Cognitive-behavioral Therapy, Behavioral Therapy, and Cognitive Therapy

Overview

Cognitive-behavioral therapy (CBT) is one of the most extensively researched forms of psychotherapy that is increasingly recognized as the treatment of choice for many disorders. Findings from randomized controlled trials (RCTs) typically suggest that CBT is better than wait-list control groups, as well as supportive treatment and other credible interventions, for specific disorders. Early implementations of CBT were largely indicated for anxiety and mood disorders. However, more recent clinical research efforts have begun to develop CBT for an increasingly wider array of problems (including bipolar disorder, eating disorders, body dysmorphic disorder, attention-deficit/hyperactivity disorder, and psychotic disorders ).

The empirical evidence for the use of CBT for a broad range of conditions is promising. However, there remains a noticeable gap between encouraging reports from clinical trials and the widespread adoption of CBT interventions among general practitioners. Moreover, questions remain regarding the limits of, and indications for, the efficacy of CBT in general practice. Nevertheless, it is clear that CBT represents the best of what the psychotherapy community currently has to offer in terms of evidence-supported treatment options.

CBT generally refers to a treatment that uses behavioral and cognitive interventions; it is derived from scientifically-supported theoretical models. Thus, there exists a theoretically consistent relationship between CBT techniques and the disorders that they are designed to treat. Depending on the disorder, interventions may be directed toward eliminating cognitive and behavioral patterns that are directly linked to the development or maintenance of the disorder, or they may be directed toward maximizing coping skills to address the elicitation or duration of symptoms from disorders driven by other (e.g., biological) factors.

Behavioral Therapy, Cognitive Therapy, and Cognitive-Behavioral Therapy

Cognitive-behavioral therapies represent an integration of two strong traditions within psychology: behavioral therapy (BT) and cognitive therapy (CT). BT employs principles of learning to change human behavior. BT techniques include exposure, relaxation, assertion training, social skills training, problem-solving training, modeling, contingency management, and behavioral activation. Many of these interventions are a direct outgrowth of principles of operant and respondent conditioning. Operant conditioning is concerned with the modification of behaviors by manipulation of the rewards and punishments, as well as the eliciting events. For example, in the treatment of substance dependence, the use of specific contingencies between drug abstinence (as frequently confirmed by urine or saliva toxicology screens) and rewards (e.g., the chance to win a monetary reward) has proven to be a powerful strategy for achieving abstinence among chronic drug abusers. Included as an operant strategy are also the myriad of interventions that use stepwise training to engender needed new skills for problem situations. For example, assertiveness training, relaxation training, and problem-solving training are all core behavioral strategies for intervening with skill deficits that may be manifest in disorders as diverse as depression, bipolar disorder, or hypochondriasis. One approach to treating depression, behavioral activation, emphasizes the return to pleasurable and productive activities, and the specific use of these activities to boost mood. Interventions involve the step-by-step programming of activities rated by patients as relevant to their personal values and likely to evoke pleasure or a sense of personal productivity. Behavioral activation will typically consist of construction of an activity hierarchy in which up to (approximately) 15 activities are rated, ranging from easiest to most difficult to accomplish. The patient then moves through the hierarchy in a systematic manner, progressing from the easiest to the most difficult activity. Depending on the patient, additional interventions or skill development may be needed. For example, assertion training may include a variety of interventions, such as behavioral rehearsal, which is acting out appropriate and effective behaviors, to manage situations in which assertiveness is problematic.

Respondent conditioning refers to the changing of the meaning of a stimulus through repeated pairings with other stimuli, and respondent conditioning principles have been particularly applied to interventions for anxiety disorders. For example, influential theories such as Mowrer's two-factor theory of phobic disorders emphasized the role of respondent conditioning in establishing fearful responses to phobic cues, and the role of avoidance in maintaining the fear. Accordingly, BT focuses on the role of exposure to help patients re-enter phobic situations and to eliminate (extinguish) learned fears about these phobic stimuli through repeated exposure to them under safe conditions. Exposure treatments may include any number of modalities or procedures. For example, a patient with social phobia may be exposed to a series of social situations that elicit anxiety, including in vivo exposure (e.g., talking on the phone, talking with strangers, giving a speech), imaginal exposure (e.g., imagining themselves in a social situation), exposure to feared sensations (termed interoceptive exposure because exposure involves the elicitation of feared somatic sensations, typically sensations similar to those of anxiety and panic), and exposure to feared cognitions (e.g., exposure to feared concepts using imaginal techniques). Exposure is generally conducted in a graduated fashion, in contrast to flooding, in which the person is thrust into the most threatening situation at the start. Exposure is designed to help patients learn alternative responses to a variety of situations by allowing fear to dissipate (become extinguished) while remaining in the feared situation. Once regarded as a passive weakening of learned exposures, extinction is now considered an active process of learning an alternative meaning to a stimulus (e.g., relearning a sense of “safety” with a once-feared stimulus), and ongoing research on the principles, procedures, and limits of extinction as informed by both animal and human studies has the potential for helping clinicians further hone in on the efficacy of their exposure-based treatments. For example, there is increasing evidence that the therapeutic effects of exposure are maximized when patients are actively engaged in, and attentive to, exposure-based learning; when exposure is conducted in multiple, realistic contexts; and when patients are provided with multiple cues for safety learning. Therapists should also ensure that the learning that occurs during exposure is independent of contexts that will not be present in the future (e.g., the presence of the therapist). Effective application of exposure therapy also requires prevention of safety behaviors that may undermine what is learned from exposure. Safety behaviors refer to those behaviors that individuals may use to reassure themselves in a phobic situation. For example, a patient with panic disorder may carry a cell phone or a water bottle for help or perceived support during a panic attack. These safety behaviors, while providing reassurance to patients, appear to block the full learning of true safety. That is, when such safety behaviors are made unavailable, better extinction (safety) learning appears to result.

CT was initially developed as a treatment for depression with the understanding that thoughts influence behavior and it is largely maladaptive thinking styles that lead to maladaptive behavior and emotional distress. Currently, however, CT includes approaches to a wider range of disorders.

As applied to depression, the cognitive model posits that intrusive cognitions associated with depression arise from a synthesis of previous life experiences. The synthesis of such experiences is also described as a schema, a form of semantic memory that describes self-relevant characteristics. For example, the cognitive model of depression posits that negative “schemas” about the self that contain absolute beliefs (e.g., “I am unlovable” or “I am incompetent”) may result in dysfunctional appraisals of the self, the world, and the future. On exposure to negative life events, negative schemas and dysfunctional attitudes are activated that may produce symptoms of depression. Thus, maladaptive cognitive patterns and negative thoughts may also be considered risk or maintaining factors for depression. Negative automatic thoughts can be categorized into a number of common patterns of thought referred to as cognitive distortions. As outlined in Table 16-1 , cognitive distortions often occur automatically and may manifest as irrational thoughts or as maladaptive interpretations of relatively ambiguous life events.

CT, and a similar approach known as rational-emotive therapy, provides techniques that correct distorted thinking and offer a means by which patients can respond to maladaptive thoughts more adaptively. In addition to examining cognitive distortions (see Hollon and Garber and Table 16-1 ), CT focuses on more pervasive core beliefs (e.g., “I am unlovable” or “I am incompetent”) by assessing the themes that lie behind recurrent patterns of cognitive distortions. Those themes may be evaluated with regard to a patient's learning history (to assess the etiology of the beliefs with the goal of logically evaluating and altering the maladaptive beliefs).

A commonly used cognitive technique is cognitive restructuring. Cognitive restructuring begins by teaching a patient about the cognitive model and by providing a patient with tools to recognize (negative) automatic thoughts that occur “on-line”. Most therapists use a daily log or a diary to monitor negative automatic thoughts. Some patients find it convenient to do this work using an “app” on their smart phone or using their tablet or laptop computer. The next step in cognitive restructuring is to provide the patient with opportunities to evaluate his or her thoughts with respect to their usefulness, as well as their validity. Through the process of logically analyzing thoughts, a patient is provided with a unique context for replacing distorted thoughts with more accurate and realistic thoughts. One method for helping a patient engage in critical analysis of thinking patterns is to consider the objective evidence for and against the patient's maladaptive thoughts. Thus, questions such as, “What is the evidence that I am a bad mother? What is the evidence against it?” might be asked. Another useful technique places the patient in the role of adviser. In the role of adviser, a patient is asked what advice he or she might give a family member or friend in the same situation. By distancing the patient from his or her own maladaptive thinking, the patient is given the opportunity to engage in a more rational analysis of the issue. These techniques allow patients to test the validity and utility of their thoughts; as they evaluate their thinking and see things more rationally, they are able to function better. In addition to techniques for changing negative thinking patterns, CT also incorporates behavioral experiments. Behavioral tasks and experiments are employed in CT to provide corrective data that will challenge beliefs and underlying negative assumptions.

Concerning the mechanism of relapse prevention in CT, there is growing attention to the importance of the processing and form of negative thoughts, not just their content. Studies suggest that cognitive interventions may be useful for helping patients gain perspective on their negative thoughts and feelings so that these events are not seen as “necessarily valid reflections of reality” (Teasdale et al., p. 285). Indeed, there is evidence that changes in meta-cognitive awareness may mediate the relapse prevention effects of CT. Accordingly, shifting an individual's emotional response to cognitions may be an important element of the strong relapse prevention effects associated with CT.

Although CT was initially developed to focus on challenging depressive distortions, basic maladaptive assumptions are also observed in a wide range of other conditions, with the development of CT approaches ranging from panic disorder, post-traumatic stress disorder (PTSD), social phobia, and hypochondriasis, to personality disorders and the prevention of suicide.

Putting Behavioral Therapy and Cognitive Therapy Together

As a functional unification of cognitive and behavioral interventions, CBT relies heavily on functional analysis of inter­related chains of thoughts, emotions, and behavior. Thus, the principles that underlie CBT are easily exportable to a wide range of behavioral deficits. As outlined in Table 16-2 , CT, BT, and their combination have garnered empirical support for the treatment of a wide range of disorders. CBT has become increasingly specialized in the last decade, and advances in the conceptualization of various disorders have brought a refinement of CBT interventions to target core features and dominant behavior patterns that characterize various disorders.

The Practice of Cognitive-behavioral Therapy: The Case of Panic Disorder

CBT for panic disorder generally consists of 12 to 15 sessions; it begins with an introduction of the CBT model of panic disorder ( Figure 16-1 ). The therapist begins by discussing the symptoms of panic with the patient. The symptoms of panic (e.g., rapid heart rate, shortness of breath, and trembling) are explained as part of our body's natural defense system that prepares us for fight or flight in the presence of a real threat. When these symptoms occur in the presence of a real danger, the response helps us survive. When the symptoms occur in the absence of a real danger, the response is a panic attack. Often when a person experiences a panic attack “out of the blue,” he or she fears that something is terribly wrong. The person fears that he or she may be having a heart attack, may be seriously ill, or may be “going crazy.” Patients are told that these catastrophic misinterpretations of the symptoms of panic disorder serve to maintain the disorder. Such interpretations cause the individual to fear another attack; as a consequence, the person becomes hypervigilant for any somatic sensations that may signal the onset of an attack. This hypervigilance, in turn, heightens the individual's awareness of his or her body and increases somatic sensations that lead to more anxiety. This cycle continues, culminating in a panic attack.

Over the course of treatment, the therapist works with the patient to examine the accuracy of catastrophic misinterpretations through Socratic questioning and provision of corrective information. For example, the patient may be asked to evaluate the evidence for all of the likely consequences of a panic attack. Additionally, the patient is gradually exposed to the somatic sensations that he or she fears (a process called interoceptive exposure ). Interoceptive exposure consists of a wide variety of procedures (such as hyperventilation, exercise, or spinning in a chair ) meant to expose a patient to feared internal bodily experiences (e.g., tachycardia, numbness, or tingling) in a controlled fashion. Through repeated exposure to these sensations, a patient habituates to the sensations, which results in a decrease in fear and anxiety linked to internal stimuli. With repeated exposure, a patient learns that the sensations are not harmful.

Cognitive restructuring is combined with interoceptive exposure to aid the patient in reinterpreting the somatic sensations and reducing fear. For a patient with agoraphobia, gradual situational exposure is also conducted to eliminate avoidance of situations that have been associated with panic. In all exposure exercises, special attention must be paid to the elimination of safety behaviors that may interfere with habituation to the fear and extinction learning. Safety behaviors include anything that the patient may do to avoid experiencing anxiety. This could include carrying a bottle of pills in the patient's pocket or having a cell phone with the patient to call for help. To maximize the exposure exercises, these behaviors must be gradually eliminated. The patient must learn that he or she will be okay even in the absence of such behaviors. The use of relaxation techniques for the treatment of panic may also be beneficial. However, Barlow and associates found that adding relaxation to the treatment (emphasizing cognitive restructuring and interoceptive exposure) appeared to reduce the efficacy of the treatment over time (see also Schmidt et al. ). This suggests that, in some cases, a patient may engage in relaxation as a safety technique (i.e., a patient may rely too much on relaxation as a panic management technique at the expense of learning not to be afraid of anxiety-related sensations). Although relaxation techniques may come to serve the function of avoidance for some patients with panic disorder, studies have shown that relaxation strategies offer some benefit to patients with a wide range of anxiety disorders. Thus, the decision to offer relaxation techniques in CBT for patients with panic disorder should be informed by the context in which the patient will apply such techniques.

The Efficacy of Cognitive-Behavioral Therapy

As outlined in Table 16-1 , cognitive and behavioral techniques and their combination (CBT) are generally considered to be empirically-supported interventions for a wide range of disorders. In fact, numerous outcome trials have demonstrated that CBT is effective for a host of psychiatric disorders, as well as for medical disorders with psychological components. However, diagnostic co-morbidity, personality disorders, or complex medical problems may complicate CBT treatment. Such complications do not imply that a patient will not respond well to CBT, but rather that the patient might have a slower response to treatment.

In an attempt to integrate findings from RCTs, multiple meta-analytic studies (which allow researchers to synthesize quantitatively the results from multiple studies in an effort to characterize the general effectiveness of various interventions) have been conducted. Two recent reviews of the most comprehensive meta-analyses conducted for the efficacy of CBT have nicely summarized the treatment outcome effect sizes for adult unipolar depression, adolescent depression, GAD, panic disorder with or without agoraphobia, social phobia, obsessive-compulsive disorder (OCD), PTSD, schizophrenia, marital distress, anger, bulimia, internalizing childhood disorders, sexual offending, and chronic pain (excluding headache). A review of these meta-analyses and other relevant findings is presented next and summarized in Tables 16-4 to 16-10 .