Overview of Cognitive Behavior Therapy-CBT
Cognitive Behavior Therapy (CBT) is often used as an umbrella term to describe therapies that are based in behavioral learning theories and/or cognitive theories. Characteristics shared by many Cognitive Behavioral Therapies include emphasizing the present, concrete goal setting, and understanding the interplay that thinking, feelings, and events have on human behaviors.
Some forms of CBT place a greater emphasis on the role of thinking on feelings and behaviors, while others may stress the influence of environmental factors. Depending on the specific Cognitive Behavior Theory, different interventions will be utilized. There are a number of different Cognitive Behavior Therapies, and a number of Behavior Therapies which may be included by some under CBT as well, even if their developers believe they are more accurately identified as Behavior Therapies, e.g., Acceptance and Commitment Therapy (ACT). Some forms of Cognitive Behavior Therapy (CBT) you may encounter include Cognitive Processing Therapy (CPT), Cognitive Therapy (CT), Dialectical Behavior Therapy (DBT), Rational Emotive Behavior Therapy (REBT), Self-Instructional Training, Stress Inoculation Training, etc.
Cognitive Behavior Therapy (CBT) is often characterized as short-term. Short-term is probably in reference to traditional psychodynamic therapy, which often involved multiple sessions per week for years. More specifically scientific studies indicate for some psychological disorders, e.g., panic attacks, Obsessive-compulsive Disorder (OCD), Post-traumatic Stress Disorder (PTSD), depression, bulimia, anger management problems CBT treatment can be delivered in eight to 20 weeks. Even Borderline Personality Disorder (BPD) has a treatment protocol of 52 weeks. While the treatment protocols in these studies have a specified number of sessions with a very defined clinical population, in practice there is greater flexibility. This means that with proper ongoing assessment a skilled clinician can tailor the treatment to what a specific therapy client needs. In some cases this may mean therapy may be effective in fewer sessions that a treatment protocol. It is also clear though that many people entering into therapy may have more than one issue to be addressed, e.g., depression and OCD. In a case like this the number of sessions may take a few more than what a particular protocol stipulates. CBT clinicians need to be familiar with the scientifically supported treatment protocols, but should also have a strong grasp on the underlying theories and clinical expertise in order to allow the effective and flexible application of interventions to specific therapy clients.
Cognitive Processing Therapy
Cognitive Processing Therapy (CPT) was developed by Dr. Patricia Resick, a psychologist. Cognitive Processing Therapy has been shown to effectively treat Post-traumatic Stress Disorder (PTSD). Military veterans and sexual assault or rape victims are PTSD populations on which Cognitive Processing Therapy has been shown to be an effective form of psychotherapy. CPT is a 12 session manualized therapy. Like many forms of Cognitive Behavioral Therapy (CBT) the CBT therapist initially works to develop a strong therapeutic alliance (good rapport). This is particularly critical for PTSD therapy clients who may often have issues around safety and trust, and who in treatment will, when the time is right, be asked to recall memories about traumatic events. Cognitive Processing Therapy also involves psychoeducation about PTSD to better help therapy clients understand the nature of how PTSD symptoms develop and are maintained. Therapy clients learn about the influence of beliefs (certain kinds of thoughts) on emotions as well as the role of avoidance in maintaining PTSD symptoms. With practice therapy clients learn to identify specific kinds of cognitive distortions like unrealistic appraisals and attributions, as well as unfounded assumptions. During therapy clients then write an account of the traumatic event and through therapeutic exchanges with the therapist are able to identify which particular cognitive distortions may be present in his or her belief system. Clients learn how to challenge these cognitive distortions, which according to theorists may exacerbate anxiety, shame, and anger and thereby lead to clients avoid reminders of the trauma. As the realistic adaptive beliefs begin to dominate the cognitive distortions therapy clients can decrease avoidance behaviors and begin to see reductions in both emotional symptoms as well as an increase in healthy behaviors, e.g., returning to work, a more normal sleep schedule, or increasing emotional and physical intimacy, etc. Cognitive Processing Therapy combines exposure therapy used by behavior therapists and cognitive techniques from Cognitive Behavior Therapy (CBT). The Veteran’s Administration (VA) has incorporated Cognitive Processing Therapy into many of their programs to help military veterans suffering from PTSD.
Cognitive Therapy (CT) was developed by psychiatrist, Dr. Aaron T. Beck. Beck’s Cognitive Therapy was one of the earliest therapies to be considered a Cognitive Behavior Therapy, as opposed to a traditional Behavior Therapy. Cognitive Therapy was originally designed to treat depression, i.e., major depressive disorder. Beck hypothesized something known as the Beck Cognitive Triad. The Cognitive Triad included three types of cognitive distortions that he proposed cause and maintain depressive symptoms. These negative cognitive distortions are about the self, the world, and the future. A depressed client may enter therapy with negative beliefs like, I am worthless (self), people don’t like me and I don’t do my job well (world), and things will never change (future).” Negative views of the future can be particularly problematic as they relate to hopelessness, which may be a risk factor for suicide.
Cognitive Therapy includes many elements, such as agenda setting, activity scheduling, collaboratively establishing homework assignments, etc. But the influence of cognitive distortions on negative emotions and maladaptive behaviors is emphasized. In this therapy, like all Cognitive Behavior Therapies, rapport is established early. Remoralization is stressed initially in order to help depressed clients begin to have hope. The overall theory of depression is presented, specifically the impact negative cognitive distortions have on emotional states and adaptive behaviors. Depressed clients learn to identify when “automatic negative thoughts” arise and then how to identify the type of cognitive distortions they are. Examples of cognitive distortions include:
1. Catastrophising (awfulizing or minimizing)
2. Dichotomous Thinking (black and white)
3. Emotional Reasoning
4. Fortune Telling
5. Jumping to Conclusions
7. Mind reading
10. Selective Abstraction
11. Should Statements
Once depressed clients are able to identify these cognitive distortions they are asked to provide evidence that supports or contradicts the belief. With successful challenges to these beliefs more realistic coping beliefs are reinforced. Behavioral experiments are also conducted. Behavioral experiments are intended to test the accuracy of negative cognitive distortions. For example, overgeneralizations can be challenged with behavioral experiments. A therapy client may believe he always fails at everything. The behavioral experiment might be for him to sign up for a night class to see if he can pass it. The behavioral experiment can then provide concrete evidence that he does not fail at everything.
Other techniqes are also used in cognitive therapy that many consider more behavioral. For example, scheduling pleasurable and mastery activities regularly is a common assignment. There is a great deal of scientific evidence that depression symptoms are relieved with increases in time spent engaged in these activities. It is typical for depressed clients to isolate and refrain from engaging in activities that they previously enjoyed or demonstrated their competence. Therefore assigning these activities is an important component of depression treatment. In fact some studies indicate that focusing on activity scheduling alone can effectively treat depression.
Dr. J Ryan Fuller has published in the areas of anger management and cognitive behavior therapy (CBT) and is currently the Clinical Director of New York Behavioral Health and is in private practice in New York City, located at380 Lexington Avenue, Suite 1619, New York, NY 10168. You can find Dr. J Ryan Fuller on Google+ and Twitter.