Insights on Cognitive Behavioral Therapy
The historical roots of psychotherapy extend back many hundreds of years. The majority of sources documenting the history of psychotherapy acknowledge the Viennese neurologist Sigmund Freud as the founding father of all modern psychotherapy, even though other forms of talking cures were used prior to Freud. Freud was one of the first people to use these types of talking interventions to deal with formal mental health disorders, and his initial theories and approach were not met with much enthusiasm by the medical community. In addition, as Freud was beginning his approach to treating mental health disorders, the primary focus in the area of psychology was in experimental psychology, primarily the use of introspection and, in some cases, studies with animals to understand and document psychological experiences.
Freud believed that the majority of his patients had suffered early experiences that were buried deep within their unconscious minds. These experiences continue to influence their behavior, and Freud’s approach was to address anxiety, depression, and other behaviors by slowly working with the patient to learn the source of their issues. Freud concentrated on issues regarding early attractions to parents or significant others, and these “sexual” explanations for psychopathology were not readily accepted by everyone in the field. Other forms of psychotherapy were developed from principles used in experimental psychology.
Early experimental psychology would foster the paradigms of behavioral psychology and cognitive psychology. Freud’s work would foster the development of clinical psychology. The paradigms that grew out of experimental psychology were eventually adapted for use in clinical psychology and in psychotherapy. Currently, there are literally hundreds of different types of psychotherapy. Even though there is a vast array of different styles or types of psychotherapy, all approaches can be traced back to one or more of five major paradigms (schools of thought) that comprise the general approaches of the different schools of psychology. Two of these paradigms are the behavioral school (paradigm) and the cognitive school (paradigm).
Cognitive and Behavioral Paradigms
Behavioral psychology grew out of experimental work with animals and focused on environmental events that shaped behavior. Behavioral psychology traditionally did not develop theories of how animals or people think about things, viewed things, or how emotions relate to behavior, but instead concentrated on only observable factors that appear to increase the probability that an organism would behave in a specific way. Behavioral psychologists attempted to understand how the events in the environment that occurred before and after behavior were related to directing that behavior. Because behavioral psychology concentrated only on observable factors, it developed numerous techniques to modify behavior that could be applied in the therapeutic situation. However, psychotherapists who use only behavioral techniques are rare, as most clinicians and researchers realize that the subjective internal or mental experience of the subject also affects their actions.
The cognitive school of psychology was developed in a response to the rather mechanistic approach of the behavioral school. The early founders of what eventually became cognitive psychology argued that understanding cognition (thoughts, beliefs, and even emotions) was essential to understanding behavior. Cognitive therapy was a clinical application of the basic principles of cognitive psychology and focused on how individuals perceive the world as the basic driving force of their issues. Helping individuals modify their attitudes and perceptions could help them relieve any distress they were experiencing according to this view. However, using purely cognitive approaches to therapy was also not sufficient for understanding the entire picture in helping individuals with their issues.
The inevitable result was that therapists began to combine principles of cognitive psychology and behavioral psychology in their treatment approaches. Albert Ellis, the founder of Rational Emotive Behavioral Therapy (sometimes referred to as Rational Emotive Therapy), is often acknowledged as one of the very first cognitive behavioral psychologists.
Cognitive Behavioral Therapy (CBT) is based on the basic principles of behavioral psychology and cognitive psychology. Its general approach is to identify patterns of thoughts or beliefs that are irrational or dysfunctional and to help the individual develop more rational and functional cognitions. Once the individual has developed a more functional approach to thinking about the world, they can work on changing their behaviors in accordance with their new understanding.
CBT Is Not Just One Type of Therapy
Cognitive Behavioral Therapy is not a specific type of therapy; it represents an approach to using psychological principles in the therapeutic situation. CBT is actually an umbrella term that describes numerous different types of psychotherapy that follow this approach (identifying irrational beliefs, helping individuals change these beliefs, and helping individuals to modify their behavior). Several of the more recognizable forms of CBT include:
- Rational Emotive Behavioral Therapy: Developed by the psychologist Dr. Albert Ellis, this form of Cognitive Behavioral Therapy proposes that people develop specific assumptions about the world and how they relate in the world. Some individuals develop assumptions that are irrational or unrealistic, and these assumptions can often lead to issues with their functioning and behavior. Rational Emotive Behavioral Therapy operates by working with the individual to identify and confront these irrational and dysfunctional belief systems, to challenge these beliefs, and to help the individual change them into beliefs that are more realistic.
- Motivational Interviewing (MI): The MI approach was originally developed as an attempt to understand where individuals with substance abuse problems stood regarding their understanding of their behavior and whether or not they believed that their substance use was problematic for them. Motivational Interviewing assumes that not everyone who gets therapy for substance abuse (and other issues) enters treatment at the same starting point. Some people do not believe they have a problem; others may believe they have a problem but do not understand how to address it, and still others may be actually trying to address their problems. MI has developed a model referred to as theTranstheoretical Stages of Change Model that helps to identify where an individual stands on their conceptualization of their issues and then develops a treatment approach based on the stage of change that the person is in when they come to the therapeutic situation. This approach is an effort to personalize CBT based on the needs of the person.
- Dialectic Behavior Therapy (DBT): This form of CBT was originally developed to treat individuals who had severe psychological issues, such as individuals who were actively suicidal or had a severe personality disorder like borderline personality disorder. DBT uses a specialized approach for these individuals.
- Acceptance and Commitment Therapy (ACT): In this form of CBT, the initial goal is to help the person develop a realistic self-appraisal that is not based on overall statements regarding their abilities or effectiveness; for example, one of the most common irrational beliefs that individuals entertain is, “Everyone must like me.” By developing more realistic self-appraisals, people can understand why they experience certain emotions and can begin to shed global expectations and labels. This can result in more positive behaviors.
- CBT for specific disorders: In addition to the above forms of CBT (and numerous others), specialized applications of CBT have been developed for specific mental health disorders. These can include specialized forms of CBT for treating depression, panic disorder, post-traumatic stress disorder, phobias, etc.
Different but the Same
All the different types of CBT have different approaches and techniques they rely on; however, they are all based on the same core principles. The central principles of any form of CBT include the notion that dysfunctional behaviors and issues with psychopathology result from dysfunctional and irrational beliefs or patterns of thinking, and that identifying, challenging, and altering these dysfunctional cognitions is associated with positive outcomes in therapy. The actual types of beliefs or irrational thoughts that individuals entertain can be quite varied; however, there are three general categories of irrational beliefs that occur in most people:
- Irrational beliefs or thoughts about the person: First, many individuals develop irrational beliefs about themselves that can lead to dysfunctional issues, such as depression, issues with anxiety, etc. For instance, many people adhere to notions that in order for them to be worthy, they must be approved by others, liked by others, or that they cannot make mistakes. Of course, any one of these beliefs is irrational and could lead to serious distress if one is committed to it because everyone will eventually meet someone who does not like or approve of them, and everyone makes mistakes.
- Irrational beliefs about the world or one’s environment: People often develop irrational beliefs about the way the world operates. For instance, many individuals with alcohol use problems believe something like, “Everyone drinks alcohol.” This belief helps them to justify their dysfunctional use of alcohol; however, this belief is not true. A quick look at the research regarding alcohol use in the US reveals that this is a falsehood (e.g., it is certainly not true that everyone drinks alcohol) and that believing in it is an attempt by the person to normalize their own dysfunctional problems.
- Irrational beliefs regarding the future: People often have irrational beliefs regarding how things will turn out as a result of some action. Often, these beliefs can be easily challenged. For instance, many individuals with substance use disorders believe that their happiness is dependent upon their ability to engage in the use of their substance of choice. This irrational belief regarding the future (“I can only be happy if I use.”) needs to be challenged and disconfirmed in order to help the individual in recovery.
One of the basic assumptions of CBT that is often overlooked is the notion that most people have belief systems that are covert and not often formally stated in a conscious manner. A good portion of modern cognitive psychology is directed at understanding schemas and script, which are very routinized belief systems that people do not consciously state to themselves; instead, these implicit belief structures drive their behavior. CBT therapists have the daunting task of working with their clients to uncover these implicit belief systems that drive the behavior. As a result, CBT often investigates how individuals acquire these belief systems by attempting to understand their past experiences and how these belief systems were developed. This requires CBT therapists to be formally trained in understanding psychological principles, the core techniques used in psychological assessment, and understanding psychometric testing methods (e.g., using formal psychological tests, surveys, etc.). This requires advanced training in the principles of psychology, psychological assessment, and even in psychometrics. Thus, only licensed and trained mental health professionals are qualified to administer any form of CBT.
Even though there are numerous different forms of CBT, and each of these forms offers slightly different approaches and interventions, all forms of CBT follow the basic general outline when it comes to treating an individual. This outline consists of:
- An initial assessment: The treating therapist begins by thoroughly attempting to understand the client’s needs. This often involves the use of the development of what is termed a functional analysis that includes understanding how the person’s beliefs or thoughts contribute to their situation, what the actual problematic behavior or behaviors are, and the consequences that the individual experiences for their actions or behaviors (both the positive and negative consequences). This functional analysis is based on the type of assessment utilized in behavioral psychology with the additional cognitive component. Even though the assessment occurs in the initial phases of treatment, a competent therapist will continue to assess the client’s situation throughout the treatment process.
- Identifying core issues: After the functional analysis is complete, the therapist will attempt to identify the major issues that drive whatever behavior or feeling is being treated or addressed. The therapist will typically develop a series of hypotheses regarding these issues.
- Helping the client recognize the issues: An important component in any form of CBT is to help the client recognize the irrational and dysfunctional belief systems that drive their behavior. Good therapists will discuss their hypotheses with the client, point out specific situations that reinforce these hypotheses, and then work with the client to refine the understanding of the situation. Often, part of the process involves having the client test their beliefs in the real world.
- Utilizing cognitive restructuring techniques: Once the dysfunctional belief systems and attitudes are identified and recognized, the therapist helps the individual to restructure these factors to more realistic and functional applications.
- Practice: As part of the entire identification, recognition, and cognitive restructuring process, the therapist typically assigns homework to the client. This allows the client to validate how they act on their dysfunctional beliefs and to try out new applications and beliefs in the real world.
- The development of competence: As the therapeutic process unfolds, the client begins to become more competent in understanding the origins of their own issues and beliefs and identifying them. The therapist and client work together to move the individual toward understanding the situation and developing satisfactory solutions to it.
- Termination and follow-up: Over time, the client begins to resolve their issues and develops greater confidence in understanding their tendencies and how to address them. CBT is a time-limited form of therapy, such that once the major issues are addressed, the therapist and client work together to have the client address their own issues in the real world. Eventually, therapy sessions are discontinued, but the therapist may schedule periodic follow-up sessions with the client to check on their progress and assist in addressing any new issues.
Does CBT Work?
Numerous sources, such as the textbook Psychotherapy Research: Foundations, Process, andOutcome, report that CBT therapies are the most researched of all forms of psychotherapy and that in general CBT has empirical evidence to demonstrate its utility in treating numerous different issues and mental health disorders. For instance, even sources such as Kaplan and Sadock’s Synopsis of Psychiatry, a text designed for reference by psychiatrists who are trained in the medical management of psychiatric/psychological disorders, reports that CBT techniques are the preferred method of intervention for several different disorders, including panic disorder, obsessive-compulsive disorder, substance use disorders, borderline personality disorder, etc.
Even though CBT has demonstrated its effectiveness over numerous situations and disorders, it does have limitations to its use. For instance, CBT techniques may help individuals with bipolar disorder or schizophrenia adjust to certain living conditions; however, there is very little evidence that it can help to directly treat the symptoms of these disorders. Individuals with severe cognitive limitations may not be able to participate in the cognitive therapy aspect of CBT and may be more suited to strict behavioral therapy interventions. In some cases, CBT techniques may be enhanced with the use of medications, such as the treatment of severe depression, OCD, psychotic behaviors, etc.
CBT is an action-oriented therapy, meaning that in order for the therapy to actually produce positive outcomes, the client in therapy must assume responsibility for doing the work. This is in contrast to insight-oriented therapies that assume that simply knowing what causes one to behave in a certain way will result in significant change (e.g., Sigmund Freud’s psychoanalysis is an insight-oriented therapy). Because CBT therapies require individuals to actually assume responsibility for doing the work, certain individuals may not be appropriate for CBT or may not fully benefit from it.