Cognitive Behavioral Therapy (CBT)
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Cognitive behavioral therapy is a classification of psychotherapies which integrate cognitive and behavioral theories and methods. CBT approaches share fundamental assumptions that cognitions mediate situational responses, that changes in cognitive activity can affect therapeutic changes in emotions and behaviors, and that maladaptive behaviors can be extinguished or reshaped, with new skills learned through practice and reinforcement.
Brief History of CBT
CBT interventions represent an integration of behavioral and cognitive theories and methods. Behavior therapy emerged in the 1950s and 1960s through research on clinical applications of classical and operant conditioning theories (e.g., systematic desensitization; Eysenck 1966; Wolpe 1958). Behavior therapy emphasizes the primacy of behaviors, and radical behaviorists view thoughts as a type of internal behavior. The primacy of thoughts in shaping situational responses appears in early philosophical traditions ranging from Stoicism to Buddhism (Wright et al. 2006). Formally, the cognitive underpinnings of CBT emerged in the 1960s and 1970s, largely through developments by Albert Ellis (rational emotive therapy; 1957) and Aaron T. Beck (cognitive therapy; 1963, 1964) and contributions from Alfred Adler, George Kelly, and behaviorists described above. Rational emotive therapy has been considered the first of the cognitive interventions to appear; it introduced a novel, directive approach to challenging patients’ irrational beliefs. Beck’s cognitive therapy also emphasized a primary role of cognitions in psychiatric problems, and he formally described the maladaptive cognitive biases associated with depression as targets for therapeutic change.
The coalescence of cognitive and behavioral therapies over the past few decades has been due to several factors, including the challenges of applying behavior theory to the complex range of human behaviors (e.g., obsessional thinking), the introduction of a formalized cognitive therapy for depression, and the growing support for CBT interventions in both research and practice. Behaviorists view behavior change as the primary goal of therapy, whereas cognitive theorists view behavior strategies as means for affecting change. Yet both schools share a commitment to applying the scientific method to clinical problems and their treatments. Since the early works which focused primarily on depression and anxiety, CBT models have since been expanded to explain and treat a wide range of psychiatric disorders.
A number of membership organizations support CBT research and practice, and their histories reflect the history of CBT itself. For instance, in 1966, the Association for Advancement of Behavioral Therapies (AABT) was founded by behaviorists due to their dissatisfaction with the psychoanalytic model. The name was formally changed to the Association for Behavioral and Cognitive Therapies (ABCT) in 2005, to reflect the increasing influence of cognitive theory and methods. Similarly, the British Association for Behavioural Psychotherapy (BABP) was founded by behaviorists in 1972; its scope was broadened in 1992 when it became The British Association for Behavioural and Cognitive Psychotherapies (BABCP).
CBT Model of Clinical Symptoms
This scenario highlights that two different interpretations without clear evidence led to quite different emotional and behavioral consequences. These interpretations also could reinforce long-standing negative beliefs about the self (in the case of J.F.) or the world (in the case of A.B.). This is a key learning point for individuals during therapy. In the long term, entrenched patterns or styles of thinking and behaving can become associated with clinically significant distress. Indeed, psychiatric disorders are distinguished by distinct profiles of cognitive and behavioral bias. In his original work, Aaron T. Beck described depression as the result of negative thinking about the self, world, and future (1963, 1964). Other examples include phobias as the inaccurate perceptions of danger and suicidality as the perception of hopelessness and deficits in problem-solving skills.
A supervisor had begun to criticize two employees, J.F. and A.B.., for minor errors at work. J.F. interpreted the situation to mean that he was a poor performer and a liability to his department. This caused J.F. to feel dejected, which led him to increase his efforts to please the supervisor. J.F. began to work late at night; drink more coffee to stay awake; and consequently experience fatigue and anxiety the next day. This led him to make more errors at work, creating a self-fulfilling prophecy which strengthened his anxiety and negative beliefs about himself. Meanwhile, A.B.. presumed that the supervisor was simply singling her out for criticism. This caused A.B.. to feel irritated, which led her to act indifferently toward the supervisor while maintaining her current level of work performance. Her relationship with the supervisor deteriorated, reinforcing A.B..’s belief that people are generally disrespectful.
Applications of the CBT Model in Behavioral Medicine
This scenario shows bidirectional relationships between depression and poor HIV self-care. In practice, the CBT case formulation would address how inaccurate cognitions, emotional distress, and coping behaviors are influencing each other in a perpetuating loop, which serves to maintain both depression and poor self-care. The case formulation would also help to highlight key areas for CBT intervention to break this loop. In developing the CBT treatment plan, a therapist may draw systematically from CBT strategies, including (1) providing psychoeducation about depression, HIV, and HIV medications, (2) increasing engagement in activities which promote enjoyment and sense of mastery, (3) challenging severe negative beliefs, and (4) problem-solving medical adherence. This approach highlights that all three domains (cognitions, emotions, and behaviors) are being addressed. Common CBT intervention elements are described further in the next section.
S.P. had been prescribed a daily HIV medication for the past year. She did not believe that the medication did much to manage her condition. Every morning, she would dread looking at the medication bottle. It was a reminder that she was ill, and this reminder provoked other familiar thoughts that her life was over and that she would never find a romantic partner due to her HIV status. These thoughts, in turn, reminded her that she was profoundly alone. For S.P., it was easier to ignore the sight of the bottle and skip her medication dose, which she frequently did. However, the thoughts remained and often provoked painful depressed moods which decreased her motivation and energy to answer phone calls from her friends. S.P. spent most of her time at home alone, which reinforced her beliefs about being undesirable to others. Most recently, she missed her regular HIV primary care visit. It seemed too difficult to secure a ride to the clinic, and she thought, “What’s the point anyway, this disease is not going away.”
Common Elements of CBT Interventions
In CBT interventions, the therapist actively collaborates with the patient (i.e., “co-therapist”). They work together to identify and alter problematic patterns of thinking and behaving and thereby help the patient manage negative emotions and improve quality of life. The therapist first collects information about the patient’s presenting problems and then shares and revises the CBT case formulation with the patient. This formulation directly informs the therapy. The therapist and patient work together to set a treatment plan and articulate goals at the outset of therapy and to set agendas at each therapy session. During the course of CBT, the therapist may use Socratic questioning to guide patients in their own discovery of problematic patterns in their thinking and behaving. Sessions are problem oriented and typically focus on building skills which address these patterns. “Homework” assignments encourage the patient to rehearse and problem-solve the skills in real-life situations. Throughout treatment, progress is monitored using symptom inventories (e.g., the Beck Depression Inventory [BDI] or the Hospital Anxiety and Depression Scale [HADS]) as well as informal feedback. Most CBT interventions are intended to be time limited; the ultimate goal is for patients to become increasingly independent in their use of the skills until the therapist is no longer needed.
Psychoeducation is used throughout CBT interventions. A critical component of CBT is to engage patients in understanding the CBT model, the rationale for treatment, and the therapeutic methods as applied to their clinical problems. In other examples, CBT for panic disorder includes information on physiologic activation, whereas a patient on long-acting pain medications may benefit from understanding the impact of missed or delayed medication doses.
Behavioral strategies are used to help patients break unhelpful behavior patterns such as fear avoidance or depressive inactivity. For example, exposure methods involve generating a hierarchy of situations that induce fear and avoidance and conducting structured “experiments” which increase real-life or imaginal exposure to these situations. In behavioral activation, the patient is guided to increase activity level by generating a list of activities that promote enjoyment and sense of mastery and then setting and monitoring daily or weekly activity goals.
Cognitive strategies are used to promote optimal thinking about difficult situations. As a primary example, cognitive restructuring is a framework for recognizing negative, inaccurate thoughts and replacing them with alternative ones that are more realistic and helpful. This may involve several steps: write down the situation; list negative thoughts that occurred during the situation; list emotions that arise when having these thoughts; identify cognitive distortions or errors that may underlie each thought; challenge each thought; and generate rational responses. The rational responses are self-statements that are used to reduce distress and view situations in a more helpful light.
Considerations for CBT in Behavioral Medicine Populations
CBT interventions have been incorporated into the American Psychiatric Association clinical practice guidelines for a wide range of psychiatric disorders. However, chronic medical conditions introduce some unique aspects to consider during CBT evaluation and delivery. Psychiatric symptoms can overlap with or mask disease symptoms and treatment side effects (e.g., cancer-related fatigue, dyspnea, or uncontrolled pain), underscoring the importance of assessment and differential diagnosis for behavioral medicine patients. Also, health cognitions and emotional distress levels can be dynamic, changing over time in response to disease-related events (e.g., receiving medical test results), uncertain disease courses, or certain disease progression. For many medical conditions, disease symptoms fluctuate, influencing mobility, fatigue, and cognitive functioning. Adaptations to CBT protocols have been recommended to incorporate these factors. For instance, behavioral activation and homework assignments can be adapted so that patients modulate daily activities according to current level of energy (activity pacing). Cognitive restructuring can be supplemented with acceptance-based or problem-solving strategies when negative health cognitions reflect both realistic and unrealistic elements and both controllable and uncontrollable stressors.
The therapist worked with S.P. to generate a CBT model of her depression and problems with HIV self-care. Socratic questioning was used to help S.P. discover links between her thoughts (perceived impact of HIV on her value as a person); feelings (sadness and loneliness); and behaviors (medical non-adherence and self-isolation). The therapist and S.P. used this model to develop a treatment plan and set goals. S.P.’s main goal was to repair some of the meaningful relationships in her life. The therapist provided psycho-education about depression and HIV. S.P. began to internalize that self-care was a step toward improving relationships with others. Behavioral activation was introduced to help S.P. increase engagement in activities that she used to enjoy and that could give her opportunities to challenge her belief that others would reject her. Activities were modified on days when S.P. experienced fatigue or medication side effects. Cognitive restructuring helped S.P. develop healthier cognitions such as more neutral perceptions of HIV medications. Finally, problem solving was introduced to help S.P. organize her efforts toward increasing her adherence and enhancing her social support. While S.P. experienced setbacks, she increasingly began to recognize her tendency to make devaluing statements about herself during stressful situations, and she continued to work toward changing this pattern.
CBT Applications in Behavioral Medicine
There is substantial evidence to support that CBT interventions improve health behaviors, enhance quality of life, and reduce psychological symptoms among individuals with medical comorbidities. For instance, Safren et al. (2008) developed a CBT intervention for depression and medical adherence (CBT-AD) in patients with chronic illness such as diabetes or HIV. Cognitive behavioral stress management (CBSM) is a group intervention developed by Antoni et al. (2007) to improve quality of life in HIV-infected adults, which was subsequently adapted for cancer survivors (Penedo et al. 2008) and has been shown in long-term follow-up to reduce depressive symptoms and improve quality of life in breast cancer survivors (Stagl et al. 2015). CBT strategies have also been adapted to treat or reduce disability associated with a range of specific medical concerns including nicotine dependence, obesity, insomnia, and various functional pain and fatigue conditions. For instance, CBT for insomnia (CBTI) protocols often focus on sleep education, self-monitoring (recording sleep habits in a sleep diary), stimulus control (associating the bed exclusively with sleeping), and coping skills for relapse prevention (Seyffert et al. 2016). For conditions like nicotine dependence in which individuals are often more ambivalent about addressing their thoughts and behaviors, motivational interviewing and goal setting may be particularly helpful (Lindson-Hawley et al. 2015). To increase the accessibility of CBT to populations with chronic medical conditions, a number of researchers have developed electronic adaptations of face-to-face CBT practices. In this modality, patients complete online sessions and homework assignments over the course of several weeks without direct contact with a therapist. A systematic review and meta-analysis of 15 randomized controlled trials identified that internet-delivered CBTI improved sleep efficiency and reduced insomnia severity, with similar efficacy to in-person therapy (Seyffert et al. 2016).
References and Further Reading
- Antoni, M. H., Schneiderman, N., & Ironson, G. (2007). Stress management for HIV: Clinical validation and intervention manual. Mahwah: Lawrence Erlbaum Associates.Google Scholar
- Ellis, A. (1957). Rational psychotherapy and individual psychology. Journal of Individual Psychology, 13, 38–44.Google Scholar
- Eysenck, H. J. (1966). The effects of psychotherapy. New York: International Science Press.Google Scholar
- Kelly, G. (1955). The psychology of personal constructs. New York: WW Norton.Google Scholar
- Lindson-Hawley, N., Thompson, T. P., & Begh, R. (2015). Motivational interviewing for smoking cessation. Cochrane Database Systematic Review, 2. CD006936Google Scholar
- Safren, S. A., Gonzalez, J. S., & Soroudi, N. (2008). Coping with chronic illness: A cognitive-behavioral therapy approach for adherence and depression: Therapist guide. Oxford: Oxford University Press.Google Scholar
- Seyffert, M., Lagisetty, P., Landgraf, J., Chopra, V., Pfeiffer, P. N., Conte, M. L., & Rogers, M. A. (2016). Internet-delivered cognitive behavioral therapy to treat insomnia: A systematic review and meta-analysis. PLoS One, 11. e0149139Google Scholar
- Stagl, J. M., Bouchard, L. C., Lechner, S. C., Blomber, B. B., Gudenkauf, L. M., Jutagir, D. R., Gluck, S., Derhagopian, R. P., Carver, C. S., & Antoni, M. H. (2015). Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer, 121, 1873–1881.CrossRefPubMedPubMedCentralGoogle Scholar
- Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press.Google Scholar
- Wright, J. H., Basco, M. R., & Thase, M. E. (2006). Learning cognitive-behavioral therapy: An illustrated guide. London/Washington, DC: American Psychiatric Publishing Inc.Google Scholar