Steven R Lawyer, Sherman M Normandin, Verena M Roberts. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
Cognitive-behavioral therapy (CBT) is a form of psychotherapy that has strong ties to the behavioral theories of John B. Watson and B. F. Skinner. However, it also incorporates general information-processing theories concerning the interactions of environment, cognition, and behavior to understand and to treat psychological problems. In this chapter, we will cover the basic theories and historical events that constitute CBT’s foundation, outline various changes in the practice of CBT over the past several decades, and detail some of the primary methods that CBT practitioners use.
The First Wave: Early Behavior Theory and Therapy
No less than the founder of the school of Behaviorism, John Watson, helped to establish the therapeutic utility of applying behavior principles to clinical problems. In these early years, clinically oriented psychologists (e.g., Salter, 1949) applied Pavlov’s (1927) classical conditioning paradigm to psychological models for understanding human psychological problems. In their classic study, Watson and Rayner (1920) showed how classical conditioning was implicated in the development of phobic reactions. They described how they used an 11-month-old infant, known only as Albert, and repeatedly paired a loud noise (the unconditioned stimulus; UCS), which elicited startle and crying (the unconditioned response; UCR), with a white rat (the neutral stimulus; NS). Although the white rat initially elicited little more than passing interest in Albert at first, after repeatedly showing Albert the rat and then making the loud noise, the white rat became a conditioned stimulus (CS) that elicited crying (the conditioned response; CR), even without the loud noise.
Although poor Albert was not treated for his newly acquired white rat phobia, Watson and Rayner illustrated in subsequent experiments the basic procedure for breaking such a phobic association by repeatedly presenting the CS (white rat) without the UCS (loud noise) in a process known as extinction.
Watson originally viewed all behavior as classically conditioned behavior, but it soon became clear that classical conditioning was not the only form of learning. Although the principles of classical conditioning provided powerful explanations for understanding involuntary responses, such as emotional responses, they did not go far in explaining voluntary, or operant, behaviors.
Beginning in the 1950s, Skinner (1953) established principles of operant learning that would advance our understanding of much human behavior. In contrast to classical conditioning, in which the stimulus of interest precedes the response of interest (e.g., the rat precedes the crying response in Little Albert), Skinner argued that a clear understanding of operant behavior required careful consideration of the stimuli (consequences) that follow the operant response. Thus, to understand the conditions under which some behavior occurs, one must focus on the consequences of that behavior.
At a very basic level, human behavior occurs in an environmental context in which it leads to one or more of various outcomes that may reinforce, punish, or extinguish it. An operant perspective is relevant to both normal and abnormal behaviors and views abnormal behavior as behavior that can be influenced by changing the behavioral outcome. An operant analysis of problem behavior includes an understanding of the antecedent stimuli that set the conditions for the problem behavior, the problem behavior itself, and the consequences that follow the problem behavior that may be maintaining it. Any consequence that increases the likelihood of that response in the future is a reinforcer. Conversely, any consequence that decreases the likelihood of that response in the future is a punisher.
Classical and operant conditioning principles formed the basic foundation for behavior therapy in the early 20th century, and buttressed the view that some held suggesting that therapy should be guided by scientifically and rigorously tested psychological principles. This perspective formed in large part in reaction to the dominant clinical approach at the time: Freud’s psychoanalysis and other psychodynamic approaches. These approaches rested heavily on theory and consisted of therapeutic techniques (hypnosis, free association, dream analysis, etc.) that lacked empirical support and focused more on events inside the individual rather than on those in the environment.
The Second Wave: Who Put the “Cognitive” in Cognitive-Behavioral Therapy?
One aspect of behavioral theories that many researchers and clinicians found troublesome was the deemphasis of the role of mentalistic events such as thoughts, images, and dreams for understanding clinical problems. Indeed, behavior theory in general avoided focusing on such aspects of the human experience, not because they weren’t believed to exist, but because such phenomena were difficult to assess reliably. In 1977, Albert Bandura’s social learning theory outlined the conditions under which behaviors could be learned in the absence of direct contact with the consequences. For example, behaviors could be learned via modeling simply by watching others perform the behavior and perceiving the consequences. Social learning theory also increased emphasis on an individual’s thoughts and beliefs about a given situation as a method of predicting behavior. Many clinicians welcomed this shift in focus because they found it impractical to avoid references to thoughts and images when clients reported great distress due to them.
The theoretical and practical developments within behavior therapy led to a steady increase in the development of cognitively oriented psychotherapy techniques that remain a part of CBT today. Unlike behavior therapy, cognitive therapy did not stem from the basic research findings associated with the larger field of experimental cognitive psychology, but rather applied a more commonsense general information-processing approach to the treatment of clinical phenomena. Such approaches are guided by the assumption that cognitive phenomena (e.g., irrational thoughts) mediate the relationship between environment and behavior and that changing the content of cognitive processes can lead to changes in dysfunctional behaviors.
At the same time, Aaron Beck (Beck, Rush, Shaw, & Emery, 1979) developed his cognitive model of therapy that focused initially on depression. In this model, negative environmental stressors activate an individual’s negative self-schema, which is created in childhood. The negative self-schema is the tendency to view oneself, the environment, and the future in negative ways. Cognitive therapy based on this model consists of identifying schema-based thoughts (e.g., “I am a bad person”) and challenging them via logical empiricism in which the validity of one’s thoughts is tested against the objective reality of the world.
One criticism of cognitive therapy is that it is not directly tied to experimental cognitive science, though there are some current efforts in CBT to correct this omission. However, several aspects of cognitive science have direct relevance to the more clinically oriented cognitive therapy. For example, research in experimental cognitive science that distinguishes between implicit and explicit memories, autobiographical and semantic cognitions, and “cold” versus “hot” cognitions are meaningfully related to clinical cognitive therapy (David & Szentagotai, 2006)
The Third Wave of CBT: Embracing Philosophy and Cognition
The move toward specifically addressing language and cognition in the context of human psychological problems in cognitive therapy addressed one shortcoming of the orthodox behavioral approaches that relied solely on learning theories, but it did so at the cost of distancing therapeutic practice from basic psychological science. Although cognitive therapy was clinically useful, its methods were not well linked to basic psychological principles. Moreover, various studies demonstrated that dysfunctional thoughts tended to go away as a function of behavioral change, suggesting that behavior change was fundamental to the alleviation of psychological problems (e.g., Jacobson & Hollon, 1996).
Over the past 10 years or so, several developments have led to changes within the field regarding the philosophical approach to understanding human psychological problems. This “movement” is still in transition, but it represents a fundamental shift in the application of CBT to psychological problems. The so-called “third wave” of behavior therapy represents a combination of the scientific principles associated with early behavior therapy while embracing human language and cognition from an empirical, rather than practical, standpoint. Hayes and colleagues (2001) outlined this approach, which is called relational frame theory, and argued that a clear understanding of language and cognition is fundamental to a comprehensive understanding of human behavior.
From this perspective, human language and cognition occur as a function of derived stimulus relations in which events and words are paired directly or indirectly, forming “relational frames,” which may interact with one another. Changes to one relational frame can influence other relational frames. For example, a child learns to point to a dog and say “dog” (dog ‡ “dog”) and that a dog is an animal (dog ‡ animal), thus forming a relational frame encompassing the word “dog,” seeing a dog, and seeing an animal. Suppose that the child is bitten by a dog and he comes to fear not only seeing dogs but even hearing the word “dog,” or to fear other animals, in spite of the fact that the bite did not take place in the context of the word “dog” or any other animals. A relational frame perspective may also explain why many clients report that talking about some past life experiences can be painful—the words and images form a relational frame encompassing past emotional experiences.
The concepts and theories associated with the third wave of behavior therapy will continue to develop and be refined (or even rejected) over time, but contemporary perspectives concerning behavior therapy have led researchers and clinicians to embrace and study a variety of clinically relevant phenomena that are novel, interesting, and effective. For example, CBT-oriented psychologists increasingly study phenomena not historically related to traditional psychology, such as “mindfulness,” which is based in the Buddhist tradition. In addition, these changes to CBT methods also have led clinicians and researchers to integrate subject matter typically addressed by other types of clinicians, such as the role of values, which have a much longer history in the client-centered tradition (Rogers, 1961).
Popular Techniques in Cognitive-Behavior Therapy
Cognitive-behavioral therapies often comprise a collection of specific techniques that focus on a particular aspect of the client’s presenting complaint. Using symptom-specific treatment techniques is particularly useful when tailoring a particular treatment to individual clients. Indeed, one thing that differentiates CBT from many traditional psychotherapy approaches, such as psychoanalytic/psychodynamic, humanistic, and interpersonal psychotherapy, is that it employs very specific techniques that treat specific problems. Another unique aspect of cognitive-behavior therapy is that the techniques that therapists employ develop as a function of the reciprocal relationship between experimental laboratory science and clinical practice in the therapist’s office. Listed now are some of the fundamental treatment techniques found in CBT treatment packages for psychological problems.
One of the most common CBT practices for psychological problems involves instructing the client to monitor some aspect of her behavior over time. Typically, a clinician will ask a client to monitor things such as the frequency of a problem behavior (such as checking or counting in obsessive-compulsive disorder) or the ABCs—the antecedents, behaviors, and consequences—of a problem behavior. A record of problem behaviors as they occur in the environment can help inform the focus and direction of an intervention, and it also can act as an intervention in its own right. In an early study, McFall (1970) found that having smokers simply monitor their desire to smoke led to decreases in smoking behavior.
A variety of different relaxation strategies have formed the cornerstone of many cognitive-behavioral treatments over the past three decades. One of the most popular therapy techniques used in CBT is progressive muscle relaxation (PMR). Jacobson (1938) first developed PMR as a method for inducing relaxation to treat a variety of medical conditions. However, behavior therapists eventually abbreviated Jacobson’s protocol and used it to treat anxiety-related problems (Bernstein & Borkovec, 1973). In the typical PMR procedure, the client systematically tenses and relaxes approximately 16 different muscle groups located in nearly every major part of the body (face, arms, torso, and legs). After practicing with all 16 muscle groups in the clinic and at home, clients combine smaller muscle groups into groups of eight and then groups of four. With continued practice, the client learns to “relax by recall,” in which relaxation occurs simply by remembering the sensations of relaxation experienced during practice.
Cognitive-behavioral therapists most frequently use PMR when treating clients with anxiety-related disorders, which often are accompanied by elevated levels of tension and arousal. One primary goal for relaxation training is to provide clients with a coping skill to be used when they become overly anxious or tense. Another important aspect of relaxation training is that it increases awareness of early muscle tension so that clients can prevent the onset of undue anxiety or tension.
One issue on which cognitive-behavioral therapists often focus is how incorrect, exaggerated, or irrational thoughts and beliefs, known as cognitive distortions, influence a client’s feelings and behavior. For example, a depressed client may report thoughts such as “I am worthless” or “There’s no hope.” A socially anxious client may be afraid to speak in front of others because of the belief that she’ll “look like an idiot.” The purpose of cognitive restructuring is to correct distortions in thinking that are negatively affecting the individual’s functioning and increase accurate thinking about the individual’s current environment.
In the typical cognitive restructuring procedure, the client first learns to identify and record dysfunctional thinking patterns. At the outset of therapy, the client is first educated about different kinds of cognitive distortions, such as all-or-none thinking (“I’m always screwing up”), mind reading (“they’ll think I’m an idiot”), and overgeneralization (“I screw up everything”), among others. After the client learns to detect and identify patterns in distorted thinking, the therapist teaches the client to test the reality status of his/her thoughts and beliefs about their automatic thoughts by listing evidence for and against their beliefs. One important aspect of this technique is that the goal is not to convince the client to think happy or positive thoughts, but to bring the client’s thoughts in line with reality.
Another popular CBT technique for treating the symptoms of depression is behavioral activation (BA). From a behavioral perspective, symptoms of depression (e.g., anhedonia, low energy) are viewed as resulting from infrequent contact with pleasant or reinforcing activities in an individual’s environment. Indeed, depressed individuals often are isolated and engage in few, if any, pleasurable activities. One proven way to help alleviate depression-related symptoms is to increase a depressed individual’s contact with reinforcing activities (Jacobson, Dobson, & Truax, 1996). In a typical BA procedure, the therapist helps the client identify and compile a list of activities that the client typically finds reinforcing. Then, the therapist puts together an activities schedule in which homework involves engaging in reinforcing activities. Although this practice may sound quite simple, depressed individuals often are not motivated to engage in these activities. However, the initial goal of BA is for the client to engage in the reinforcing behavior even if he does not find the behavior immediately reinforcing. In essence, the client is asked to “engage in the behavior and let the motivation catch up.” Over time, repeated contact with previously reinforcing activities reliably leads to decreases in depressive symptoms.
One of Skinner’s enduring influences on CBT was the incorporation of various operant technologies in therapy. From an operant perspective, a clinician conceptualizes clinical phenomena as voluntary behavior patterns that, because they have developed over time and as a function of the consequences that follow them, can be influenced by altering the consequences that follow them. Contingency management (CM) interventions fundamentally involve altering the client’s environment such that incentives and rewards are delivered following desired behaviors (to increase their probability and frequency) and incentives and rewards are withheld following problem behaviors (to decrease their probability and frequency).
Stimulus control methods involve altering the relationship between some stimulus and some response (or behavior). For example, problematic behaviors can result from respondent stimulus control (e.g., a spider phobic has an exaggerated fear response when he sees even harmless spiders) or operant stimulus control (e.g., someone with social skills deficits may be insensitive to facial expressions). Stimulus control is not a technique per se, but represents one way to think about problem behaviors. Stimulus control that is associated with problem behaviors can be influenced by the pairing of stimuli, contingency management, and establishing rules regarding responses to stimuli.
One of the most frequently used treatment techniques in CBT, especially in the context of anxiety disorders, is exposure. One hallmark characteristic of many anxiety disorders (e.g., phobias, panic disorder) is that clients fear situations and stimuli that pose no objective harm to them. For example, someone with a dog phobia may have had a history of being attacked by a dog, but now avoids contact with any dog, even those that pose no threat. In such cases, some sort of exposure therapy often is used, but the type of exposure used may differ, depending on the circumstances.
In vivo exposure involves systematically exposing anxious clients to actual feared (though nonharmful) situations. In the case of our dog phobia example, in vivo exposure may involve a woman going to a pet store and confronting her fear while looking at and interacting with real dogs. In some cases, however, in vivo exposure is not the preferred form of exposure because (a) it is impractical (in the case of flying phobia), (b) it is impossible (the feared stimulus is a fear-related thought or memory), or (c) the client is unwilling to engage in the exposure process. When in vivo exposure is not feasible, a therapist is likely to incorporate imaginal exposure into the treatment. Imaginal exposure involves having the client imagine fear-provoking situations as a way to reduce anxiety.
Interoceptive exposure is yet another type of therapeutic exposure in which the client is systematically exposed to physical sensations associated with anxiety. For example, panic disorder is characterized by a fear of anxiety-related sensations such as increases in heart rate, dizziness, and shallow breathing. This response pattern is known as anxiety sensitivity, or “fear of fear” (Reiss & McNally, 1985). People come to fear such sensations because those stimuli have become conditioned stimuli that cue the onset of a panic attack. During interoceptive exposure, the patient performs a series of one or more symptom-induction exercises that bring about a feared physiological reaction. In other words, the client is repeatedly “exposed” to physiological sensations that evoke a fear response. For example, running in place for a minute will induce increased heart rate, breathing through a straw can induce sensations of breathing difficulties, and shaking one’s head side to side can induce dizziness.
Recently, some clinicians have incorporated virtual reality (VR) technologies that mimic feared situations into their exposure-based therapies. VR may be especially useful in situations where exposure to feared stimuli cannot be duplicated as part of an in vivo exposure protocol and/or when imaginal exposure is not useful. VR is a developing technology in clinical psychology, and has been integrated into exposure-based treatments for post-traumatic stress disorder (PTSD), including war-related PTSD (Rothbaum & Hodges, 2001) and PTSD related to the September 11 World Trade Center terror attacks in 2001 (Difede, Hoffman, & Jaysignhe, 2002).
Anxious clients seeking treatment often will report that “exposure doesn’t work” because they have tried it on their own to no avail. Unfortunately, some attempts at exposure may actually make the problem worse. For example, let’s say Jane is afraid of enclosed spaces, but she has tried to “get over” her fear by purposely placing herself in feared situations, such as elevators, only to become very afraid (perhaps she even had a panic attack). From a conditioning standpoint, a psychologist would predict that Jane’s anxiety would not go away and may even get worse because she always experiences fear when in the elevator, and the removal of the fear may negatively reinforce her avoidance behavior (Mowrer, 1960). If Jane goes to a therapist and does any form of therapeutic exposure, she will remain in the feared situation until her anxiety response habituates. Repeated exposure to the feared situation in which the anxiety response habituates within the session and systematically decreases across sessions is called “emotional processing” (Foa & Kozak, 1986), and reliably leads to fear reduction.
Mindfulness is a technique adapted from meditation and Buddhist philosophy aimed at producing insight and increasing an individual’s ability to focus and stay present in their psychological context. In mindfulness training, the client learns to observe her own thoughts, feelings, and actions without judging them as either good or bad. For example, someone with PTSD may experience recurrent and intrusive trauma-related thoughts and images and may work very hard to avoid having such thoughts. Although this strategy may have short-term benefit, oftentimes the avoidance of such images can have more of an impact on the client’s life than experiencing the images would.
Many different CBT methods are available for treating psychological problems. Descriptions of most CBT treatments are available as treatment manuals in which the procedures and processes are structured according to how the treatment was validated in research outcome studies. However, clinicians often extract specific techniques from one or more treatment packages and use them as part of a “prescriptive” treatment formulated based on client characteristics and presenting problems. A fundamental aspect of these treatment techniques is that they typically result from the interplay between clinical practice and experimental science.
Clinical and research outcomes studies show clearly that CBT has broad applicability to a wide range of psychological problems. Following is a description of the major psychological problems to which clinicians and researchers have applied CBT procedures.
Anxiety-related disorders represent some of the most frequent problems reported by those seeking psychological services, and cognitive-behavioral therapies often are treatments of choice for such problems. Although the content and specific aspects of cognitive-behavioral therapies differ somewhat across the anxiety disorders, most CBT therapies use some form of exposure therapy while also incorporating other treatment components, such as progressive muscle relaxation and cognitive restructuring.
The treatment of phobic disorders (e.g., an extreme and unreasonable fear of snakes) is a long-standing success story for CBT. The first well-studied behavior therapy that was applied to phobic disorders was systematic desensitization (Wolpe, 1990). In this treatment, the client is asked to imagine fear-evoking images while inhibiting the fear response by engaging in progressive muscle relaxation. The success of systematic desensitization led to a subsequent boon in laboratory research, which in turn led to the development of a wide array of exposure-based treatment methods aimed at alleviating pathological anxiety. For example, flooding-based treatments, which do not attempt to inhibit the anxiety response, are quite effective and can work very rapidly, often in just a few sessions and sometimes in a single session (Öst, Ferebee, & Furmar, 1997). This outcome is especially notable, as many people with phobic disorders suffer from the symptoms for many years before seeking treatment.
Although certain aspects of these various methods differed, it is now evident that a key component of CBT for anxiety disorders is therapeutic exposure of some sort. Isaac Marks (1987) later referred to this fundamental ingredient for anxiety reduction as the “exposure principle.”
Panic Disorder and Agoraphobia
Panic disorder is characterized by recurrent experiences of intense and severe episodes of fear or discomfort that typically involve physical symptoms of heart palpitations, chest pain, shortness of breath, and sweating, as well as fears of dying, going crazy, or losing control. Agoraphobia is characterized by significant avoidance of situations in which escape might be difficult or there is limited access to help in the case of a panic attack. In his groundbreaking book, Anxiety and Its Disorders, David Barlow (1988, 2002) described a treatment protocol that has since evolved into the “gold standard” psychological treatment for panic disorder and agoraphobia.
Consistent with other exposure-based protocols for anxiety problems, Barlow’s panic control treatment involves psychoeducation about panic attacks and agoraphobia, behavioral assessment, cognitive restructuring, and exposure to feared situations using in vivo and interoceptive exposure. Historically, exposure-based treatments for panic disorders have incorporated some form of relaxation training as a coping mechanism. However, many researchers are beginning to question the use of any relaxation strategies in exposure-based therapies, viewing them potentially as avoidance strategies in their own right, which may ultimately hamper treatment.
Post-traumatic Stress Disorder
After experiencing a trauma, many people develop post-traumatic stress disorder (PTSD), which is characterized by reexperiencing (e.g., having flashbacks in repeated intrusive memories of the trauma), arousal (e.g., being easily startled and hypervigilant) and avoidance (e.g., avoiding situations associated with the trauma and emotional numbing) symptoms. Several CBT treatments for PTSD have proved useful for alleviating symptoms. The current “gold standard” treatment for PTSD is prolonged exposure (Foa, Rothbaum, Riggs, & Murdock, 1991). Prolonged exposure consists of a combination of imaginal exposure to intrusive trauma-related memories, in vivo exposure to trauma-related situations that the client avoids, and sometimes cognitive restructuring regarding trauma-related distorted thought processes. Relaxation techniques such as PMR and breathing retraining often are taught during the treatment, though they are typically used to reduce the intensity of fear exposure to prevent dissociation rather than to keep the client relaxed during the exposures.
Several other CBT treatments reduce PTSD symptoms, including systematic desensitization (Wolpe, 1973), stress inoculation training (Meichenbaum, 1974; Veronen & Kilpatrick, 1983), and eye movement desensitization and reprocessing (EMDR; Shapiro, 1989). EMDR is a relatively controversial treatment in which the client recalls trauma-related images while simultaneously following the therapist’s fingers as she moves them from left to right in front of the client. Proponents argue that the eye movements facilitate the “processing” of trauma memories and point to data that support EMDR’s efficacy, but a substantive literature suggests that the eye movements are not a necessary treatment component and some argue that EMDR is simply a different form of imaginal exposure.
Social Anxiety Disorder
Individuals who seek treatment for social anxiety disorder typically avoid a variety of social and interpersonal interactions for fear of being criticized, humiliated, or embarrassed. For example, they may avoid giving a class presentation for fear that they will tremble and shake or turn red, leading audience members to laugh at them or think they look silly. Alternatively, they may avoid interactions with persons of the opposite sex because they fear humiliation and embarrassment.
The core CBT treatment components for social anxiety disorder are cognitive restructuring and exposure therapy, which are used together to reduce socially related fears. Specific feared situations are identified in session, associated irrational thoughts and beliefs are challenged, and rational appraisals of the feared situation are established. Social anxiety clients then are asked to expose themselves in vivo to feared situations, allowing fear to habituate, and using cognitive techniques to appraise the situation accurately. CBT for social anxiety disorder is often delivered in a group context (Turk, Heimberg, & Hope, 2001), which itself serves as in vivo exposure, but also provides a supportive context for challenging irrational thoughts.
Obsessive-Compulsive Disorder (OCD)
OCD is characterized by distressing recurrent and persistent thoughts and images (obsessions) often related to contamination, violence, or similar things, which lead to persistent efforts to ignore, suppress, or neutralize the distress (compulsions), such as hand-washing, checking, counting, and so on. The primary method for treating OCD is a combination of exposure to feared situations (e.g., contamination or aversive images) accompanied by the prevention of compulsive rituals (e.g., Foa & Franklin, 2001) that reduce anxiety. Graduated in vivo exposure typically is used when the feared stimulus can be replicated objectively, such as touching doorknobs or dirty clothes. Imaginal exposure typically is used when the fear stimulus is an image. For example, some people who suffer from OCD have repeated unacceptable intrusive thoughts, such as pushing a baby carriage into traffic, an image that they work hard to suppress. Imaginal exposure entails replaying the image over and over until anxiety decreases.
Cognitive treatments for OCD tend to focus less on the specific content of the thought (e.g., the probability of getting sick) than on thoughts that result from the intrusive images (such as being a bad person for having a particular thought). However, these treatments may also incorporate techniques that help increase tolerance of uncertainty regarding concerns that being exposed to germs now may lead to illness far in the future.
Generalized Anxiety Disorder (GAD)
Many people seeking psychological care report symptoms associated with GAD, which is characterized by excessive and uncontrollable anxiety and worry and is accompanied by restlessness, fatigue, irritability, concentration problems, muscle tension, and sleep disturbance. CBT for GAD consists mainly of a combination of cognitive therapy aimed at detecting and correcting irrational thoughts, imaginal exposure to worry scenarios that evoke fear so that fear will habituate, prevention of worry-related rituals that may negatively reinforce fear, time management, relaxation training, and problem solving (Brown, O’Leary, & Barlow, 2001).
For many years, CBT has led the way toward psychological treatments for depression, beginning with Beck et al.’s (1979) cognitive conceptualization of depression. As a result, many treatments use cognitive restructuring to focus on the irrational thought processes that are involved in such negative thinking. However, nearly all “cognitive” approaches also include behavioral components that increase contact with pleasurable activities on the part of the individual (behavioral activation) and some treatments focus on behavioral activation as the primary component of treatment. A behavioral approach to treatment promotes the individual’s rate of reinforcement in his or her natural environment by increasing the frequency of activities that give a sense of mastery and/or pleasure. Treatment typically involves a functional analysis, in which self-monitoring of everyday activities provides information regarding factors that may be contributing to depressive symptoms, mood monitoring, and scheduled activities aimed at increasing contact with natural reinforcers.
Weight-related problems, such as obesity, anorexia nervosa, and bulimia nervosa, are relatively common presenting problems that are very responsive to cognitive-behavioral therapies. Behavioral therapies for obesity typically consist of self-monitoring, stimulus control, modification of eating behaviors (e.g., eating more slowly), caloric restriction, exercise, cognitive restructuring, and contingency management. From a CBT perspective, anorexia nervosa and bulimia nervosa result in part from social norms and expectations concerning body shape that lead to an overvaluation of thinness and unrealistic ideas about healthy weight. Purging behaviors, such as vomiting or excessive exercise, are viewed as irrational methods for attaining or maintaining weight loss or as ways to compensate for episodes of binge eating, which is prominent in bulimia. CBT for eating disorders such as these focus on developing regular patterns of eating, coping skills for high-risk situations for binge eating and purging, modification of abnormal perspectives concerning weight and body image, and relapse prevention (Wilson & Pike, 2001).
Traditional approaches to treating addictive disorders often endorse a disease model of addiction in which the “loss of control” over one’s behaviors is viewed to be a symptom of an underlying biological condition (i.e., a disease). From this perspective, any addictive behavior is viewed to be a sign of progressive deterioration, and abstinence from the problem behavior is viewed as fundamental to recovery. Twelve-step programs that emphasize abstinence are a logical offshoot of this paradigm, and represent a common approach to treating addiction-related problems, in spite of relatively little evidence for their effectiveness. By contrast, CBT models of addiction assume that addictive behaviors are learned behaviors that are maintained by external (e.g., social reinforcement) and internal (e.g., drinking-related expectancies) factors (e.g., Marlatt & Gordon, 1985). A CBT approach does not deny the possibility of physiological vulnerability to addictive behaviors, but views it only as one of many potentially contributing factors.
A variety of CBT-oriented treatments have been applied to addictive disorders over the years, some with more success than others. Aversion therapies involve the pairing of the problem substance (e.g., alcohol) with an aversive stimulus of some sort in the hopes that the aversive pairing will inhibit ingestion of the substance. Chemical aversion involves having the patient ingest a substance (e.g., antabuse or disulfiram) that induces nausea if the problem drug is consumed. Physical aversion techniques involve the pairing of the drug-related stimulus and some physically aversive stimulus (e.g., a shock). Covert sensitization is a technique in which the client imagines a drinking episode along with vivid imagery regarding nausea, vomiting, and so on. Although well grounded in learning theory, aversion therapy techniques have not proved very effective, in part due to high rates of attrition and low rates of treatment adherence.
In cue exposure with response prevention, addicts confront addiction-related cues (e.g., hypodermic needles or the smell of alcohol) either imaginally or in vivo without engaging in drug-taking behavior as a way to address the classical and operant conditioning aspects of addictive behavior. Some research supports the use of cue exposure as part of a comprehensive treatment program, though it has not become a fundamental component of most treatment programs to date.
CM interventions for addictive disorders increasingly receive empirical support as methods for reducing addictive behaviors. Drawn directly from Skinner’s operant principles, CM approaches view drug taking as a choice behavior that is influenced by its consequences. Specifically, CM practitioners view drug users as being more sensitive to the short-term consequences of drug use (e.g., euphoria) and less sensitive to the long-term consequences (e.g., interpersonal, legal, and health problems). As such, altering the consequences of the behavior that decrease the probability of drug taking and increase the probability of healthy behaviors is a fundamental approach.
In the typical CM treatment, addicts provide routine urine samples to test for the presence of the drug and receive points that can be collected and exchanged for vouchers good for various community goods and services (e.g., movies, health clubs) when they submit clean urine samples. The value of clean urine samples goes up over time, and patients often receive a bonus for consecutively clean urine samples. If the patient tests positive for the drug, he receives no voucher and the value of the voucher to be received for clean samples is reduced. Over time, as the addict comes into contact with the nondrug reinforcers in the natural environment, the point system is no longer necessary and can be phased out. CM interventions also include other treatment components, such as cognitive restructuring, relationship counseling, and relapse prevention strategies. Research strongly supports CM approaches to treating drug addiction (Stitzer & Petry, 2006).
Personality disorders are characterized by chronic patterns of interpersonal dysfunction due to maladaptive cognitions, emotional regulation problems, and dysfunctional behavior patterns. Such conditions have long been viewed as treatment resistant, but recent development in CBT approaches have slowly led to changes in our optimism regarding helping such individuals. One clear standout in the treatment of personality disorders is Linehan’s (1993) CBT for Borderline Personality Disorder. This groundbreaking treatment incorporates many concepts associated with the “third wave” of behavior therapies, such as mindfulness, and promotes identification, validation, and regulation of affective experiences, problem solving, exposure and response prevention regarding emotional behaviors, and crisis intervention. This treatment has proved highly effective in a patient population that historically has received little valid clinical attention. Other CBT interventions for personality disorders highlight engagement (with a focus on a trusting and collaborative relationship between the patient and therapist), pattern analysis (identification of faulty thinking patterns), pattern change (modification of faulty thinking patterns), and relapse prevention (dealing with tendencies to return to old patterns).
Emphasis on Science
One consistent characteristic of CBT is the reciprocal relationship between experimental research and clinical procedures in which scientifically meaningful hypotheses regarding clinical phenomena can be tested in a laboratory setting. The findings of those experiments can influence how clinicians deliver psychotherapy in the clinical context. For example, Wolpe’s early laboratory work regarding fear reduction via reciprocal inhibition in cats set the stage for the later development of systematic desensitization to reduce fear and anxiety in humans. Later laboratory-based experimental research demonstrated clearly that some aspects of systematic desensitization (e.g., relaxation) were not fundamental to the fear reduction process, which prompted changes in how clinicians conducted exposure-based therapies for anxiety disorders. More recent advances in CBT procedures, such as incorporating mindfulness and acceptance into treatment programs, have come on the heels of various experimental studies that support their use in a clinical context.
CBT practitioners and researchers also encourage clinicians to focus their efforts on scientifically valid clinical methods and avoid pseudoscientific methods that do not meet the standards of scientific inquiry. Despite a long history of emphasizing the scientific method in clinical psychology, a variety of debates remain within the field concerning scientifically valid clinical behavior. In their book, Science and Pseudoscience in Clinical Psychology, CBT clinicians and researchers Scott Lilienfeld, Steven Jay Lynn, and Jeffrey Lohr (2003) compiled a series of chapters concerning controversial assessment and treatment methods and addressed the need for adherence to good scientific thinking in clinical psychology. For example, some clinicians enthusiastically endorse various clinical assessment methods, such as the Rorschach Inkblot test, or treatment methods, such as thought-field therapy (Callahan & Callahan, 1996), that have received little or no empirical support as meaningful clinical methods.
One significant development in clinical psychology has been the push toward establishing objective criteria for determining what clinical interventions are effective in treating psychological disorders. Beginning in the early 1990s, the field of clinical psychology became more focused on disseminating its therapies as part of a larger focus on health care in the United States. Since then, a variety of treatment packages have been identified as being effective, based on how well those treatments stand up when compared to no treatment at all, a placebo condition, or against the standard treatment. Indeed, cognitive-behavioral therapies populate the vast majority of empirically supported treatments identified in the research literature (e.g., Chambless & Ollendick, 2001).
Emphasis on “Here and Now” Rather Than “Underlying” Past Issues
When most people think of psychotherapy, they assume that going to a therapist means talking primarily about past painful experiences as a way to solve problems occurring in the present. Although a CBT approach to psychological problems assumes that current behavior problems are fundamentally tied to previous learning experiences, the treatments themselves tend to be primarily oriented toward “here-and-now” issues rather than focusing on past experiences. This emphasis does not mean that CBT therapists are not interested in past experiences. On the contrary, CBT assumes that current psychological problems are tied to those experiences. However, from a CBT perspective, it is not necessary to understand or “deal with” the past experiences directly. Instead, it is only necessary to alter current thoughts and behaviors to make them more functional given the current environmental context.
For example, a woman who has been sexually assaulted in the past may avoid contact with men due in part to the thought that “all men are dangerous.” Such avoidance behavior may cause problems in her social and work life. Although her problem clearly lies in a past event, the therapeutic focus would primarily be on helping her challenge the reality status of her thought (perhaps via cognitive restructuring) that all men are dangerous, which occurs in the here and now. Of course, other aspects of her presentation may require discussion of her sexual assault, but such efforts are not fundamental to CBT.
The Role of the Therapeutic Relationship
Over the years, some critics have argued that CBT focuses too much on technique and does not place enough emphasis on the therapeutic relationship as a means of intervention. It probably is true that CBT places less emphasis on the therapeutic relationship than do other treatment approaches. However, it would be quite inaccurate to suggest that CBT therapists are not concerned with promoting a good therapist-client relationship. For instance, in their classic book on cognitive-behavior therapy, Goldfried and Davison (1994) stated that a solid client-therapist relationship is fundamental to any therapeutic process, and “Any behavior therapist who maintains that principles of learning and social influence are all one needs to know in order to bring about behavior change is out of contact with clinical reality” (p. 55).
In fact, CBT practitioners count on the therapeutic relationship for three reasons. First, the therapeutic relationship can offer a sample of the client’s interpersonal relationship behavior patterns, which may be relevant to his or her presenting complaint. Second, the therapist’s role as a significant other in the client’s life may engender confidence regarding the potential impact of therapy on his or her presenting complaints. Third, any CBT practitioner would find it difficult to convince clients to complete some aspects of their therapy without having a good therapeutic alliance, especially with procedures, such as fear exposure, that can be aversive in the short term.
Cognitive-behavioral therapies for psychological problems have a long and distinguished place in the larger field of clinical psychology. By and large, CBT has retained its prominence in the field due to its faithful adherence to scientific methods and embodiment of a translational (e.g., “bench-to-bedside”) approach to psychotherapy research: Laboratory research and clinical practice reciprocally inform each other’s methods and foci. Consistent with its adherence to the scientific method, CBT embraces change that comes with empirical findings that confirm or refute our strongly held beliefs about human suffering and how best to alleviate it.