aspect of skills acquisition and
rehearsal that continues from the earlier phase of conceptualization.
The client is taught skills that help them cope with their stressors.
These skills are then practised in the space of therapy. These skills
involve self-regulation, problem-solving, interpersonal communication
skills, etc.
The third and final phase is the application and following
through of the skills learned in the training process. This gives the
client opportunities to apply their learned skills to a wide range of
stressors. Activities include role-playing, imagery, modeling, etc. In
the end, the client will have been trained on a preventative basis to
inoculate personal, chronic, and future stressors by breaking down their
stressors into problems they will address in long-term, short-term, and
intermediate coping goals.
Mindfulness-based cognitive behavioral hypnotherapy
Mindfulness-based
cognitive behavioral hypnotherapy (MCBH) is a form of CBT focusing on
awareness in reflective approach with addressing of subconscious
tendencies. It is more the process that contains basically three phases
that are used for achieving wanted goals.
Unified Protocol
The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a form of CBT, developed by David H. Barlow and researchers at Boston University,
that can be applied to a range of depression and anxiety disorders. The
rationale is that anxiety and depression disorders often occur together
due to common underlying causes and can efficiently be treated
together.
The UP includes a common set of components:
- Psycho-education
- Cognitive reappraisal
- Emotion regulation
- Changing behaviour
The UP has been shown to produce equivalent results to single-diagnosis protocols for specific disorders, such as OCD and social anxiety disorder.
The UP is disseminated by the Unified Protocol Institute.
Criticisms
Relative effectiveness
The
research conducted for CBT has been a topic of sustained controversy.
While some researchers write that CBT is more effective than other
treatments, many other researchers and practitioners have questioned the validity of such claims. For example, one study determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers
responding directly to that study conducted a re-analysis and found no
evidence of CBT being superior to other bona fide treatments, and
conducted an analysis of thirteen other CBT clinical trials and
determined that they failed to provide evidence of CBT superiority.
A major criticism has been that clinical studies of CBT efficacy
(or any psychotherapy) are not double-blind (i.e., either the subjects
or the therapists in psychotherapy studies are not blind to the type of
treatment). They may be single-blinded, i.e. 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, major depressive disorder (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.
Declining effectiveness
Additionally,
a 2015 meta-analysis revealed that the positive effects of CBT on
depression have been declining since 1977. The overall results showed
two different declines in effect sizes:
1) an overall decline between 1977 and 2014, and 2) a steeper decline
between 1995 and 2014. Additional sub-analysis revealed that CBT studies
where therapists in the test group were instructed to adhere to the
Beck CBT manual had a steeper decline in effect sizes since 1977 than
studies where therapists in the test group were instructed to use CBT
without a manual. The authors reported that they were unsure why the
effects were declining but did list inadequate therapist training,
failure to adhere to a manual, lack of therapist experience, and
patients' hope and faith in its efficacy waning as potential reasons.
The authors did mention that the current study was limited to depressive
disorders only.
High drop-out rates
Furthermore, other researchers
write that CBT studies have high drop-out rates compared to other
treatments. At times, the CBT drop-out rates can be more than five times
higher than other treatments groups. For example, the researchers
provided statistics of 28 participants in a group receiving CBT therapy
dropping out, compared to 5 participants in a group receiving
problem-solving therapy dropping out, or 11 participants in a group
receiving psychodynamic therapy dropping out. This high drop-out rate is also evident in the treatment of several disorders, particularly the eating disorder anorexia nervosa,
which is commonly treated with CBT. Those treated with CBT have a high
chance of dropping out of therapy before completion and reverting to
their anorexia behaviors.
Other researchers conducting an analysis of treatments for youths who self-injure found similar drop-out rates in CBT and DBT
groups. In this study, the researchers analyzed several clinical trials
that measured the efficacy of CBT administered to youths who
self-injure. The researchers concluded that none of them were found to
be efficacious. These conclusions were made using the APA Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures to determine intervention potency.
Philosophical concerns with CBT methods
The
methods employed in CBT research have not been the only criticisms;
some individuals have called its theory and therapy into question. For
example, Fancher
argues that CBT has failed to provide a framework for clear and correct
thinking. He states that it is strange for CBT theorists to develop a
framework for determining distorted thinking
without ever developing a framework for "cognitive clarity" or what
would count as "healthy, normal thinking". Additionally, he writes that
irrational thinking cannot be a source of mental and emotional distress
when there is no evidence of rational thinking causing psychological
well-being. Or, that social psychology has proven the normal cognitive
processes of the average person to be irrational, even those who are
psychologically well. Fancher also says that the theory of CBT is
inconsistent with basic principles and research of rationality, and even
ignores many rules of logic. He argues that CBT makes something of
thinking that is far less exciting and true than thinking probably is.
Among his other arguments are the maintaining of the status quo promoted
in CBT, the self-deception encouraged within clients and patients
engaged in CBT, how poorly the research is conducted, and some of its
basic tenets and norms: "The basic norm of cognitive therapy is this:
except for how the patient thinks, everything is ok".
Meanwhile, Slife and Williams write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will.
They argue that CBT invokes a type of cause-and-effect relationship
with cognition. They state that CBT holds that external stimuli from the
environment enter the mind, causing different thoughts that cause
emotional states: nowhere in CBT theory is agency, or free will,
accounted for. According to Slife and Williams, at its most basic
foundational assumptions, CBT holds that human beings have no free will
and are just determined by the cognitive processes invoked by external
stimuli.
Another criticism of CBT theory, especially as applied to major
depressive disorder (MDD), is that it confounds the symptoms of the
disorder with its causes.
Side effects
CBT is generally seen as having very low if any side effects. Calls have been made for more appraisal of CBT side effects.
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). the 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".
The NICE
also recommends offering CBT to people suffering from schizophrenia, as
well as those at risk of suffering from a psychotic episode.
