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Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing
cognitive distortions A cognitive distortion is an exaggerated or irrational thought pattern involved in the onset or perpetuation of psychopathological states, such as depression and anxiety. Cognitive distortions are thoughts that cause individuals to perceive rea ...
(such as thoughts, beliefs, and attitudes) and their associated behaviors to improve
emotional regulation Emotional self-regulation or emotion regulation is the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well ...
and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of many mental health conditions, including
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
, substance use disorders, marital problems, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies. CBT is a common form of
talk therapy Talk may refer to: Communication * Communication, the encoding and decoding of exchanged messages between people * Conversation, interactive communication between two or more people * Lecture, an oral presentation intended to inform or instruct ...
based on the combination of the basic principles from
behavioral Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as wel ...
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 to alleviate symptoms of the disorder. CBT is based on the belief that thought distortions and
maladaptive In evolution, a maladaptation () is a trait that is (or has become) more harmful than helpful, in contrast with an adaptation, which is more helpful than harmful. All organisms, from bacteria to humans, display maladaptive and adaptive traits. ...
behaviors play a role in the development and maintenance of many
psychological disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
s and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms. When compared to
psychoactive medication A psychoactive drug, psychopharmaceutical, psychoactive agent or psychotropic drug is a chemical substance, that changes functions of the nervous system, and results in alterations in perception, mood, consciousness, cognition or behavior. Th ...
s, review studies have found CBT alone to be as effective for treating less severe forms of depression, anxiety,
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
(PTSD), tics, substance use disorders, eating disorders, and
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
. Some research suggests that CBT is most effective when combined with medication for treating mental disorders, such as major depressive disorder.Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents With Depression: Treatment for Adolescents With Depression Study (TADS) Randomized Controlled Trial. JAMA. 2004; 292(7):807–820. CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and
conduct disorder Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckles ...
. Researchers have found that other ''
bona fide In human interactions, good faith ( la, bona fides) is a sincere intention to be fair, open, and honest, regardless of the outcome of the interaction. Some Latin phrases have lost their literal meaning over centuries, but that is not the case ...
'' 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.


History


Early roots

Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Stoic philosophers, particularly
Epictetus Epictetus (; grc-gre, Ἐπίκτητος, ''Epíktētos''; 50 135 AD) was a Greek Stoic philosopher. He was born into slavery at Hierapolis, Phrygia (present-day Pamukkale, in western Turkey) and lived in Rome until his banishment, when ...
, 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.
Aaron T. Beck Aaron Temkin Beck (July 18, 1921 – November 1, 2021) was an American psychiatrist who was a professor in the department of psychiatry at the University of Pennsylvania.
'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 Epictetus (; grc-gre, Ἐπίκτητος, ''Epíktētos''; 50 135 AD) was a Greek Stoic philosopher. He was born into slavery at Hierapolis, Phrygia (present-day Pamukkale, in western Turkey) and lived in Rome until his banishment, when ...
on
Albert Ellis Albert Ellis (September 27, 1913 – July 24, 2007) was an American psychologist and psychotherapist who founded rational emotive behavior therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was cer ...
. A key philosophical figure who influenced the development of CBT was John Stuart Mill. The modern roots of CBT can be traced to the development of
behavior therapy Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or ...
in the early 20th century, the development of
cognitive therapy Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Co ...
in the 1960s, and the subsequent merging of the two.


First wave: behavior therapy roots

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 Ivan Petrovich Pavlov ( rus, Ива́н Петро́вич Па́влов, , p=ɪˈvan pʲɪˈtrovʲɪtɕ ˈpavləf, a=Ru-Ivan_Petrovich_Pavlov.ogg; 27 February 1936), was a Russian and Soviet experimental neurologist, psychologist and physiolo ...
's work on learning and conditioning, that influenced
Hans Eysenck Hans Jürgen Eysenck (; 4 March 1916 – 4 September 1997) was a German-born British psychologist who spent his professional career in Great Britain. He is best remembered for his work on intelligence and personality, although he worked on other ...
and
Arnold Lazarus Arnold Allan Lazarus (27 January 1932 – 1 October 2013) was a South African-born clinical psychologist and researcher who specialized in cognitive therapy and is best known for developing multimodal therapy (MMT). A 1955 graduate of South Africa ...
to develop new behavioral therapy techniques based on
classical conditioning Classical conditioning (also known as Pavlovian or respondent conditioning) is a behavioral procedure in which a biologically potent stimulus (e.g. food) is paired with a previously neutral stimulus (e.g. a triangle). It also refers to the learn ...
. During the 1950s and 1960s, behavioral therapy became widely used by researchers in the United States, the United Kingdom, and South Africa. Their inspiration was by the
behaviorist Behaviorism is a systematic approach to understanding the behavior of humans and animals. It assumes that behavior is either a reflex evoked by the pairing of certain antecedent stimuli in the environment, or a consequence of that individual ...
learning theory of
Ivan Pavlov Ivan Petrovich Pavlov ( rus, Ива́н Петро́вич Па́влов, , p=ɪˈvan pʲɪˈtrovʲɪtɕ ˈpavləf, a=Ru-Ivan_Petrovich_Pavlov.ogg; 27 February 1936), was a Russian and Soviet experimental neurologist, psychologist and physiolo ...
, John B. Watson, and
Clark L. Hull Clark Leonard Hull (May 24, 1884 – May 10, 1952) was an American psychologist who sought to explain learning and motivation by scientific laws of behavior. Hull is known for his debates with Edward C. Tolman. He is also known for his work in ...
. In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of
systematic desensitization Systematic desensitization, or graduated exposure therapy, is a behavior therapy developed by the psychiatrist Joseph Wolpe. It is used when a phobia or anxiety disorder is maintained by classical conditioning. It shares the same elements of both c ...
, 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 Hans Jürgen Eysenck (; 4 March 1916 – 4 September 1997) was a German-born British psychologist who spent his professional career in Great Britain. He is best remembered for his work on intelligence and personality, although he worked on other ...
presented behavior therapy as a constructive alternative. At the same time as Eysenck's work,
B. F. Skinner Burrhus Frederic Skinner (March 20, 1904 – August 18, 1990) was an American psychologist, behaviorist, author, inventor, and social philosopher. He was a professor of psychology at Harvard University from 1958 until his retirement in 1974. C ...
and his associates were beginning to have an impact with their work on
operant conditioning Operant conditioning, also called instrumental conditioning, is a learning process where behaviors are modified through the association of stimuli with reinforcement or punishment. In it, operants—behaviors that affect one's environment—are c ...
. Skinner's work was referred to as radical behaviorism and avoided anything related to cognition. However,
Julian Rotter Julian B. Rotter (October 22, 1916 – January 6, 2014) was an American psychologist known for developing social learning theory and research into locus of control. He was a faculty member at Ohio State University and then the University of Conne ...
in 1954 and
Albert Bandura Albert Bandura (; December 4, 1925 – July 26, 2021) was a Canadian-American psychologist who was the David Starr Jordan Professor in Psychology at Stanford University. Bandura was responsible for contributions to the field of education and to ...
in 1969 contributed behavior therapy with their respective work on
social learning theory Social learning is a theory of learning process social behavior which proposes that new behaviors can be acquired by observing and imitating others. It states that learning is a cognitive process that takes place in a social context and can occur ...
by demonstrating the effects of cognition on learning and behavior modification. The work of the Australian Claire Weekes dealing with anxiety disorders in the 1960s is also seen as a prototype of behavior therapy. The emphasis on behavioral factors constituted the "first wave" of CBT.


Second wave: cognitive therapy roots

One of the first therapists to address cognition in psychotherapy was
Alfred Adler Alfred Adler ( , ; 7 February 1870 – 28 May 1937) was an Austrian medical doctor, psychotherapist, and founder of the school of individual psychology. His emphasis on the importance of feelings of belonging, family constellation and birth order ...
(1870–1937). Notably, his idea of basic mistakes and how they contributed to creation of unhealthy or useless behavioral and life goals. Abraham Low (1891–1954) believed that someone's thoughts were best changed by changing their actions. Adler and Low influenced the work of
Albert Ellis Albert Ellis (September 27, 1913 – July 24, 2007) was an American psychologist and psychotherapist who founded rational emotive behavior therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was cer ...
, who developed the earliest cognitive-based psychotherapy called rational emotive therapy (contemporarily known as
rational emotive behavioral therapy Rational emotive behavior therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioral pr ...
, or REBT). The first version was announced to the public in 1956. In the late 1950s,
Aaron T. Beck Aaron Temkin Beck (July 18, 1921 – November 1, 2021) was an American psychiatrist who was a professor in the department of psychiatry at the University of Pennsylvania.
was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as
Freud Sigmund Freud ( , ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating pathologies explained as originating in conflicts in ...
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 Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Co ...
, and called these thoughts "automatic thoughts". He first published his new methodology in 1967, and his first treatment manual in 1979. Beck has been referred to as "the father of cognitive behavioral therapy". 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.


Third wave: behavior and cognitive therapies merge

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
cognitive revolution The cognitive revolution was an intellectual movement that began in the 1950s as an interdisciplinary study of the mind and its processes. It later became known collectively as cognitive science. The relevant areas of interchange were between th ...
. The therapeutic approaches of
Albert Ellis Albert Ellis (September 27, 1913 – July 24, 2007) was an American psychologist and psychotherapist who founded rational emotive behavior therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was cer ...
and
Aaron T. Beck Aaron Temkin Beck (July 18, 1921 – November 1, 2021) was an American psychiatrist who was a professor in the department of psychiatry at the University of Pennsylvania.
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, with the primary focus being 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 Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, sho ...
by David M. Clark in the UK and David H. Barlow in the US. Over time, cognitive behavior therapy came 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 behavior therapy (REBT),
cognitive therapy Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Co ...
, acceptance and commitment therapy, dialectical behavior therapy,
metacognitive therapy Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Ge ...
,
metacognitive training Metacognitive training, (MCT), is an approach for treating the symptoms of psychosis in schizophrenia, especially delusions, which has been adapted for other disorders such as depression, obsessive-compulsive disorder and borderline over the ye ...
,
reality therapy Reality therapy (RT) is an approach to psychotherapy and counseling. Developed by William Glasser in the 1960s, RT differs from conventional psychiatry, psychoanalysis and medical model schools of psychotherapy in that it focuses on what Glasser c ...
/ choice theory,
cognitive processing therapy Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the ...
,
EMDR Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro in the 1980s that was originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress d ...
, and
multimodal therapy Multimodal therapy (MMT) is an approach to psychotherapy devised by psychologist Arnold Lazarus, who originated the term ''behavior therapy'' in psychotherapy. It is based on the idea that humans are biological beings that think, feel, act, sense, ...
. All of these therapies are a blending of cognitive- and behavior-based elements. This blending of theoretical and technical foundations from both
behavior Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as we ...
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. Despite the increasing popularity of third-wave treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with non-third wave CBT for the treatment of depression.


Description

Mainstream cognitive behavioral therapy assumes that changing
maladaptive In evolution, a maladaptation () is a trait that is (or has become) more harmful than helpful, in contrast with an adaptation, which is more helpful than harmful. All organisms, from bacteria to humans, display maladaptive and adaptive traits. ...
thinking leads to change in
behavior Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as we ...
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 A cognitive distortion is an exaggerated or irrational thought pattern involved in the onset or perpetuation of psychopathological states, such as depression and anxiety. Cognitive distortions are thoughts that cause individuals to perceive rea ...
, 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 overgeneralization 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 Psychological evaluation is a method to assess an individual's behavior, personality, cognitive abilities, and several other domains. A common reason for a psychological evaluation is to identify psychological factors that may be inhibiting a pers ...
; # 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: # Identify critical behaviors # Determine whether critical behaviors are excesses or deficits # Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline) # 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 Biofeedback is the process of gaining greater awareness of many physiological functions of one's own body by using electronic or other instruments, and with a goal of being able to manipulate the body's systems at will. Humans conduct biofeedbac ...
, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and
goal setting A goal is an idea of the future or desired result that a person or a group of people envision, plan and commit to achieve. People endeavour to reach goals within a finite time by setting deadlines. A goal is roughly similar to a purpose or a ...
". 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 Self-help or self-improvement is a self-guided improvement''APA Dictionary of Physicology'', 1st ed., Gary R. VandenBos, ed., Washington: American Psychological Association, 2007.—economically, intellectually, or emotionally—often with a subst ...
applications. Some clinicians and researchers are cognitively oriented (e.g.
cognitive restructuring Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions,Gladding, Samuel. Counseling: A Comprehensive Review. 6th. Columbus: Pearson Educatio ...
), 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 processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the ...
,
cognitive therapy Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Co ...
,
metacognitive therapy Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Ge ...
,
metacognitive training Metacognitive training, (MCT), is an approach for treating the symptoms of psychosis in schizophrenia, especially delusions, which has been adapted for other disorders such as depression, obsessive-compulsive disorder and borderline over the ye ...
, 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 be an effective part of treatment plans for
anxiety disorder Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
s,
body dysmorphic disorder Body dysmorphic disorder (BDD), occasionally still called dysmorphophobia, is a mental disorder characterized by the obsessive idea that some aspect of one's own body part or appearance is severely flawed and therefore warrants exceptional meas ...
, depression,
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
s, chronic low back pain,
personality disorder Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's cultur ...
s,
psychosis Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior t ...
, schizophrenia, substance use disorders, and bipolar disorder. It is also effective as part of treatment plans in the adjustment, depression, and anxiety associated with fibromyalgia, and with post-
spinal cord injuries A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal co ...
. In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and
suicidality Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and subs ...
, eating disorders and obesity, obsessive–compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), as well as
tic disorder Tic disorders are defined in the ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM) based on type (motor or phonic) and duration of tics (sudden, rapid, nonrhythmic movements). Tic disorders are defined similarly by the World Health ...
s, trichotillomania, and other repetitive behavior disorders. CBT has also been applied to a variety of childhood disorders, including depressive disorders and various anxiety disorders. CBT has shown to be the most effective intervention for people exposed to
adverse childhood experiences Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood. The harms of ACEs can be long-lasting, affecting people even in their adulthood. ACEs have ...
in the form of abuse or neglect. 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. Evidence suggests that the addition of
hypnotherapy Hypnotherapy is a type of mind–body intervention in which hypnosis is used to create a state of focused attention and increased suggestibility in the treatment of a medical or psychological disorder or concern. Popularized by 17th and 18th c ...
as an adjunct to CBT improves treatment efficacy for a variety of clinical issues. The United Kingdom's
National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies wit ...
(NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including PTSD, OCD,
bulimia nervosa Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
, and
clinical depression Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introd ...
.


Patient age

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. Of the small number of studies examining CBT for the management of depression in older people, there is currently no strong support.


Depression and anxiety disorders

Cognitive behavioral therapy has been shown as an effective treatment for clinical depression. The
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
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. A 2001 meta-analysis comparing CBT and psychodynamic psychotherapy suggested the approaches were equally effective in the short term for depression. In contrast, a 2013 meta-analyses suggested that CBT,
interpersonal therapy Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limite ...
, and problem-solving therapy outperformed psychodynamic psychotherapy and
behavioral activation Behavioral activation (BA) is a third generation behavior therapy for treating depression. It is one form of functional analytic psychotherapy, which is based on a Skinnerian psychological model of behavior change, generally referred to as appl ...
in the treatment of depression. 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 mental disorders. This included depression,
panic disorder Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, sho ...
,
post-traumatic stress Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, and other anxiety disorders. CBT has been shown to be effective in the treatment of adults with anxiety disorders. Results from a 2018 systematic review found a high strength of evidence that CBT-exposure therapy can reduce PTSD symptoms and lead to the loss of a PTSD diagnosis. CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age). A Cochrane review found low quality evidence that CBT may be more effective than other psychotherapies in reducing symptoms of posttraumatic stress disorder in children and adolescents. 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." Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.


Theoretical approaches

One
etiological Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, e ...
theory of depression is
Aaron T. Beck Aaron Temkin Beck (July 18, 1921 – November 1, 2021) was an American psychiatrist who was a professor in the department of psychiatry at the University of Pennsylvania.
'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 The word schema comes from the Greek word ('), which means ''shape'', or more generally, ''plan''. The plural is ('). In English, both ''schemas'' and ''schemata'' are used as plural forms. Schema may refer to: Science and technology * 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 In clinical psychology, selective abstraction is a type of cognitive bias or cognitive distortion in which a detail is taken out of context and believed whilst everything else in the context is ignored. It commonly appears in Aaron T. Beck's work i ...
, overgeneralization, magnification, and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema. A basic concept in some CBT treatments used in anxiety disorders is ''in vivo''
exposure Exposure or Exposures may refer to: People * The Exposures, a pseudonym for German electronic musician Jan Jeline Arts, entertainment, and media Films * ''Exposure'' (film), a 1932 American film * ''Exposure'', another name for the 1991 movie ...
. CBT-exposure therapy 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 a 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).


Specialised forms of CBT

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. 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. Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children. 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.


Combined with other treatments

Studies have provided evidence that when examining animals and humans, that glucocorticoids may lead to a more successful extinction learning during exposure therapy for anxiety disorders. 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 people with anxiety disorders.


Prevention

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. Individuals with subthreshold levels of panic disorder significantly benefitted 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.


Bipolar disorder

Many studies show CBT, combined with pharmacotherapy, is effective in improving depressive symptoms, mania severity and psychosocial functioning with mild to moderate effects, and that it is better than medication alone. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including bipolar disorder. This included schizophrenia, depression,
bipolar disorder Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each. If the elevated mood is severe or associated with ...
,
panic disorder Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, sho ...
,
post-traumatic stress Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, anxiety disorders,
bulimia Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eate ...
,
anorexia Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gre ...
, personality disorders and
alcohol dependency Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol). In 2013, it was reclassified as alcohol use disorder ...
.


Psychosis

In long-term
psychoses Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior t ...
, 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. Meta-analyses confirm the effectiveness of
metacognitive training Metacognitive training, (MCT), is an approach for treating the symptoms of psychosis in schizophrenia, especially delusions, which has been adapted for other disorders such as depression, obsessive-compulsive disorder and borderline over the ye ...
(MCT) for the improvement of positive symptoms (e.g., delusions). For people at risk of
psychosis Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior t ...
, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT.


Schizophrenia

INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including schizophrenia. A Cochrane review reported CBT had "no effect on long‐term risk of relapse" and no additional effect above standard care. A 2015 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia and determined that there is no clear advantage over other, often less expensive, interventions but acknowledged that better quality evidence is needed before firm conclusions can be drawn.


Addiction and substance use disorders


Pathological and problem gambling

CBT is also used for pathological and problem gambling. 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. There is evidence of efficacy of CBT for treating pathological and problem gambling at immediate follow up, however the longer term efficacy of CBT for it is currently unknown.


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. Since 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 with strong cravings, which are a major reported reason for relapse during treatment. In a 2008 controlled study out of Stanford University School of Medicine suggested CBT may be an effective tool to help maintain abstinence. 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. Individuals with a history of depressive disorders had a lower rate of success when using CBT alone to combat smoking addiction. A Cochrane review was unable to find evidence of any difference between CBT and hypnosis for smoking cessation. While this may be evidence of no effect, further research may uncover an effect of CBT for smoking cessation.


Substance use disorders

Studies have shown CBT to be an effective treatment for substance use disorders. For individuals with substance use disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimizing and catastrophizing thought patterns, with healthier narratives. Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including
alcohol dependency Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol). In 2013, it was reclassified as alcohol use disorder ...
.


Internet addiction

Research has identified
Internet addiction Problematic internet use or pathological internet use is generally defined as problematic, compulsive use of the internet, that results in significant impairment in an individual's function in various life domains over a prolonged period of time ...
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.


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 Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
, and Eating Disorder Non-Specific. While there is evidence to support the efficacy of CBT for bulimia nervosa and binging, the evidence is somewhat variable and limited by small study sizes. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including
bulimia Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eate ...
and
anorexia nervosa Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gre ...
.


With autistic adults

Emerging evidence for cognitive behavioral interventions aimed at reducing symptoms of depression, anxiety, and obsessive-compulsive disorder in autistic adults without intellectual disability has been identified through a systematic review. While the research was focused on adults, cognitive behavioral interventions have also been beneficial to autistic children.


Dementia and mild cognitive impairment

A Cochrane review in 2022 found that adults with dementia and mild cognitive impairment (MCI) who experience symptoms of depression may benefit from CBT, whereas other counselling or supportive interventions might not improve symptoms significantly. Across 5 different psychometric scales, where higher scores indicate severity of depression, adults receiving CBT reported somewhat lower mood scores than those receiving usual care for dementia and MCI overall. In this review, a sub-group analysis found
clinically significant In medicine and psychology, clinical significance is the practical importance of a treatment effect—whether it has a real genuine, palpable, noticeable effect on daily life. Types of significance Statistical significance Statistical significance ...
benefits only among those diagnosed with dementia, rather than MCI. The likelihood of remission from depression also appeared to be 84% higher following CBT, though the evidence for this was less certain. Anxiety, cognition and other neuropsychiatric symptoms were not significantly improved following CBT, however this review did find moderate evidence of improved quality of life and daily living activity scores in those with dementia and MCI.


Other uses

Evidence suggests a possible role for CBT in the treatment of
attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inapp ...
(ADHD), hypochondriasis, and bipolar disorder, but more study is needed and results should be interpreted with caution. CBT has been studied as an aid in the treatment of anxiety associated with
stuttering Stuttering, also known as stammering, is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words, or phrases as well as involuntary silent pauses or blocks in which the ...
. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter, but not in reducing stuttering frequency. There is some evidence that CBT is superior in the long-term to
benzodiazepine Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, i ...
s and the nonbenzodiazepines in the treatment and management of insomnia. Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating 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 insomnia. A Cochrane review of interventions aimed at preventing psychological stress in healthcare workers found that CBT was more effective than no intervention but no more effective than alternative stress-reduction interventions. Cochrane Reviews have 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 Abuse is the improper usage or treatment of a thing, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, assault, violation, rape, unjust practices, crimes, or other t ...
their intimate partners. CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality disorders and behavioral problems. INSERM's 2004 review found that CBT is an effective therapy for personality disorders.


Individuals with medical conditions

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. A 2015 Cochrane review also found that CBT for symptomatic management of non-specific chest pain is probably effective in the short term. However, the findings were limited by small trials and the evidence was considered of questionable quality.
Cochrane reviews Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health profess ...
have found no evidence that CBT is effective for
tinnitus Tinnitus is the perception of sound when no corresponding external sound is present. Nearly everyone experiences a faint "normal tinnitus" in a completely quiet room; but it is of concern only if it is bothersome, interferes with normal hearin ...
, although there appears to be an effect on management of associated depression and quality of life in this condition. CBT combined with hypnosis and distraction reduces self-reported pain in children. There is limited evidence to support its use in coping with the impact of multiple sclerosis, sleep disturbances related to aging, and
dysmenorrhea Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the ...
, but more study is needed and results should be interpreted with caution. Previously CBT has been considered as moderately effective for treating
chronic fatigue syndrome Chronic fatigue syndrome (CFS), also called myalgic encephalomyelitis (ME) or ME/CFS, is a complex, debilitating, long-term medical condition. The causes and mechanisms of the disease are not fully understood. Distinguishing core symptoms are ...
. however a National Institutes of Health Pathways to Prevention Workshop stated that in respect of improving treatment options for ME/CFS that the modest benefit from cognitive behavioral therapy should be studied as an adjunct to other methods. The Centres for Disease Control advice on the treatment of ME/CFS makes no reference to CBT while the
National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies wit ...
states that cognitive behavioral therapy (CBT) has sometimes been assumed to be a cure for ME/CFS, however, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness."


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 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 are informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and the attainment of goals. These are often met through "
homework Homework is a set of tasks assigned to students by their teachers to be completed outside the classroom. Common homework assignments may include required reading, a writing or typing project, mathematical exercises to be completed, informatio ...
" 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 with 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 A therapeutic alliance, or working alliance, is a partnership between a patient and his or her therapist that allows them to achieve goals through agreed-upon tasks. The concept of therapeutic alliance dates back to Sigmund Freud. Over the cour ...
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 (CCBT)

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 Educational technology (commonly abbreviated as edutech, or edtech) is the combined use of computer hardware, software, and educational theory and practice to facilitate learning. When referred to with its abbreviation, edtech, it often refe ...
. Although improvements in both research quality and treatment adherence is required before advocating for the global dissemination of CCBT, it 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. In February 2006 NICE recommended that CCBT be made available for use within the
NHS The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
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.


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 A chatbot or chatterbot is a software application used to conduct an on-line chat conversation via text or text-to-speech, in lieu of providing direct contact with a live human agent. Designed to convincingly simulate the way a human would beha ...
applications in delivering CBT as an early intervention to support mental health, to build
psychological resilience Psychological resilience is the ability to cope mentally or emotionally with a crisis or to return to pre-crisis status quickly. The term was coined in the 1970s by a psychologist named Emmy E. Werner as she conducted a forty year long study of ...
, and to promote emotional well-being.
Artificial intelligence Artificial intelligence (AI) is intelligence—perceiving, synthesizing, and inferring information—demonstrated by machines, as opposed to intelligence displayed by animals and humans. Example tasks in which this is done include speech re ...
(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


Brief cognitive behavioral therapy

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 and specifically for those struggling with suicidal ideation and/or making suicide attempts. BCBT was based on Rudd's proposed "suicidal mode", an elaboration of Beck's modal theory. 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 with soldiers on active duty by Dr. M. David 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 Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
, depression, obsessive compulsive disorder (OCD),
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
(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 Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health ...
and psychology: most notably,
Albert Ellis Albert Ellis (September 27, 1913 – July 24, 2007) was an American psychologist and psychotherapist who founded rational emotive behavior therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was cer ...
'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 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 Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard of, or violation of, the rights of others as well as a difficulty sustaining long-term relationships. Lack ...
(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 certain 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 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 preventive 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.


Activity-guided CBT: Group-knitting

A newly developed group therapy model based on CBT integrates knitting into the therapeutical process and has been proven to yield reliable and promising results. The foundation for this novel approach to CBT is the frequently emphasized notion that therapy success depends on the embeddedness of the therapy method in the patients' natural routine. Similar to standard group-based CBT, patients meet once a week in a group of 10 to 15 patients and knit together under the instruction of a trained psychologist or mental health professional. Central for the therapy is the patient's imaginative ability to assign each part of the wool to a certain thought. During the therapy, the wool is carefully knitted, creating a knitted piece of any form. This therapeutical process teaches the patient to meaningfully align thought, by (physically) creating a coherent knitted piece. Moreover, since CBT emphasizes the behavior as a result of cognition, the knitting illustrates how thoughts (which are tried to be imaginary tight to the wool) materialize into the reality surrounding us.


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 Boston University (BU) is a Private university, private research university in Boston, Massachusetts. The university is nonsectarian, but has a historical affiliation with the United Methodist Church. It was founded in 1839 by Methodists with ...
, that can be applied to a range of 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 Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
. Several studies have shown that the UP is easier to disseminate as compared to single-diagnosis protocols.


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. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e., measures of general functioning) no significant differences have been typically found between CBT and other treatments. 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 Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each. If the elevated mood is severe or associated with ...
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.


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 size In statistics, an effect size is a value measuring the strength of the relationship between two variables in a population, or a sample-based estimate of that quantity. It can refer to the value of a statistic calculated from a sample of data, the ...
s: 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. One meta-analysis found that CBT drop-out rates were 17% higher than those of other therapies. This high drop-out rate is also evident in the treatment of several disorders, particularly the
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
anorexia nervosa Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gre ...
, 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 analyzing 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.


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. 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 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. 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 regarded as having very few if any side effects. Calls have been made by some for more appraisal of possible side effects of CBT. Many randomized trials of psychological interventions like CBT do not monitor potential harms to the patient. In contrast, randomized trials of pharmacological interventions are much more likely to take adverse effects into consideration. A 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications. Nevertheless, CBT therapists do sometimes report 'unwanted events' and side effects in their outpatients with "negative wellbeing/distress" being the most frequent.


Socio-political concerns

The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with "the parallel rise of neoliberalism, with its focus on marketization, efficiency, quantification and
managerialism Managerialism is the reliance on professional managers and organizational strategies to run a society. It may be justified in terms of efficiency, or characterized as an ideology. It is a belief system that requires little or no evidence to justi ...
", and he questions the scientific basis of CBT, suggesting that "the 'science' of psychological treatment is often less a scientific than a political contest". In his book, Dalal also questions the ethical basis of CBT.


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 Improving Access to Psychological Therapies (IAPT), also known as talking therapies is a National Health Service (England) initiative to provide more psychotherapy to the general population. It was developed and introduced by the Labour Party as ...
(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 Andrew Samuels (born 19 January 1949) is a British psychotherapist and writer on political and social themes from a psychological viewpoint. He has worked with politicians, political organisations, activist groups and members of the public in Eu ...
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 The United Kingdom Council for Psychotherapy (UKCP) is a professional association of psychotherapy organisations and practitioners in the United Kingdom. It is restricted to registered clinical psychotherapists and psychotherapeutic counsell ...
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 with schizophrenia, as well as those at risk of a psychotic episode.


References


Further reading

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External links

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Association for Behavioral and Cognitive Therapies (ABCT)

British Association for Behavioural and Cognitive Psychotherapies

National Association of Cognitive-Behavioral Therapists

International Association of Cognitive Psychotherapy

Information on Research-based CBT Treatments

Associated Counsellors & Psychologists CBT Therapists
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