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A Cognitive Behavioral Therapy (CBT) is a psychotherapy that integrates the approaches of behavior therapy and cognitive therapy. It is based on modifying everyday thoughts and behaviors, with the aim of positively influencing emotions. The general approach developed out of behavior modification and cognitive therapy, and has become widely used to treat mental disorders. The particular therapeutic techniques vary according to the particular kind of client or issue, but commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation and distraction techniques are also commonly included. CBT is widely accepted as an evidence-based, cost-effective psychotherapy for many disorders. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages.
- 1 The basics
- 2 Thoughts as the cause of emotions
- 3 Cognitive Behavioral Therapy
- 4 Depression
- 5 CBT with children and adolescents
- 6 Computerised CBT
- 7 Cognitive behavior therapy with different mental disorders
- 8 See also
- 9 Professional Organizations & Institutes
- 10 Bibliography
- 11 Key Texts – Books
- 12 Additional material – Books
- 13 Key Texts – Papers
- 14 Additional material - Papers
- 15 External links
CBT is really based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior. Therefore, negative - and unrealistic - thoughts can cause us distress and result in problems.
One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on mood, making the person feel depressed; the problem may be worsened if the individual reacts by avoiding activities. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks in response to similar situations and by developing more flexible thought patterns, along with reducing the avoidance of activities. If, as a result, the client escapes the negative thought pattern, the feelings of depression may be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.
Thoughts as the cause of emotions
With thoughts stipulated as being the cause of emotions rather than the outcome or by-product, cognitive therapists reverse the causal order more of generally used by psychotherapists. Therefore, the therapy is to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts, in a process sometimes referred to as cognitive-shifting.
Cognitive Behavioral Therapy is not an overnight process. Even after patients have learned to recognize when and where their thought processes go awry, it can take months of concerted effort to replace an irrational thought process or habit with a more reasonable, salutary one.
The cognitive model says that a person's core beliefs (often formed in childhood) contribute to 'automatic thoughts' that pop up in every day life in response to situations. Cognitive Therapy practitioners hold that clinical depression is typically associated with negatively biased thinking and irrational thoughts. Cognitive Behavioral Therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS.
Cognitive Behavioral Therapy
CBT can be seen as an umbrella term for many different therapies that share some common elements. While similar views of emotion have existed for millennia, the earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Ellis eventually called his approach Rational Emotive Behavioral Therapy, or REBT, as a reaction against popular psychoanalytic and increasingly humanistic methods at the time . Aaron T. Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.
Cognitive Behavioral Group Therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg. In this case, clients participate in a group and recognize they are not alone in suffering from their problems.
A sub-field of Cognitive Behavior Therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. (The specific technique, Exposure with Response Prevention (ERP) has been demonstrated to be more effective than the use of medication--typically SSRIs--alone.) CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia and Panic Disorder. In recent years, CBT has been used to treat symptoms of schizophrenia, such as delusions and hallucinations. This use has been developed in the UK by Douglas Turkington and David Kingdon.
Other types of Cognitive Behavioral Therapy include Dialectical Behavior Therapy, Self-Instructional Training, Schema-Focused Therapy and many others.
CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse. It has been clinically demonstrated in over 400 studies to be effective for many psychiatric disorders and medical problems for both children and adolescents. It has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression. Cognitive Behavioral Therapy most closely allies with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment.
Negative thinking in depression can result from biological sources (i.e., endogenous depression), modelling from parents, peers or other sources. The depressed person experiences negative thoughts as being beyond their control: the negative thought pattern can become automatic and self-perpetuating.
Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.
Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad."
An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First put forth by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves . There is considerable evidence that depressives do exhibit such an attributional style, but it is important to remember that Abramson et al. do not claim that an attributional style of this nature is necessarily going to cause depression — only that it will lead to clinical depression if combined with a negative event. This theory is sometimes known as a revised version of learned helplessness theory.
In 1989, this theory was challenged by Hopelessness Theory . This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions.
The ABCs of Irrational Beliefs
A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. The first three steps analyse the process by which a person has developed irrational beliefs and may be recorded in a three-column table.
- A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
- B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to them.
- C - Consequence. The third column is for the negative feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc.
For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.
- Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.
Effectiveness of CBT with or without drugs for depression
- Main article: Cognitive behavioral analysis system of psychotherapy
A large-scale study in 2000 showed substantially higher results of response and remission when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either method was used alone.
The effectiveness of combination therapy is endorsed by the Australian depressioNet group:
- Currently the most effective treatment for major (clinical) depression is considered to be a combination of antidepressant medication and Cognitive Behavioral Therapy.
For more general results confirming that CBT alone can provide lower but nonetheless valuable levels of relief from depression, and result in increased ability for the patient to stay in employment, see The Depression Report, which states:
- The typical short-term success rate for CBT is about 50%. In other words, if 100 people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work.
The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal therapy had the best-documented efficacy for treatment of major depressive disorder, although they noted that rigorous evaluative studies had not been published .
CBT with children and adolescents
The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression , anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder. Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago.
CBT is also used as a treatment modality for children who have experienced Complex Post Traumatic Stress Disorder, chronic maltreatment, and Post Traumatic Stress Disorder. It would be one component of treatment for children with C-PTSD, along with a variety of other components, which are discussed in the Complex Post Traumatic Stress Disorder article. While Dialectical Behavior Therapy has been shown to be an effective treatment for adults with personality disorders, it has not been tested with child or adolescent patients.
The importance of relationship factors in effective CBT with adolescents is described by Aaron T. Beck, M.D.,
The authors have emphasized repeatedly the importance of a trusting, secure relationship with the therapist. This attitude reminds the reader of Bowlby, who also developed the idea of an internal map of the world, a set of schemas in which self and others and their relationships are represented. This conceptualization clearly integrates will the cognitive model's concepts of core beliefs and primary and secondary assumptions about self and others and the future. As a result of the collaborative approach, the therapist shares the adolescent's perceptions of loss and pain. Therapist and patient are able to reconstruct narrative, a process that facilitates for patients a more helpful view of their world, themselves, and their future.
- Main article: CBT with children and adolescents
As the name suggests, this is a computerised form of CBT, in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face-to-face with a therapist.
- Main article: Computerized CBT
Cognitive behavior therapy with different mental disorders
- Main article: CBT treatment for different problems
==List of prominent theorists and researchers
Professional Organizations & Institutes
- Academy of Cognitive Therapy
- The Albert Ellis Institute
- Association for Behavioral and Cognitive Therapies (ABCT)
- Beck Institute for Cognitive Therapy and Research
- William Glasser Institute
- The Lazarus Institute
- The British Association of Behavioural and Cognitive Psychotherapies
- "A Guide to Understanding Cognitive and Behavioural Psychotherapies" British Association of Behavioural and Cognitive Psychotherapies. Retrieved on 2007-1-11
- Ellis, Albert (1975). A New Guide to Rational Living, Prentice Hall. ISBN 0-13-370650-8.
- Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-8236-0990-1
- Group Therapy. Stress and Anxiety Services of New Jersey. URL accessed on 2006-06-25.
- What is CBT? …What’s in a Name?. Association for Behavioral and Cognitive Therapies. URL accessed on 2007-1-11.
- Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74
- Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.
- Keller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression. New England Journal of Medicine Volume 342:1462-1470 May 18, 2000.
- Treatments: Cognitive Behavioral Therapy. depresioNet. URL accessed on 2006-08-27.
- The Depression Report: A New Deal for Depression and Anxiety Disorders. The Centre for Economic Performance's Mental Health Policy Group. URL accessed on 2006-06-25.
- Treatment Recommendations for Patients with Major Depressive Disorder (Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition). American Psychiatric Association. URL accessed on 2006-07-02.
- Wilkes, T, Belsher, G., Rush, A., Frnk, E., & Associates. (1994). Cognitive therapy for depressed adolescents. NY: Guilford Press
- (2005-12-05) Kendall, Philip C. (ed). Child and Adolescent Therapy: Cognitive-Behavioral Procedures, (3rd ed.), Guilford Press. ISBN 1-59385-113-8.
- (2003-05-02) Reinecke, Mark A.; Dattilio, Frank M.; Freeman, A. (eds). Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (2nd ed.), Guilford Press. ISBN 1-57230-853-2.
- (2006) Briere, John; Scott, Catherine (eds). Principles of Trauma Therapy, Sage. ISBN 0-7619-2921-5. (see especially Chapter 7, "Cognitive Interventions", pp. 109-119).
- Reinecke, M., & Freeman, M., (2007) Development and Treatment of Personality Disorder in Mark Freemand and Mark Reinecke (Eds.) (2007), Personality Disorders in Childhood and Adolescence. NY: Wiley
- Beck, A., (1994). Forward. In T. Wilkes, G. Belsher, A. Rush, E. Frank, & Associates. (1994). Cognitive therapy for depressed adolescents. NY: Guilford Press
Key Texts – Books
- Albano, M. & Kearney, Ca., (2000) When children refuse school: a cognitive behavioral therapy approach: Therapist guide. Psychological Corporation.
- Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York: The Guilford Press.
- Beck, J. (1995). Cognitive Therapy: Basics and Beyond. London:Guildford.
- Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
- Beck, A. T., Emery, G., & Greenberg, R. (1985). Anxiety disorders and phobias: A cognitive perspective. New York:Basic Books.
- Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York: The Guilford Press.
- Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.
- Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: The Guilford Press.
- Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press.
- Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-82-360990-1
- Dryden, Windy. Ten Steps to Positive Living. Sheldon Press, 1994.
- Ellis, Albert. A Guide to Rational Living. Prentice Hall, 1975. ISBN 0-13-370650-8
- Deblinger, E. & Heflin, A. (1996) Treating sexually abused children and their non-offending parents: a cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.
- Kuyken, W., Padesy, C>A> & Dudley, D (2009) Colaborative case conceptualization:Working Efffectively with Clients in Cognitive-Behavioural Therapy. Guildford Press. ISBN:9781606230725
- Wilson, P.H., Spence, S.H. & Kavanagh, D. J. (1989) Cognitive behavioural Interviewing for Adult Disorders: A Practical Handbook. London: Routledge.
Additional material – Books
- Bennett-Levy,James ( ) Oxford Guide to Behavioural Experiments in Cognitive Therapy (Cognitive Behaviour Therapy: Science & Practice)
- Beck,Judith S. ( ) Cognitive Therapy: Basics and Beyond
- Burns, D. D. (1980). Feeling good. New York: Avon Books.
- Dobson, K. S. (Ed.). (2001). Handbook of cognitive-behavioral therapies (2nd ed.). New York: The Guilford Press.
- Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (1990). Clinical applications of cognitive therapy. New York: Plenum Press.
- Greenberger, D., & Padesky, C. (1995). Mind over mood: Changing how you feel by changing the way you think. New York: The Guilford Press.
- Hawton, Keith ( ) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide
- Leahy, R. (1996). Cognitive therapy: Basic principles and applications. Northvale, NJ: Jason Aronson.
- Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: Norton.
- Westbrook, D., Kennerley, H.& Kirk,J.(2007)An Introduction to Cognitive behaviour Therapy.Sage.
Key Texts – Papers
- Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74
- Butler, A., & Beck, J. S. (2001). Cognitive therapy outcomes: A review of meta-analyses. Tidsskrift for Norsk Psykologforening, 38, 698–706.
- Crits-Cristoph, P., Chambless, D. L., Frank, E., Brody, C., & Karp, J. (1995). Training in empirically validated treatments: What are clinical psychology students learning? Professional Psychology: Research and Practice, 26, 514–522.
- Dattilio, F. M., & Padesky, C. A. (1990). Cognitive therapy with couples. Sarasota: Professional Resource Exchange.
- Dobson, K. S., Shaw, B. F., & Vallis, T. M. (1985). Reliability of a measure of the quality of cognitive therapy. British Journal of Clinical Psychology, 24, 295–300.
- Norcross, J. C., Hedges, M., & Prochaska, J. O. (2002). The face of 2010: A Delphi poll on the future of psychotherapy. Professional Psychology: Research and Practice, 33, 316–322.
- Pedesky, C.A. & Mooney, K.A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6,11-12.
Additional material - Papers
- Keller, M. et al. 2000A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression].New England Journal of Medicine Volume 342:1462-1470 [http://content.nejm.org/cgi/content/abstract/342/20/1462 Full text
- American Institute for Cognitive Therapy
- The Beck Institute for Cognitive Therapy and Research
- NACBT fact sheet what is CBT.
- The Academy of Cognitive Therapy
- The Albert Ellis Institute
- Rational.org New Zealand
- NACBT Online - What is CBT?
- An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches
- An Introduction to Rational Emotive Behaviour Therapy
- New York Institute for Cognitive and Behavioral Therapies
- Moodgym - Training CBT for preventing depression
- Patient.co.uk article on CBT
- An Introduction to Cognitive Therapy & CBT
- The Royal College of Psychiatrists' cognitive therapy leaflet
- REBT Network
- REBT-CBT NET- The Internet Guide to Rational Emotive Behavior Therapy and Cognitive Behavior Therapy
- Marks, Isaac (2003). Review of Introducing Cognitive Analytic Therapy. Principles and Practice by Ryle and Kerr. British Journal of Psychiatry. URL accessed on 2006-07-12.
- Moodgym. Australian National University. URL accessed on 2006-07-04. (Free online CBT training program for preventing depression.)
- Living Life to the Full. URL accessed on 2006-07-04. (Free online CBT life skills course, sponsored by Scottish Executive Health Department Centre for Change and Innovation)
- Mental Health Foundation report on the use of CCBT
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health
- Guide to using CBT to treat depression
- Free guide to learning skills to overcome depression
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