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Cognitive Behavioural Therapy: What Is It and When Is It Indicated?

Behaviour, Depression, Infant and Children | August 26, 2014 | Author: The Super Pharmacist

behaviour, depression

Cognitive Behavioural Therapy: What Is It and When Is It Indicated?

There are different ways to experience every situation. Our interpretations, responses, thoughts and emotions hold the key to how we approach, react and handle the events of our lives. And so the basic concept underlying cognitive behavioral therapy is that perception is far more important to how we handle everything in our lives than the reality of the experience itself. In addition, reinforcing a behavior will, over time, condition us to respond in a habitual way.

Cognitive behavioural therapy arose in the 1950-60s as an outgrowth of two therapeutic approaches — behavioural and cognitive.

Behavioural psychology

Behavioural psychology, also known as behaviourism, is a theory of learning based upon the idea that all behaviours are acquired through conditioning. The behavioural approach is evident in the classic experiments conducted by Pavlov with dogs, in which they were conditioned to respond to a stimulus they associated with food even when food was no longer supplied. Advocated by famous psychologists such as John B. Watson and B.F. Skinner, behavioral theories dominated psychology during the early half of the twentieth century. The primary tenet of behaviourism, as expressed in the writings of John B. Watson, B.F. Skinner, and others, is that psychology should concern itself with the observable behavior of people and animals, not with unobservable events that take place in their minds.

The behaviourist school of thought maintains that behaviors can be described scientifically without reference to hypothetical constructs such as thoughts and beliefs.

Cognitive therapy

Cognitive therapy was developed by American psychiatrist, Aaron T. Beck. Trained as a psychoanalyst in the concepts of Austrian physician, Dr. Sigmund Freud, Beck challenged the psychoanalytic notion that depression results from anger which is then turned inward. From Beck's research, he contended: people with emotional difficulties tend to commit characteristic "logical errors" which slant objective reality to the path of self-deprecation. 

According to Beck, "If beliefs do not change, there is no improvement. If beliefs change, symptoms change," which means that one's thoughts and beliefs affect one's behaviour and subsequent actions.

He believed that dysfunctional behaviour is caused by dysfunctional thinking, and that thinking is shaped by beliefs. Our beliefs decide the course of our actions.

Beck was convinced of positive results if patients could be persuaded to think constructively and forsake negative thinking.

The overall premise is that thoughts influence feelings and behavior. Based on this assumption, cognitive reconstruction can break destructive cycles in which negative thoughts feed negative feelings that create negative behavior that reinforce more negative thoughts.

Rational Emotive Behaviour Therapy

Albert Ellis, an American psychologist, had been working on similar ideas since the 1950s. He called his approach Rational Therapy at first, then Rational Emotive Therapy, and later, Rational Emotive Behaviour Therapy. According to Ellis, the therapist should seek to help the client understand — and act on the understanding — that his personal philosophy contains beliefs that contribute to his own emotional pain. This new approach stressed actively working to change a client's problematic beliefs and behaviours by demonstrating their irrationality, self-defeatism and rigidity. Ellis believed that through rational analysis and cognitive reconstruction, people could identify their core irrational beliefs and proceed to develop more rational constructs.

The Cognitive Revolution

Together with Beck, he is generally considered to be one of the originators of the cognitive revolutionary paradigm shift in psychotherapy that occurred in the mid-twentieth century. The new cognitive approach came into conflict with behaviourism which was the dominant school of thought at the time. However, the 1970s saw a general "cognitive revolution" in psychology.

The Cognitive RevolutionBehavioural modification techniques and cognitive therapy techniques became joined together, giving rise to cognitive behavioural therapy.

Where cognitive elements include thinking, imagining, reasoning, and remembering abilities, behavioral elements are the reactions or actions that we take in response to stimuli in our environment.

However, our minds and our bodies are not isolated from each other.

Cognitive therapies unearth problems in our cognition which lead to maladaptive behaviours. Behavioural therapies facilitate the "unlearning" of these maladaptive behaviours.

 

Components of Cognitive Behavioural Therapy

People often experience thoughts or feelings that reinforce or compound faulty beliefs. Such beliefs can result in problematic behaviors that can affect numerous life areas, including family, romantic relationships, work, and academics. For example, a person suffering from low self-esteem might experience negative thoughts about his or her own abilities or appearance. As a result of these negative thinking patterns, the individual might start avoiding social situations or pass up opportunities for advancement at work or at school. In order to combat these destructive thoughts and behaviors, a cognitive behavioural therapist begins by helping the client to identify the problematic beliefs.

This stage, known as functional analysis, is important for learning how thoughts, feelings, and situations can contribute to maladaptive behaviors. The process can be difficult, especially for patients who struggle with introspection, but it can ultimately lead to self-discovery and insights that are an essential part of the treatment process.

The second part of cognitive behavior therapy focuses on the actual behaviors that are contributing to the problem. The client begins to learn and practice new skills that can then be put into use in real-world situations. For example, a person suffering from drug addiction might start practicing new coping skills and rehearsing ways to avoid or deal with social situations that could potentially trigger a relapse.

In most cases, cognitive behavioural therapy is a gradual process that helps a person take incremental steps towards a behaviour change. Someone suffering from social anxiety might start by simply imagining themself in an anxiety-provoking social situation. Next, the client might start practicing conversations with friends, family, and acquaintances. By progressively working toward a larger goal, the process seems less daunting and the goals easier to achieve.

Ellis suggested that people mistakenly blame external events for unhappiness. He argued, however, that it is our interpretation of these events that truly lies at the heart of our psychological distress.

cognitive behavioural therapyThe ABC Model

To explain this process, Ellis developed what he referred to as the ABC Model which has been incorporated into cognitive behavioural therapy techniques.

The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

A - Activating Event or objective situation - The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.

B - Beliefs - In the second column, the client writes down the negative thoughts that occurred to them.

C - Consequence - The third column is for the negative feelings and dysfunctional behaviors that ensued.

The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc. Ellis believed that it is not the activating event (A) that causes negative emotional and behavioural consequences (C), but rather that a person interprets these events unrealistically and therefore has a irrational belief system (B) that helps cause the consequences (C).

According to Ellis, "people are not disturbed by things but rather by their view of things." The fundamental assertion of his Rational Emotive Behaviour Therapy is that the way people feel is largely influenced by how they think. When people hold irrational beliefs about themselves or the world, problems result. According to Ellis, some of the most common irrational beliefs include:

  • Feeling excessively upset over other people's mistakes or misconduct.
  • Believing that you must be 100 percent competent and successful in everything to be valued and worthwhile.
  • Believing that you will be happier if you avoid life's difficulties or challenges.
  • Feeling that you have no control over your own happiness; that your contentment and joy are dependent upon external forces.

Beck further identified a number of common illogical thinking processes that can lead to great anxiety or depression for the individual:

  • Selective attention: seeing only the negative features of an event
  • Magnification: exaggerating the importance of undesirable events
  • Overgeneralisation: drawing broad negative conclusions on the basis of a single insignificant event

Beck suggested that these thinking patterns are set up in childhood, and become automatic and relatively fixed. He invented the term automatic thoughts to describe emotion-filled thoughts that might pop up in the mind. If a person was feeling upset in some way, the thoughts were usually negative and neither realistic nor helpful. Beck found that identifying these thoughts was the key to the client understanding and overcoming his or her difficulties.

How Cognitive Behavioural Therapy Differ From Other Therapies

Cognitive-behavioral therapy is one of the most extensively researched forms of psychotherapy. Cognitive-behavioral therapy is evidence-based, which means that it is supported by research that proves that it is effective in helping people make emotional and behavioural changes.

Cognitive behavioural therapy differs from other therapies in the nature of the relationship that the therapist will try to establish. Some therapies encourage the client to be dependent on the therapist, as part of the treatment process. Cognitive behavioural therapy favours a more equal relationship that is, perhaps, more business-like, being problem-focused and practical. The therapist will frequently ask the client for feedback and for their views about what is going on in therapy. Beck coined the term ‘collaborative empiricism,’ which emphasises the importance of client and therapist working together to test out how the ideas behind cognitive behavioural therapy might apply to the client’s individual situation and problems.

Cognitive behavioural therapy is generally short-term and focused on helping clients deal with a very specific problem. Because cognitive behavioural therapy is an active intervention, the patient can expect to do homework or practice outside of sessions.

How¬†Cognitive Behavioural Therapy Differ From Other TherapiesCognitive behavioural therapy is considered among the most rapid in terms of results obtained. The average number of sessions clients receive is only sixteen. Other forms of therapy, like psychoanalysis, can take years.

It is important to note that cognitive behavioural therapy does not just involve identifying problematic thought patterns; it is focused on using a wide range of strategies to help clients overcome these thoughts.

The behavior part of the therapy involves setting homework for the client to do.

Such strategies may include journaling, role-playing, relaxation techniques, and mental distractions. Clients are also encouraged to change unwanted behaviors using such things as meditation, journaling, and guided imagery.

When Is CBT an appropriate treatment option?

In a review which summarises the current literature on treatment outcomes of cognitive behavioural therapy for a wide range of psychiatric disorders, a search of the literature resulted in a total of 16 analyses. The review focuses on effect sizes that contrast outcomes for cognitive behavioural therapy with outcomes for various control groups for each disorder.

Depression

The intervention for depression that is most widely used is antidepressant medication. The first analysis on this topic found cognitive therapy to be superior to untreated controls, wait list, pharmacotherapy, behavior therapy, and a heterogeneous group of other therapies. In the most extensive and methodologically rigorous meta-analysis on cognitive behavioural therapy for depression to date, researchers found that cognitive behavioural therapy was superior when compared with waiting list or placebo controls. These authors also found that cognitive behavioural therapy was significantly better than antidepressant medication. More recently, however, a major high-quality controlled trial comparing cognitive therapy with a commonly prescribed serotonin reuptake inhibitor (SSRI), paroxetine, found that cognitive therapy was equally effective for the initial treatment of moderate to severe major depression.

The combination of cognitive and pharmacotherapy for depression is widely practiced in the community. In a study of the combination of cognitive behavioural therapy and pharmacotherapy, authors reported a small advantage over either modality alone. There is some evidence that the combination of psychotherapy and antidepressant medication leads to significantly better outcomes with severely depressed patients.

The effectiveness of cognitive behavioural therapy in preventing relapse of depression has been evaluated. In that meta-analysis, the authors examined a subset of eight studies that compared relapse rates for cognitive behavioural therapy versus antidepressants at least a year after discontinuation of treatment. They concluded that cognitive behavioural therapy was associated with a preventative effect in five of the eight studies. On average, only 29.5% of cognitive behavioural therapy patients relapsed versus 60% of patients treated with antidepressants. Another study corroborated the substantial difference in relapse rate between cognitive behavioural therapy (26%) and pharmacotherapy (64%).

Recently, a large multi-site clinical trial found that cognitive behavioural therapy had an enduring effect for moderate-to-severely depressed patients that extended beyond the end of treatment and was equivalent to the effect of keeping patients on antidepressant medication. 

Generalised anxiety disorder

The effectiveness of cognitive therapy for generalised anxiety disorder was recently investigated in a meta-analysis. The preliminary results are strong, with cognitive therapy being substantially superior to wait list or no-treatment controls, non-directive therapy, and pill placebo. The authors reported that cognitive therapy and pharmacotherapy showed similar levels of improvement from pre- to post-treatment.

Generalised anxiety disorderWith respect to long-term outcome, the authors found that cognitive behavioural therapy treatment effects were maintained through at least 6 months post-treatment. These results were not available for pharmacotherapy due to a lack of long-term outcome data. A review of generalised anxiety disorder clinical trials found a robust persistence of effects for cognitive therapy over 3, 6 and 12 months. Additionally recent reports indicate a persistence of cognitive therapy effects as far as 8–10 years post-treatment. 

Panic disorder

In panic disorder, cognitive behavioural treatments in general have the highest effect size compared to pharmacological treatments or combination treatments. Among the cognitive-behavioral treatments, those that combined cognitive restructuring with interoceptive exposure showed the strongest effect was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. This combination of interventions is the standard cognitive behavioural therapy approach to treating panic disorder. Perhaps most impressive is that the cognitive behavioural therapy treatment showed virtually no slippage in effect size by 1-year follow-up as compared to sizable slippage for pharmacological treatment.

Post-traumatic stress disorder

The studies reviewed on trauma-based cognitive behavioural therapy covered a range of patient populations including survivors of accidents, assault, sexual assault (including childhood sexual assault), domestic violence, military combat, mixed trauma groups and refugees with multiple traumatic events. Overall, the findings showed clinically important benefits for trauma-focused cognitive behavioural therapy over wait list control groups on all measures of post-traumatic stress disorder symptoms. 

Obsessive-compulsive disorder

Exposure with response prevention is sometimes considered the psychological treatment of choice for obsessive-compulsive disorder, but there is growing evidence that cognitive behavioural therapy is equally effective. An example of how exposure with response prevention works: Imagine a person who repeatedly checks light switches to ensure they are in the "off" position, even when entering a clearly unlit room. The person would be exposed to their feared stimulus (leaving lights switched on), and would refuse to respond with any safety behaviours (turning light switch off). A meta-analysis found that cognitive or cognitive behavioral treatments for obsessive-compulsive disorder led to substantial reductions in obsessive-compulsive disorder symptoms as rated by patients and clinical assessors. Furthermore, these treatment effects tended to persist at 6-month and even 12-month follow-ups. 

Social phobia

Exposure therapy is the most commonly used technique for social phobia. The main goal of exposure therapy is to expose the patient to situations that elicit anxiety. By exposing the individual to these situations in a gradual and systematic way, he or she can slowly habituate to environments that once caused great fear and panic. The most recent and extensive meta-analysis showed that cognitive therapy was superior to wait-list and placebo and similar to exposure interventions without cognitive restructuring and to the combination of the two interventions. 

Schizophrenia

While pharmacotherapy is the front-line treatment for schizophrenia, adjunctive treatments are needed since antipsychotic medications may not be sufficiently effective and noncompliance is a common problem.

SchizophreniaSeveral researchers reviewed 15 early studies on cognitive and behavioral interventions for delusions and hallucinations. Their summary indicated that cognitive behavioural therapy produced significant reductions in these symptoms. Since that review, there have been five randomised clinical trials published on cognitive behavioural therapy of schizophrenia. One study concluded that cognitive behavioural therapy plus routine care (pharmacotherapy and case management) led to substantial pre-treatment to post-treatment improvements in positive symptoms, negative symptoms, and total symptoms. Patients receiving only routine care did much less well.

A meta-analysis was performed on seven controlled trials of cognitive therapy for schizophrenia. The intervention consisted of targeted cognitive behavioural therapy strategies for modifying patients’ distorted beliefs about delusions and hallucinations so as to decrease the negative consequences of these symptoms on their daily functioning. Researchers found a large effect size for reduction in psychotic symptoms between pre- and post-treatment. Of the seven studies, five reported significant differences in psychotic symptoms between the control and treatment conditions at post-treatment.

With respect to follow-up findings, two studies found that the follow-up effect size for change in frequency of and distress associated with delusions and hallucinations was large between pre-test and follow-up. 

Anger

Researchers reviewed 50 outcome studies on anger covering a total of 1640 subjects, many of whom were in programs for violent offenders. The average cognitive behavioral therapy patients did better than 76% of untreated subjects in terms of anger reduction. 

Bulimia nervosa

Researchers examined 54 comparisons in their meta-analysis of psychosocial and pharmacological treatments for bulimia nervosa. They found that cognitive behavioural therapy was associated with substantial improvements in eating disorder behaviors and eating attitudes. Improvements with cognitive behavioural therapy were significantly larger than those for medication in terms of binge frequency, purge frequency, and eating attitudes. Incidentally, there are very few controlled studies on cognitive behavioral treatment for anorexia nervosa.

Other disorders

Cognitive behavioural therapy can also be an effective adjunctive treatment for substance abuse and chronic pain.

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