Cognitive Behaviour Therapy


 * This article is about cognitive therapy. For the behaviorist technique, see behavior modification.

Cognitive therapy or cognitive behavior therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder.

It involves recognising unhelpful patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that typically clinical depression is associated with (although not necessarily caused by) negatively biased thinking and irrational thoughts. Cognitive therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS. According to the U.S.-based National Association of Cognitive-Behavioral Therapists:


 * "There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.".

A related approach, Cognitive Analytic Therapy, can be regarded as a form of integrative therapy, integrating insights of both psychodynamic (especially Kleinian) therapy with a broad cognitive approach to therapy.

The basics
Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) all interact together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative thoughts can cause us distress and result in problems.

One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on their mood and makes them feel depressed; then they worsen the problem by reacting to avoid activities. As a result they reduce their chance of successful experience, which reinforces their original thought of being "useless". In therapy the latter example could be identified as a self-fulfilling prophecy or "problem cycle", and the efforts of the therapist and client would be to work together to change this. This is done by addressing the way the client thinks in response to similar situations and by helping them think more flexibly, along with reducing their avoidance of activities. If as a result they escape the negative thought pattern, they will already feel less depressed. They may hopefully also then become more active, succeed more, and further reduce their depression.

Thoughts as the cause of emotions
With thoughts stipulated as being the cause of emotions rather than vice-versa, cognitive therapists reverse the causal order more generally used by psychotherapists. The therapy is essentially, therefore, to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts.

Cognitive therapy is not an overnight process. Even after a patient has learned to recognise when and where his thought processes are going awry, it can take months of concerted effort to replace an irrational thought with a more reasonable one. With patience and a good therapist, however, cognitive therapy can be a valuable tool in recovery.

Cognitive behavioral therapy
While similar views of emotion have existed for millennia, cognitive therapy was developed in its present form by Albert Ellis and Aaron T. Beck in the 1950s and 1960s. It rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.

A sub-field of cognitive behavior therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia, and Panic Disorder.

CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse, and has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, and depression.

Depression
Negative thinking in depression can result from biological sources (i.e., endogenous depression), modeling from parents, peers, or other sources. The depressed person experiences negative thoughts as being beyond their control: the negative thought pattern can become automatic and self-perpetuating.

Negative thinking can be categorized into a number of common patterns called "cognitive distortions". The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions, or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.

Negative thoughts in depression are generally about one of three areas: negative view of self, negative view of the world, and negative view of the future. These constitute what Beck called the "cognitive triad".

An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First put forth by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style — they tend to attribute negative events in their lives to stable and global characteristics of themselves (Abramson, Seligman & Teasdale, 1978). There is considerable evidence that depressives do exhibit such an attributional style, but it is important to remember that Abramson et al. do not claim that an attributional style of this nature is necessarily going to cause depression — only that it will lead to clinical depression if combined with a negative event. This theory is sometimes known as a revised version of learned helplessness theory. In 1989, this theory was challenged by Hopelessness Theory. This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinicial depression as are causal attributions.

The four column technique
A major technique in cognitive therapy is the four column technique. It consists of a four step process. The first three steps analyze the process by which a person has become depressed or distressed. The first column records the objective situation. In the second column, the client writes down the negative thoughts which occurred to them. The third column is for the negative feelings and dysfunctional behaviors which ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. Finally, the fourth column is used for challenging the negative thoughts on the basis of evidence from the client's experience.

Treating depression with CBA
A relatively new version of cognitive behavioral therapy for depression is the cognitive behavioral-analysis system of psychotherapy (CBASP). When combined with appropriate antidepressants, it can be extremely effective.

A study published by Martin Keller MD of Brown University and others in the May 18, 2000 New England Journal of Medicine compared the antidepressant Serzone with the talking therapy CBASP. CBASP is largely derivative of other talking therapies such as cognitive, behavioral, and interpersonal therapy. Six hundred and eighty-one patients with severe chronic depression (some with other psychiatric illnesses) were enrolled in the trial, and were assigned to either Serzone, CBASP, or combination Serzone-CBASP for 12 weeks. The response rates to either Serzone or CBASP alone were rather underwhelming - 55 percent and 52 percent, respectively, for the 76 percent who completed the study. In other words, a little more than half of the completers in those two arms of the trial reduced their depression by 50 percent or better.

The Serzone findings roughly correspond with many other trial results for antidepressants, and underscore a major weakness in these drugs - that while they are effective, the benefit is often marginal and the treatment outcome problematic. Similarly, the CBASP findings validate other studies finding talking therapy about equal in efficacy to taking antidepressants.

The results for the combination drug-therapy group, however, were surprising, with 85 percent of the completing patients achieving a 50 percent reduction in symptoms or better. 42 percent in the combination group achieved remission (a virtual elimination of all depressive symptoms) compared to 22 percent in the Serzone group and 24 percent in the CBASP group.

The authors of the study confessed to being caught by surprise by the results, acknowledging that "the rates of response and remission in the combined-treatment group were substantially higher than those that might have been anticipated."