What is Cognitive Behavioral Therapy (CBT)
The cognitive behavioral approach to psychotherapy is widely utilized by many clinicians. The approach blends both traditional behavioral and cognitive methods of psychotherapy in treating a variety of mental health conditions. Cognitive Behavioral Therapy, (CBT), is currently the most researched form of psychotherapy (Hoffman, et al, 2004). This is in part due to the integration of this modality utilizing strategies borrowed from cognitive therapy, traditional behavior therapy, and rational emotive therapy (Wedding & Corsini, 2018). CBT includes directive, brief interventions to elicit almost immediate responses improving functioning and quality of life for the client. This evidence-based approach is solution-oriented focusing on adjusting maladaptive responses to emotions, behavior, and thoughts. The CBT approach offers a collection of diverse techniques for treating a variety of problems and disorders. This approach is adaptable to various treatment settings, client populations, and mental and physiological health conditions.
Cognitive Behavioral Therapy origins can be traced back partially to the theories of B.F. Skinner and Joseph Wolpe, who pioneered the behavioral therapy movement in the 1950’s (Kaczkurkin & Foa, 2015). CBT developed mainly through the work of Aaron Beck and Albert Ellis however, there were numerous psychologists that influenced what we know as CBT. Beck in the 1960’s, noticed that the psychoanalytic approach was not effective in treating depressed clients who were experiencing negative thoughts that prevented them from progress. Following his desire to explore a form of therapy more empirical than Freudian psychoanalysis in treating depression, he defined and described the procedures of cognitive therapy (Wedding & Corsini, 2018). Albert Ellis in the 1950’s also became discouraged with psychoanalysis, he postulated that distress was not only constructed in our early experiences but also a product of our dysfunctional demands of ourselves continuously reinforced with behavior (Wedding & Corsini, 2018). Ellis developed Rational Emotive Behavior Therapy based on his core philosophy that behavioral and emotional problems stem from our own irrational beliefs. Ellis hypothesized that changing our irrational beliefs would allow for a change of emotion followed by behavioral change resulting in overall improvement. The result of the work of both behavioral and cognitive psychologists inspired a significant shift in psychotherapy offering clients CBT, a treatment option that is short-term, goal-oriented, and scientifically validated.
The Beck Institute for Cognitive Behavioral Therapy defines CBT as, “a time-sensitive, structured, present-oriented psychotherapy that has been scientifically tested and found to be effective in more than 2,000 studies for the treatment of many different health and mental health conditions” (Beckinstitue.org, 2021). CBT is theoretically based in the way in which individuals perceive a situation connected to their reaction to that situation itself. In essence, thoughts, feelings, and behaviors are all closely connected and have a decisive influence on well-being. Perceptions are often distorted in an unhelpful manner especially when an individual is experiencing distress. From these distorted perceptions dysregulated emotions develop which provokes maladaptive behavioral patterns as a way of coping with the experienced distress. If negative cognitions are learned and reinforced through behavioral intervention, this can become an automatic response further solidifying distress and dysfunction.
According to the APA (2017), the core principles of CBT are that: psychological problems are based, in part, on faulty or unhelpful ways of thinking, in part, on learned patterns of unhelpful behavior, and that people suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives. CBT is a problem-focus approach oriented in the here-and-now. Opposed to traditional methods of psychotherapy, CBT does not elaborate on past experiences as a foundation or trigger for current problems. Instead, the approach focuses on present circumstances and emotions in real-time in congruence to their impact on well-being and daily functioning. In CBT therapists must develop a strong therapeutic alliance to support clients in recognizing the relationship between their belief systems, their emotions, and their behavior. Psychoeducation is an essential component in CBT assisting with the client’s understanding of the relationship between dysfunctional cognitive schemas and maladaptive behaviors as well as the empirical basis for the structured techniques CBT embraces. CBT clinicians assist their clients in identifying harmful and/or distorted thoughts occurring presently. This is followed by structured and systematic challenging or disproving of these thoughts and then replacing them with realistic alternatives. Problem solving strategies are utilized to identify whether or not beliefs are rooted in reality as well as if the problem can be addressed to make it more manageable. New behaviors and habits are built to replace maladaptive coping skills that can be utilized immediately and practiced outside of therapy sessions. The role of homework outside of therapy sessions is emphasized in CBT and requires the client’s commitment and initiative in accomplishing their treatment goals. Homework provides an opportunity for client to practically apply the techniques which can be used to specify their goals and develop the skills needed to achieve them (Corey & Corey, 2018).
The course of CBT is time-limited and generally completed in under 20 sessions but, may require follow up sessions as clients practice new skills. Due to this brief nature it is a preferred modality for clinicians and managed care companies. The ultimate goal of CBT is for the client to acquire the skills to eventually become their own therapist. One of the strengths of CBT is the wide range of interventions to deconstruct client difficulties into workable segments (Yalom, 2020). These interventions include but are not limited to activities such as; recording automatic thoughts, monitoring mood, creating an arousal hierarchy, monitoring activity, problem-solving, psychoeducation, relaxation training, performing a risk appraisal, employing guided imagery for exposure, and creating a relapse prevention plan. Another strength of CBT is the adaptability to a wide variety of problems and special populations. Wedding & Corsini state that, “overtime CBT has become more eclectic and integrative and therefore, is among the most widely used approaches for managing psychological and behavioral problems” (2018, p. 163). Versatility in delivery of CBT is dependent upon the particular needs of the client. Techniques are tailored to assist the client in learning to develop a greater sense of confidence in their abilities to transform ways of thinking and behaving that stand in the way of positive outcomes. Tailored techniques include facing fears through exposure techniques instead of avoiding them, using role playing to prepare for potentially distressing situations or interactions, and relaxation training to calm the mind and body. The therapist and client collaborate to develop a treatment plan focused on individual problems and goals identifying objectives focused on positive results.
CBT possesses diversity in its delivery and application and has been adapted for use in online therapy, telephone interactions, psychotherapy groups, schools, prisons, as well as traditional individual therapy. According to the National Center for Biotechnology Information (National Center for Biotechnology Information [NCBI], 2016), creative practitioners have adapted CBT for working with a multitude of issues including: depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder, substance abuse, chronic pain, tinnitus, rheumatism, attention-deficit disorders, eating disorder, insomnia, and autism spectrum disorders. There is recent research (Murphy et al., 2020), suggesting that in light of the COVID-19 pandemic, CBT delivered through telehealth or other online applications can be more effective than traditional in person methods due to its accessibility.
Significant research has been done to illustrate the effectiveness of CBT for a wide array of conditions however anxiety disorders seem to be at the top of the list. The dodo bird verdict debates the superiority versus equivalency of heterogeneous psychotherapy methods, recent meta-analysis disagrees (Elliott et al., 2015). The most influential review of CBT done in 2004 identifies CBT as, “arguable the most widely studied form of psychotherapy” (Hoffman et al., 2012). The results of this study present the review of meta-analytic studies done examining the efficacy of CBT to be strong and positive (Hoffman et al., 2012). The empirical data coupled with the diverse application and variety of techniques for implementation make this approach useful, effective, and successful in sponsoring positive outcomes.
