Developed by Dr. Aaron T. Beck, Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT), is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. Therapists help clients to overcome their difficulties by changing their thinking, behavior, and emotional responses.
A System of Psychotherapy
Cognitive therapy is a comprehensive system of psychotherapy, and treatment is based on an elaborated and empirically supported theory of psychopathology and personality. It has been found to be effective in more than 400 outcome studies for a myriad of psychiatric disorders, including depression, anxiety disorders, eating disorders, and substance abuse, among others, and it is currently being tested for personality disorders. It has also been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. Cognitive therapy has been extended to and studied for adolescents and children, couples, and families. Its efficacy has also been established in the treatment of certain medical disorders, such as irritable bowel syndrome, chronic fatigue syndrome, hypertension, fibromyalgia, post-myocardial infarction depression, noncardiac chest pain, cancer, diabetes, migraine, and other chronic pain disorders.
In the mid-1960s, Dr. Aaron T. Beck developed cognitive therapy as a time-sensitive, structured therapy that uses an information-processing model to understand and treat psychopathological conditions. The theory is based, in part, on a phenomenological approach to psychology, as proposed by Epictetus and other Greek Stoic philosophers and more contemporary theorists such as Adler, Alexander, Horney, and Sullivan. The approach emphasizes the role of individuals’ views of themselves and their personal worlds as being central to their behavioral reactions, as espoused by Kelly, Arnold, and Lazarus. Cognitive therapy was also influenced by theorists such as Ellis, Bandura, Lewinsohn, Mahoney, and Meichenbaum.
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The Cognitive Model
Cognitive therapy is based on a cognitive theory of psychopathology. The cognitive model describes how people’s perceptions of, or spontaneous thoughts about, situations influence their emotional, behavioral (and often physiological) reactions. Individuals’ perceptions are often distorted and dysfunctional when they are distressed. They can learn to identify and evaluate their “automatic thoughts” (spontaneously occurring verbal or imaginal cognitions), and to correct their thinking so that it more closely resembles reality. When they do so, their distress usually decreases, they are able to behave more functionally, and (especially in anxiety cases), their physiological arousal abates.
Individuals also learn to identify and modify their distorted beliefs: their basic understanding of themselves, their worlds, and other people. These distorted beliefs influence their processing of information, and give rise to their distorted thoughts. Thus, the cognitive model explains individuals’ emotional, physiological, and behavioral responses as mediated by their perceptions of experience, which are influenced by their beliefs and by their characteristic ways of interacting with the world, as well as by the experiences themselves. Therapists use a gentle Socratic questioning process to help patients evaluate and respond to their automatic thoughts and beliefs—and they also teach them to engage in this evaluation process themselves. Therapists may also help patients design behavioral experiments to carry out between sessions to test cognitions that are in the form of predictions. When patients’ thoughts are valid, therapists do problem solving, evaluate patients’ conclusions, and work with them to accept their difficulties.
The Goal of Cognitive Therapy
The goals of cognitive therapy are to help individuals achieve a remission of their disorder and to prevent relapse. Much of the work in sessions involves aiding individuals in solving their real-life problems and teaching them to modify their distorted thinking, dysfunctional behavior, and distressing affect. Therapists plan treatment on the basis of a cognitive formulation of patients’ disorders and an ongoing individualized cognitive conceptualization of patients and their difficulties. A developmental framework is used to understand how life events and experiences led to the development of core beliefs, underlying assumptions, and coping strategies, particularly in patients with personality disorders.
A strong therapeutic alliance is a key feature of cognitive therapy. Therapists are collaborative and function as a team with patients. They provide rationales and seek patients’ agreement when undertaking interventions. They make mutual decisions about how time will be spent in a session, which problems will be discussed, and which homework assignments patients believe will be helpful. They engage patients in a process of collaborative empiricism to investigate the validity of the patient’s thoughts and beliefs.
Cognitive therapy is educative, and patients are taught cognitive, behavioral, and emotional-regulation skills so they can, in essence, become their own therapists. This allows cognitive therapy to be time-limited for many patients; those with straightforward cases of anxiety or unipolar depression often need only 6 to 12 sessions. Patients with personality disorders, comorbidity, or chronic or severe mental illness usually need longer courses of treatment (6 months to 1 year or more) with additional periodic booster sessions.
Cognitive therapists elicit patients’ goals at the beginning of treatment. They explain their treatment plan and interventions to help patients understand how they will be able to reach their goals and feel better. At every session, they elicit and help patients solve problems that are of greatest distress. They do so through a structure that seeks to maximize efficiency, learning, and therapeutic change. Important parts of each session include a mood check, a bridge between sessions, prioritizing an agenda, discussing specific problems and teaching skills in the context of solving these problems, setting of self-help assignments, summary, and feedback.
Cognitive Therapy Techniques
Therapists use a wide variety of techniques to help patients change their cognitions, behavior, mood, and physiology. Techniques may be cognitive, behavioral, environmental, biological, supportive, interpersonal, or experiential. Therapists select techniques based on their ongoing conceptualization of the patient and his or her problems and their specific goals for the session. They continually ask themselves, “How can I help this patient feel better by the end of the session and how can I help the patient have a better week?” These questions also guide clinicians in planning strategy.
There is no one typical client for this approach, as cognitive therapy has been demonstrated in numerous research studies to be effective for depression, anxiety disorders, substance abuse, eating disorders; for bipolar disorder and schizophrenia (as an adjunct to medication); and for a variety of medical problems with psychological components. Of course, treatment has to be varied for each disorder and therapists must not only understand the cognitive formulation of a specific disorder but also be able to conceptualize individual clients accurately and devise a treatment plan based on this formulation and conceptualization. Cognitive therapy interventions must also be adapted for older adults, children, and adolescents and for group, couples, and family treatment.
Effectiveness of Cognitive Behavior Therapy
In hundreds of clinical trials, CBT has been demonstrated to be an effective treatment for a wide variety of disorders. To name just a few, it has been found useful for:
- psychiatric disorders such as depression, the full range of anxiety disorders, eating disorders, substance abuse, personality disorders, and (along with medication) bipolar disorder and schizophrenia;
- medical disorders with a psychological component, including several conditions involving chronic or acute pain, chronic fatigue syndrome, pre-menstrual syndrome, colitis, sleep disorders, obesity, Gulf War syndrome, and somatoform disorders; and
- psychological problems such as anger, relationship difficulties, and compulsive gambling.
CBT is also used to address stress, low self-esteem, grief and loss, work-related problems and problems associated with aging.
Studies have shown that CBT is effective for children and adolescents, adults, and older adults. It is used in individual, couples, family, and group formats and in a wide variety of settings, such as schools, correctional facilities, outpatient, inpatient, and partial hospitalization units.