Cognitive Behavioral Therapy

The history of psychotherapy extends back many centuries. The notion that individuals could relieve certain types of stress by talking about their experiences with someone else is not a finding that originated with the advent of modern psychology. Even though certain types of “talking cures” had been used far before the development of psychoanalysis by Sigmund Freud, the majority of historical resources point to Freud as the founding father of what we now know as psychotherapy.

Freud initially used hypnosis and dream analysis to treat issues with his patients, but eventually he found that he could get equivalent results just having an individual speak what was on their mind at the moment (free association). Free association became the basis for Freud’s psychoanalysis and also resulted in the beginning of more formalized methods for “talking cures.”

Despite many of Freud’s original theories/ideas losing popularity, it is important to understand his contribution to psychotherapy. These aspects of Freud’s theories are still relevant today and embraced by all types of psychotherapy:

  • People often do not say what they mean directly.
  • People develop defense mechanisms to protect themselves from issues with anxiety, to protect their self-image, or just to avoid being found out.
  • People very often do not understand the origins of their feelings, beliefs, or even of some of their actions.
  • Experiences that occur during childhood can affect adult behavior.
  • Discussing one’s feelings with a professional psychologist (or therapist) is a formalized treatment method.

Several major schools of psychotherapy developed in response to Freudian theory, and two of these schools were the school of behavioral therapy (from behavioral psychology) and the school of cognitive therapy (from the cognitive paradigm in psychology).

What Is Psychotherapy?

The American Psychological Association defines psychotherapy as a collaborative intervention that uses the cooperative efforts of a psychologist, counselor, or therapist, and one or more clients. This intervention is designed to provide information, ideas, and treatment for issues with the client’s actions, mood, beliefs, relationships, or other areas of the client’s personal or professional life.

Therapists who perform psychotherapy are formally trained in psychological principles, and the therapist directly applies these principles in the application of therapy. Psychotherapy is heavily based on dialogue between the therapist and client. The therapist provides a supportive milieu that helps the client to achieve desired goals.

Other similar types of interventions do not meet the qualifications of psychotherapy. These include asking for assistance or advice from friends or someone who is not formally trained as a psychotherapist, attending 12-Step meetings or other social support groups, the use of motivational books or tapes, or other self-help supports. Many individuals may perceive these activities as being “therapeutic” and that they help them with their issues; however, these are not formal types of psychotherapy as they are not delivered by a trained psychologist or therapist. For example, many individuals experience therapeutic effects from vigorous exercise, but no one would formally state that exercising is a form of psychotherapy. In addition, in most states, the application of formal psychotherapy (therapeutic services that require clients to pay fees) can only be administered by individuals who are licensed to perform therapy within that state. These individuals must meet certain educational criteria, have completed specific training, and must pass a formal licensing examination.

Thus, some individuals may actually apply techniques from various forms of psychotherapy, such as Cognitive Behavioral Therapy; however, unless they meet the above specifications, they are not psychotherapists performing psychotherapy.

The Development of Cognitive Behavioral Therapy

The behavioral paradigm in psychology and the cognitive paradigm both originated from experimental psychology where psychologists often used animal models to understand behavior. Freud’s work is actually the forerunner of the development of modern clinical psychology. As Freudian theory became popular, numerous individuals began to have negative reactions to Freud’s notions of the unconscious mind, sexuality as a driving force in behavior, etc. The paradigms that developed from experimental psychology had demonstrated that behaviors could be associated with reinforcement or due to the effect of certain types of cognitive structures (e.g., memory or belief systems) that were even possessed by rodents. Experimental psychologists began to make the connection between experimental findings from the laboratory, human behavior, and utility of these findings for psychotherapy.

The behavioral paradigm in psychology originated from experimental work with animals, and its focus was primarily on how environmental events contributed to their behavior. Early behavioral psychologists may have implicitly understood that mental events were impacted by environmental stimuli to produce behavior; however, with the advent of famous behaviorists, such as B.F. Skinner, these mental events were considered either to be uninterpretable (cannot be observed under empirical conditions) or inferior to environmental events (e.g., reinforcement, punishment, etc.) in producing changes in behavior. Experimental behavioral psychologists emphasized understanding only observable phenomena, and thoughts and attitudes are not observable.

The factors associated with behavioral psychology were found to transfer readily to forms of psychotherapeutic interventions. For example, the use of reinforcement, exposure (actually confronting people with their fears), and other behavioral techniques were found, through research evidence to be particularly effective in changing behavior. However, even though many of the techniques used in modern-day therapy have their origins in behavioral psychology, because of its lack of emphasis on trying to understand thoughts, emotions, etc., therapists who adopt an approach that is purely a “behavioral approach” are nonexistent.

The cognitive paradigm in psychology actually developed as a reaction to the mechanistic and cold approach of the behavioral paradigm as well as many of the issues associated with Freudian theory. Cognitive psychology got its start from experiments by researchers like Edward Toleman. Behavioral theorists had posited that learning can only occur as a result of reinforcement or punishment; however, Toleman brilliantly display that rodents could learn the location of food or water in their environment by creating “cognitive maps” of their environment, without being reinforced or punished. This type of research opened up a whole new paradigm in psychology that was applicable to applications in psychotherapy.

Cognitive therapy grew out of the experimental research. Cognitive psychology techniques concentrate on helping individuals to modify their attitudes and beliefs in order to help them change their behavior.

The first person who is recognized to have developed a form of Cognitive Behavioral Therapy (CBT) is the therapist Albert Ellis who applied both the principles of cognitive psychology and behavioral psychology to his own brand of therapy, Rational Emotive Behavioral Therapy. Ellis, like many other researchers and psychotherapists, had become dissatisfied with the Freudian school of psychotherapy and sought to combine the effectiveness of behavioral approaches with changing an individual’s mental state.

Types of Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy is not just one type of therapy with one specific application; it is now an umbrella term to describe numerous approaches that operate on the same basic principles. The general principles of all CBT therapies are quite simple:

  • Thinking and behavior are related.
  • Individuals who have irrational beliefs or dysfunctional beliefs often have dysfunctional behaviors.
  • Helping an individual to modify specific beliefs to be more realistic and functional can help them change dysfunctional behaviors.

Each type of CBT has specific techniques that operate on these general principles. Some of the more familiar applications of CBT are outlined below.

  • Motivational Interviewing:

    Motivational interviewing (MI) was formulated in order to understand where individuals who had issues with tobacco abuse (and later people with other substance abuse issues) stood regarding their understanding of whether their behavior was problematic and needed to change. It has long been recognized that individuals with substance use disorders often do not see their behavior as problematic or dysfunctional, even if everyone else who associates with them believes that their behavior is destroying them.

    The MI approach operates on the notion that individuals must somehow come to realize that their behavior is problematic in order for them to change their behavior. The first step in helping individuals is to identify how they perceive their behavior and then offer interventions based on that finding. An individual who does not see their behavior as particularly problematic might be challenged to defend their behavior; whereas an individual who believes they have a problem but is unsure of how to address the problem would require a different approach.

    The Transtheoretical Stages of Change Model was developed out of the MI paradigm and lists the different stages the individual may progress through as they begin to understand their need to change. The model can be used to identify where an individual’s understanding of their need to change is and to help them based on their understanding of their own behavior. The MI approach uses CBT techniques to help individuals change. It can be combined with other forms of CBT as well.

  • Dialectical Behavior Therapy:

    Dialectical Behavior Therapy (DBT) is a form of CBT that was originally developed to treat suicidal individuals. These individuals were notoriously difficult to treat and often very reactive in therapy. DBT developed a specialized approach to deal with these individuals, and this approach became the standard approach to deal with severe personality disorders, such as borderline personality disorder. DBT has specific applications for specific types of disorders, including substance use disorders, that are all based on the principles of CBT.

  • Acceptance and Commitment Therapy:

    Acceptance and Commitment Therapy (ACT) is a form of CBT that helps individuals develop realistic self-images. Once they develop more realistic self-images that are not based on generalized statements or beliefs (e.g., I am a failure, everyone must love me, etc.), they can learn to alter their behavior accordingly.

  • Rational Emotive Behavioral Therapy:

    As mentioned above, Rational Emotive Behavioral Therapy is a form of Cognitive Behavioral Therapy that was one of the seminal CBT approaches. It was initially primarily used to treat issues with depression and personality disorders.

    REBT operates on the assumption that people sometimes develop assumptions about themselves, others, or the world in general that are unrealistic or irrational. These irrational assumptions or beliefs can lead to significant distress and impairment. REBT works with individuals to address the specific irrational beliefs about the world, challenge them, help the individual restructure them to more realistic appraisals, and help the individual to change their behavior based on their new understanding of reality.

  • Specific CBT applications:

    There are specific CBT protocols for treating depression, panic disorder, phobias, personality disorders, etc. All of the specific protocols are designed to treat the specific issue in question by using the principles of CBT, such as CBT for phobias, CBT for panic disorder, CBT for depression, etc.

Irrational Beliefs

Even though there are many different types of CBT, and each different type may have a tailored approach or techniques used to address specific issues, all forms of CBT are based on the same core principles that involve the restructuring of irrational beliefs or attitudes in conjunction with directly addressing behavior. There are three general manifestations of irrational beliefs:

  1. Irrational beliefs about oneself

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    Many people develop dysfunctional or irrational beliefs about themselves that result in significant distress for them and can lead to issues with anxiety, depression, decreased feelings of self-worth, etc. Often, individuals develop these belief systems as a result of their early upbringing and the expectations placed upon them when they are young. For example, many individuals harbor the notion that making mistakes is always bad and deserving of punishment. Of course, everyone will make a mistake at one time or another, not all mistakes deserve punishment, and anyone who adopts this type of implicit belief system is bound to suffer distress associated with it.

  2. Beliefs about the state of the world

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    Some people harbor notions that the world operates in a certain manner and that this condition represents reality. One of the most common applications of a false and irrational belief about the state of the world comes from individuals with alcohol use disorders who justify their behavior by believing that everyone drinks. This fosters a number of dysfunctional behaviors in these individuals as it allows them to justify their own issues, externalize their behavior, and excuse themselves from attempting to change. This type of belief is associated with the fact that quitting drinking would be abnormal for anyone. The reality is that everyone does not drink alcohol, and for an individual with an alcohol use disorder, drinking alcohol is dysfunctional.

  3. Beliefs about the future

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    Some individuals harbor irrational beliefs about the future. Individuals with substance use disorders often believe that if they change their behavior, their future will be negatively affected because they cannot envision themselves not using alcohol, cannabis, etc. These individuals associate the notion of their wellbeing and happiness as being dependent on their ability to use their substance of choice and engage in associated behavior, when it is their substance use that is actually dysfunctional. This type of belief needs to be addressed, challenged, and then restructured.

The belief systems discussed above are not the type of conscious, overt beliefs that individuals often associate with overall philosophies. For instance, few people consciously think, “I am going to believe I have to be perfect in order to be liked.” Instead, most of these belief systems are mental structures that are not consciously implemented. These structures are often referred to as schemas, working models of the world that drive an individual’s behavior. Most schemas are functional; however, sometimes, schemas can lead to dysfunctional behavior, such as those that promote ethnic stereotypes. Schemas are not conscious manifestations of thoughts and behaviors as much as they are implicit structures that drive behavior and contribute to belief systems, attitudes, and actions.

Cognitive-behavioral therapists require special training to foster their ability to recognize these types of mental structures, decide how to best address them based on the individual’s desires and needs, and then determine what techniques to use. Cognitive Behavioral Therapy is not just a simple matter of telling someone that their belief system is irrational and to change; it requires much sophistication in its approach.

The Implementation of CBT

Even though there are many different types of CBT, all types follow the general approach in recognizing and providing treatment. This general approach includes the following components:

  • Assessing the individual’s behavior

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    The first step for any form of psychotherapy is to thoroughly understand what the client wants, why they came to the therapeutic situation, and what is going on in the individual’s life that brought them into therapy. Therapists need to fully assess the individual, and CBT therapists typically use a functional analysis that is a formalized assessment process to help the therapist understand how the individual’s belief system is contributing to their issues. The functional analysis is a direct application from techniques used in behavioral psychology.

  • Understanding the major issues

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    Therapists use a functional analysis to identify the core issues that are present in the client’s case. These issues include both cognitive and behavioral facets of the individual’s situation. Therapists often develop a system of hypotheses to test with the client in order to understand them better. This type of approach comes from experimental psychology and behavioral analysis.

  • Organizing goals

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    Psychotherapy without formal goals cannot work. The therapist and client work together after the therapist has an idea of the individual’s issues, understands the issues, and has discussed the situation with the client to develop the goals for therapy. These goals are not set in stone and can be altered as needed, but they set the trajectory for the rest of the therapy.

  • Recognizing irrational beliefs

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    Once the therapist has developed a working hypothesis regarding the specific types of irrational thoughts and dysfunctional behaviors and how they are related, they will discuss these issues with the client and challenge the client’s belief system. Clients are challenged to actually test these irrational beliefs in the real world, which often results in them realizing that these beliefs are contributing to their issues.

  • Cognitive restructuring

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    Different forms of CBT apply different types of restructuring techniques to help individuals alter their beliefs to more realistic and functional beliefs. The cognitive restructuring component comes directly from cognitive psychology.

  • Using behavioral techniques

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    In conjunction with the use of cognitive restructuring techniques, a therapist will also often apply techniques from behavioral psychology, such as using different types of reinforcement to help the individual change their behaviors.

  • Encouraging practice and assigning homework

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    Therapists and clients work together to practice new skills in session, and therapists will often assign clients homework to complete in the real world. Homework consists of applying the principles learned in the therapy sessions to the real world and testing them out. A client will return with feedback regarding how these applications are working, and the therapist and client work together to adjust them based on the personal needs of the individual.

  • Engaging in transfer and competence

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    As the therapeutic alliance (the working bond between the client and therapist) strengthens and the client becomes more competent and adept in learning new skills, the client begins to develop insight into their issues and how to address them, and can implement these changes.

  • Terminating treatment

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    As the client becomes more competent in addressing their issues and the goals of the therapy are met, the therapist works with the client to make the client more self-sufficient. A specific termination date is agreed upon, and the client and therapist work together to finish up any work that needs to be completed as the termination date gets closer. Once the work is completed, the therapist and client review their progress, decide if any other issues need to be addressed, and if all is well, the therapy can be terminated. Clients are encouraged to contact the therapist if they believe they need additional assistance in the future. In many instances, periodic follow-up sessions may be set up, so the client can come back and fine-tune their new skills or address other issues.

The Evidence of CBT’s Effectiveness

CBT is the most researched form of psychotherapy. Numerous research studies and texts have documented its success in treating nearly every type of psychological disorder. For instance, the textbook Psychotherapy Research: Foundations, Process, and Outcome reports numerous studies documenting the effectiveness of CBT, and the manual A Guide to Treatments That Work present numerous empirically validated applications of CBT for a number of different disorders and conditions. Psychiatric texts often refer to CBT as the preferred intervention for different disorders, including substance use disorders, anxiety disorders, obsessive-compulsive disorder, certain personality disorders, etc.

Cognitive Behavioral Therapy is an effective therapeutic approach, but it is not a panacea. CBT is not recommended as a primary treatment approach for psychotic disorders, such as schizophrenia (however, it may be used in conjunction with medication to help individuals adjust) or as a primary approach to treat severe disorders like bipolar disorder. It is also not effective in treating individuals with severe cognitive limitations.

CBT requires a collaborative effort between the therapist and client. Clients who are not willing to invest the time and energy into the type of work that is required in CBT will not fully experience its benefits.