What is cognitive behavior therapy (CBT)?
The cognitive behavior therapies are not a single therapeutic approach, but rather a loosely organized collection of therapeutic approaches that share a similar set of assumptions. At their core, cognitive behavior therapies share three fundamental propositions: Cognitive activity affects behavior; cognitive activity may be monitored and altered; and desired behavior change may be effected through cognitive change.
The first of the three fundamental propositions of cognitive behavior therapy suggests that it is not the external situation that determines feelings and behavior, but rather the person’s view or perception of that external situation that determines feelings and behavior. For example, if a person has failed the first examination of a course, that individual could appraise it as a temporary setback to be overcome or as a horrible loss. Although the situation remains the same, the thinking about that situation is radically different in the two examples cited. Each of these views will lead to significantly different emotions and behaviors.
The third cognitive behavioral assumption suggests that desired behavior change may be effected through cognitive change. Therefore, although cognitive behavior theorists do not reject the notion that rewards and punishment (reinforcement contingencies) can alter behavior, they are more likely to emphasize that there are alternative methods for behavior change, one in particular being cognitive change. Many approaches to therapy fall within the scope of cognitive behavior therapy as it is defined here. Although these approaches share the theoretical assumptions described, a review of the major therapeutic procedures subsumed under the heading of cognitive behavior therapy reveals a diverse amalgam of principles and procedures, representing a variety of theoretical and philosophical perspectives.
Rational emotive therapy, developed by psychologist Albert Ellis, is regarded by many as one of the premier examples of the cognitive behavioral approach; it was introduced in the early 1960s. Ellis proposed that many people are made unhappy by their faulty, irrational beliefs, which influence the way they interpret events. The therapist interacts with patients, attempting to direct patients to more positive and realistic views. Cognitive therapy, pioneered by Aaron T. Beck, has been applied to such problems as depression and stress. For stress reduction, ideas and thoughts that are producing stress in the patient are identified, and the therapist then gets the patient to examine the validity of these thoughts. Working together, they restructure thought processes so that the situations seem less stressful. Cognitive therapy has been found to be quite effective in treating depression, as compared with other therapeutic methods. Beck held that depression is caused by certain types of negative thoughts, such as devaluing the self or viewing the future in a consistently pessimistic way.
Rational behavior therapy, developed by psychiatrist Maxie Maultsby, is a close relative of Ellis’s rational emotive therapy. In this approach, Maultsby combines several approaches to include rational emotive therapy, neuropsychology, classical and operant conditioning, and psychosomatic research; however, Maultsby was primarily influenced by his association with Ellis. In this approach, Maultsby attempts to couch his theory of emotional disturbance in terms of neuropsychophysiology and learning theory. Rational behavior therapy assumes that repeated pairings of a perception with evaluative thoughts lead to rational or irrational emotive and behavioral reactions. Maultsby suggests that self-talk, which originates in the left hemisphere of the brain, triggers corresponding right-hemisphere emotional equivalents. Therefore, to maintain a state of psychological health, individuals must practice rational self-talk that will, in turn, cause the right brain to convert left-brain language into appropriate emotional and behavioral reactions.
Rational behavior therapy techniques are quite similar to those of rational emotive therapy. Both therapies stress the importance of monitoring one’s thoughts to become aware of the elements of the emotional disturbance. In addition, Maultsby advocates the use of rational emotive imagery, behavioral practice, and relaxation methods to minimize emotional distress.
Self-instructional training was developed by psychologist Donald Meichenbaum in the early 1970s. In contrast to Ellis and Beck, whose prior training was in psychoanalysis, Meichenbaum’s roots were in behaviorism and the behavioral therapies. Therefore, Meichenbaum’s approach is heavily couched in behavioral terminology and procedures. Meichenbaum’s work stems from his earlier research in training schizophrenic patients to emit “healthy speech.” By chance, Meichenbaum observed that patients who engaged in spontaneous self-instruction were less distracted and demonstrated superior task performance on a variety of tasks. As a result, Meichenbaum emphasizes the critical role of “self-instructions”—simple instructions such as “Relax . . . Just attend to the task”—and their noticeable effect on subsequent behavior.
Meichenbaum developed self-instructional training to treat the deficits in self-instructions manifested in impulsive children. The ultimate goal of this program was to decrease impulsive behavior. The way to accomplish this goal, as hypothesized by Meichenbaum, was to train impulsive children to generate verbal self-commands and to respond to their verbal self-commands and to encourage the children to self-reinforce their behavior appropriately.
The specific procedures employed in self-instructional training involve having the child observe a model performing a task. While the model is performing the task, he or she is talking aloud. The child then performs the same task while the model gives verbal instructions. Subsequently, the child performs the task while instructing himself or herself aloud, then while whispering the instructions. Finally, the child performs the task while silently thinking the instructions. The self-instructions employed in the program included questions about the nature and demands of the task, answers to these questions in the form of cognitive rehearsal, self-instructions in the form of self-guidance while performing the task, and self-reinforcement. Meichenbaum and his associates have found that this self-instructional training program significantly improves the task performance of impulsive children across a number of measures.
Systematic rational restructuring is a cognitive behavioral procedure developed by psychologist Marvin Goldfried in the mid-1970s. This procedure is a variation on Ellis’s rational emotive therapy; however, it is more clearly structured than Ellis’s method. In systematic rational restructuring, Goldfried suggests that early social learning experiences teach individuals to label situations in different ways. Further, Goldfried suggests that emotional reactions may be understood as responses to the way individuals label situations, as opposed to responses to the situations themselves. The goal of systematic rational restructuring is to train clients to perceive situational cues more accurately.
The process of systematic rational restructuring is similar to systematic desensitization, in which a subject is to imagine fearful scenes in a graduated order from the least fear-provoking to the most fear-provoking scenes. In systematic rational restructuring, the client is asked to imagine a hierarchy of anxiety-eliciting situations. At each step, the client is instructed to identify irrational thoughts associated with the specific situation, to dispute them, and to reevaluate the situation more rationally. In addition, clients are instructed to practice rational restructuring in specific real-life situations.
Stress inoculation training incorporates several of the specific therapies already described. This procedure was developed by Meichenbaum. Stress inoculation training is analogous to being inoculated against disease. That is, it prepares clients to deal with stress-inducing events by teaching them to use coping skills at low levels of the stressful situation and then gradually to cope with more and more stressful situations. Stress inoculation training involves three phases: conceptualization, skill acquisition and rehearsal, and application and follow-through.
In the conceptualization phase of stress inoculation training, clients are given an adaptive way of viewing and understanding their negative reactions to stressful events. In the skills-acquisition and rehearsal phase, clients learn coping skills appropriate to the type of stress they are experiencing. With interpersonal anxiety, the client might develop skills that would make the feared situation less threatening (for example, learning to initiate and maintain conversations). The client might also learn deep muscle relaxation to lessen tension. In the case of anger, clients learn to view potential provocations as problems that require a solution rather than as threats that require an attack. Clients are also taught to rehearse alternative strategies for solving the problem at hand.
The application and follow-through phase of stress inoculation training involves the clients practicing and applying the coping skills. Initially, clients are exposed to low levels of stressful situations in imagery. They practice applying their coping skills to handle the stressful events, and they overtly role-play dealing with stressful events. Next, clients are given homework assignments that involve gradual exposure to actual stressful events in their everyday life. Stress inoculation training has been effectively applied to many types of problems. It has been used to help people cope with anger, anxiety, fear, pain, and health-related problems (for example, cancer and hypertension). It appears to be suitable for all age levels.
Problem-solving therapy, as developed by psychologists Thomas D’Zurilla and Goldfried, is also considered one of the cognitive behavioral approaches. In essence, problem-solving therapy is the application of problem-solving theory and research to the domain of personal and emotional problems. Indeed, the authors see the ability to solve problems as the necessary and sufficient condition for emotional and behavioral stability. Problem solving is, in one way or another, a part of all psychotherapies.
Cognitive behavior therapists have taught general problem-solving skills to clients with two specific aims: to alleviate the particular personal problems for which clients have sought therapy and to provide clients with a general coping strategy for personal problems.
Clients are given steps of problem solving that they are taught to carry out systematically. First, clients need to define the dilemma as a problem to be solved. Next, they must select a goal that reflects the ultimate outcome they desire. Clients then generate a list of many different possible solutions, without evaluating their potential merit (a kind of brainstorming). They then evaluate the pros and cons of each alternative in terms of the probability that it will meet the goal selected and its practicality, which involves considering the potential consequences of each solution to themselves and to others. They rank the alternative solutions in terms of desirability and practicality and select the highest one. Next, they try to implement the chosen solution. Finally, clients evaluate the therapy, assessing whether the solution alleviated the problem and met the goal, and if not, what went wrong—in other words, which of the steps in problem solving needs to be redone.
Problem-solving therapies have been used to treat a variety of target behaviors with a wide range of clients. Examples include peer relationship difficulties among children and adolescents, examination and interpersonal anxiety among college students, relapse following a program to reduce smoking, harmony among family members, and the ability of chronic psychiatric patients to cope with interpersonal problems.
Self-control therapy for depression, developed by psychologist Lynn Rehm, is an approach to treating depression that combines the self-regulatory notions of behavior therapy and the cognitive focus of the cognitive behavioral approaches. Essentially, Rehm believes that depressed people show deficits in one or some combination of the following areas: monitoring (selectively attending to negative events), self-evaluation (setting unrealistically high goals), and self-reinforcement (emitting high rates of self-punishment and low rates of self-reward). These three components are further broken down into a total of six functional areas.
According to Rehm, the varied symptom picture in clinically depressed clients is a function of different subsets of these deficits. Over the course of therapy with clients, each of the six self-control deficits is described, with emphasis on how a particular deficit is causally related to depression, and on what can be done to remedy the deficit. A variety of clinical strategies are employed to teach clients self-control skills, including group discussion, overt and covert reinforcement, behavioral assignments, self-monitoring, and modeling.
Structural psychotherapy is a cognitive behavioral approach that derives from the work of two Italian mental health professionals, psychiatrist Vittorio Guidano and psychologist Gianni Liotti. These authors are strongly influenced by cognitive psychology, social learning theory, evolutionary epistemology, psychodynamic theory, and cognitive therapy. Guidano and Liotti suggest that for an understanding of the full complexity of an emotional disorder and subsequent development of an adequate model of psychotherapy, an appreciation of the development and the active role of an individual’s knowledge of self and the world is critical. In short, to understand a patient, one must understand the structure of that person’s world.
Guidano and Liotti’s therapeutic process uses the empirical problem-solving approach of the scientist. Indeed, the authors suggest that therapists should assist clients in disengaging themselves from certain ingrained beliefs and judgments, and in considering them as hypotheses and theories subject to disproof, confirmation, and logical challenge. A variety of behavioral experiments and cognitive techniques are used to assist patients in assessing and critically evaluating their beliefs.
The area of cognitive behavior therapy involves a wide collection of therapeutic approaches and techniques. Other cognitive behavioral approaches include anxiety management training, which comes from the work of psychologist Richard Suinn, and personal science, from the work of psychologist Michael Mahoney.
The cognitive behavioral approaches are derived from a variety of perspectives, including cognitive theory, classical and operant conditioning approaches, problem-solving theory, and developmental theory. All these approaches share the perspective that internal cognitive processes, called thinking or cognition, affect behavior, and that behavior change may be effected through cognitive change.
These approaches have several other similarities. One is that all the approaches see therapy as time limited. This is in sharp distinction to the traditional psychoanalytic therapies, which are generally open-ended. The cognitive behavior therapies attempt to effect change rapidly, often with specific, preset lengths of therapeutic contact. Another similarity among the cognitive behavior therapies is that their target of change is also limited. For example, in the treatment of depression, the target of change is the symptoms of depression. Therefore, in the cognitive behavioral approaches to treatment, one sees a time-limited focus and a limited target of change.
Cognitive behavior therapy evolved from two lines of clinical and research activity: First, it derives from the work of the early cognitive therapists (Ellis and Beck); second, it was strongly influenced by the careful empirical work of the early behaviorists.
Within the domain of behaviorism, cognitive processes were not always seen as a legitimate focus of attention. In behavior therapy, there has always been a strong commitment to an applied science of clinical treatment. In the behavior therapy of the 1950s and 1960s, this emphasis on scientific methods and procedures meant that behavior therapists focused on events that were directly observable and measurable. Within this framework, behavior was seen as a function of external stimuli that determined or were reliably associated with observable responses. Also during this period, there was a deliberate avoidance of such “nebulous” concepts as thoughts, cognitions, or images. It was believed that these processes were by their very nature vague, and one could never be confident that one was reliably observing or measuring these processes.
It is important to note that by following scientific principles, researchers developed major new treatment approaches that in many ways revolutionized clinical practice (among them are systematic desensitization and the use of a token economy). Yet during the 1960s, several developments within behavior therapy had emphasized the limitations of a strict conditioning model to understanding human behavior.
In 1969, psychologist Albert Bandura published his influential volume Principles of Behavior Modification. In this volume, Bandura emphasized the role of internal or cognitive factors in the causation and maintenance of behavior. In response, behavior therapists who were dissatisfied with the radical behavioral approaches to understanding complex human behavior began actively to seek and study the role of cognitive processes in human behavior.
In the case of depression, cognitive behavior therapy holds that patients’ excessive self-criticism and self-rejection are the causes of their depression. However, other psychologists argue that the patients’ negative thoughts are the result of their depression, and that these patients are better helped through pharmacological means. Other criticisms are that cognitive behavior therapy, because it holds that people’s perceptions of events, rather than events cause their emotions and feelings, does not delve deeply enough when causes of mental illness are deeply rooted in childhood abuse or trauma.
Cognitive behavior therapy has been used in combination with drug therapy in the treatment of schizophrenia and bipolar disorder, with some success. It has been suggested by some psychologists that the best use of cognitive behavior therapy is in combination with other therapies.
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