Cognitive Behavioral Therapy

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Cognitive behavioral therapy (CBT) is a psychotherapeutic approach, a talking therapy, that aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure. The title is used in diverse ways to designate behavior therapy, cognitive therapy, and to refer to therapy based upon a combination of basic behavioral and cognitive research.

There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Some clinicians and researchers are more cognitive oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (in vivo exposure therapy). Other interventions combine both (e.g. imaginal exposure therapy).

CBT was primarily developed through a merging of behavior therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the ‘here and now,’ and on alleviating symptoms. Many CBT treatment programs for specific disorders have been evaluated for efficacy and effectiveness; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments.

The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behavior therapeutical approaches appeared as early as 1924, with Mary Cover Jones’ work on the unlearning of fears in children. In 1937 Abraham Low developed cognitive training techniques for patient aftercare following psychiatric hospitalization. Low designed his techniques for use in his organization, Recovery International, which supports people recovering from mental illness.

It was during the period 1950 to 1970 that behavioral therapy became widely utilized, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull. In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization, the precursor to today’s fear reduction techniques.

British psychologist Hans Eysenck, inspired by the writings of Karl Popper, criticized psychoanalysis in arguing that ‘if you get rid of the symptoms, you get rid of the neurosis,’ and presented behavior therapy as a constructive alternative. In the United States, psychologists were applying the radical behaviorism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior and autism.

Although the early behavioral approaches were successful in many of the neurotic disorders, they had little success in treating depression. Behaviorism was also losing in popularity due to the so-called ‘cognitive revolution.’ The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behavior therapists, despite the earlier behaviorist rejection of ‘mentalistic’ concepts like thoughts and cognitions.

Both these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Albert Ellis’s system, originated in the early 1950s, was first called rational therapy, and can arguably be called one of the first forms of cognitive behavioral therapy. It was partly founded as a reaction against popular psychotherapeutic theories at the time, mainly psychoanalysis.

Aaron T. Beck, inspired by Albert Ellis, developed cognitive therapy in the 1960s. Beck describes his therapeutic approach as originating in a realization he made while conducting free association with patients in the context of classical psychoanalysis—he noted that patients had not been reporting certain thoughts at the fringe of consciousness, thoughts which often preceded intense emotional reactions; this realization led Beck to begin viewing emotional reactions as resulting from cognitions, rather than understanding emotion within the abstract psychoanalytic framework.

The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly included.

A basic concept in CBT treatment of anxiety disorders is in vivo exposure—a gradual exposure to the actual, feared stimulus. This treatment is based on the theory that the fear response has been classically conditioned and that avoidance negatively reinforces and maintains that fear. Through exposure to the stimulus, this conditioning can be unlearned; this is referred to as extinction and habituation.

One etiological theory of depression is Aaron Beck’s cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events. When the person with such schemata encounters a situation that in some way resembles the conditions in which the original schema was learned, the negative schemata of the person are activated.

Beck also described a negative cognitive triad, made up of the negative schemata and cognitive biases of the person; Beck theorized that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as, ‘I never do a good job,’ ‘It is impossible to have a good day,’ and ‘things will never get better.’ A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. This is the negative triad.

Also, Beck proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalization, magnification and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.

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