cbt when did it start?

Cognitive behavioural therapy (CBT) is a popular psychological treatment which has been shown to be effective in treating common disorders such as anxiety and depression.

CBT is not a new therapy by any means and it has a practical structure which makes it easily measurable. These factors have resulted in a large body of successful clinical trials which, more recently, have secured its position as one of a range of recommended treatments on the NHS.

Cognitive behavioural therapy is a type of talking therapy which involves identifying and challenging unhelpful thoughts.  It works to help people learn alternative thinking patterns and behaviours which can then improve the way they feel. CBT explores the relationship between feelings, thoughts, and behaviours, and evolved from two distinct schools of psychology: behaviourism and cognitive therapy. Its roots can be traced to these two approaches.

Behavioural treatment for mental disorders has been around since the early 1900’s. Key proponents like Skinner, Pavlov, and Watson developed theories of change and behavioural treatments.  Behaviourism is based on the idea that behaviours can be measured, modelled, and changed.

The first wave of behavioural therapy came about in the 1930/40s in response to the emotional impacts faced by the many WWII veterans returning from war. This need for effective short-term therapy for depression and anxiety coincided with a build up of behavioural research regarding how people learn to behave and react to life situations.  Behaviourism offered an alternative to the dominant model of that time, psychoanalysis.

American psychologist Albert Ellis was one of the key figures who developed cognitive therapy.  He stressed the importance of thoughts/feelings and behaviours and devised a theory called rational emotive behaviour therapy (REBT) in the 1950s. This is now considered one of the earliest forms of cognitive psychotherapy. It is based on the idea that a person’s emotional distress arises from their thoughts about an event rather than the actual event itself.

In the 1950s and 1960s, American psychiatrist Aaron T. Beck noticed patterns with his depressed clients.  They seemed to hold negative views of self, others and their future, and no matter how much exploration of their past occurred, these negative views did not shift.   This led him to start researching whether holding negative views about self, others and the world, might be part of the reason somebody was depressed.  Cognitive therapy was up and running.

Beck understood the importance of the link between thoughts and feelings, and he coined the term “automatic thoughts” to describe the thoughts that pop up in people’s minds. He discovered that although people aren’t always aware of these thoughts, they can learn to identify and report them. He found that people who were upset had negative thoughts that tended to be unrealistic, and by uncovering and challenging these thoughts, long-lasting and positive change can result. In essence, CBT helps people to recognise their thoughts and test them out.  This then allows the possibility of finding alternatives and opens up choice.

By the 1960s, a number of empirical studies into how cognitions affect behaviours and emotions were carried out. This period became known as the cognitive revolution. It emphasised the role that conscious thinking plays in psychotherapy.

Behavioural therapies were successful in treating a number of conditions, including phobias and anxiety.  As the popularity of cognitive therapies began to soar, therapists started to use behavioural techniques and incorporate these to successfully treat disorders.  Although each of these schools of thought has a different emphasis, both are concerned with what is happening to the individual in the here and now.

CBT continues to evaluate it’s techniques and treatments.  This has built up a large body of  research about its effectiveness for use with  a broad range of psychological issues.   It has been shown as an effective form of therapy for treating a range of conditions, including:

Today, a number of therapies blend cognitive and behavioural elements into their approach, including:

How Cognitive Behavioural Therapy Can Help Treat Anxiety Disorders

How Can Cognitive Behavioural Therapy Help to Treat Depression?

Panic Attacks: How Can Cognitive Behavioural Therapy Help?

by Emma Bender

Why is cognitive behavioural therapy (CBT)  so popular with people seeking counselling? What are the limitations of this form of therapy? And is it suitable for you?

Not really. It’s been around since the 198os. This was when cognitive therapy (focused on changing moods by looking at our thoughts) and behavioural therapy (looking at how thoughts effect our actions and choices) started to be combined.

In the UK, cognitive behavioural therapy really gained steam in 2005. This was when the government made a commitment to making psychological therapies more accessible.  They chose CBT therapy as their preferred treatment for depression and anxiety.

What led to this choice? And why has CBT had such a quick rise to one of the most popular forms of talk therapy on offer today?

A major factor behind the popularity of CBT therapy is its accessibility. Again, the NHS has put a focus on this psychological therapy. According to an article in The Independent, in 2007, the government earmarked a whopping £173m to train an extra 3,600 CBT therapists in the approach.

As a focused, short-term therapy, cognitive behavioural therapy can produce relatively rapid results. This means it can be more affordable than more traditional, time-intensive therapies.

In his easy-to-read book Brilliant Cognitive Behavioural Therapy, Dr Stephen Briers shows how the underlying principles of CBT can be mastered relatively quickly.

Because CBT is skills-based,  with techniques that can be used to tackle issues such as negative thinking? You learn skills that mean you can tackle your problems on your own.

CBT is evidence-based (shown to be effective by research studies). Research studies provide strong evidence that this therapy is helpful in treating:

There is also some evidence to suggest is can be useful in treating bipolar disorder, obsessive compulsive disorder (OCD), anorexia nervosa, cocaine abuse, and sexual problems.

The Royal College of Psychiatrists suggests that CBT can be as effective as anti-depressants for many types of depression.  And the National Institute for Health and Clinical Excellence (NICE) recommends CBT should be the first approach treatment for mild and moderate depression. It should be followed by drug treatment only if CBT is unsuccessful in producing positive change.

Cognitive behavioural therapy seeks to measure the gains you’ve made. For example, during CBT, you will be asked to rate the intensity and occurrences of your negative thoughts. A person experiencing anxiety may be asked to rate the intensity of the anxious feelings from one to 10, thinking about the situation that makes them nervous.

If, during or after a course of CBT, you then repeat the exercise, and rate your level of negative feelings as lower? Then you have a concrete (if subjective) demonstration that you have undergone positive change. It can feel more scientific and reliable than other forms of therapy.

If stressful events arise in life? And feelings of anxiety, depression, or other negative feelings return? The skills learnt through CBT interventions should help you tackle them and keep them under control.

CBT produces faster results than some conventional therapies. But no form of talk therapy is a “quick fix”. They all require effort and commitment.

But given that CBT therapy provides you with tools you can use as self-help for the rest of your life, it seems a very worthwhile investment, if it’s popularity is anything to go by.

With a deeper understanding of personal cognition and its relationship to behavior, people can change their lives through changing the way they think.

Increasing mindfulness with regard to conscious thought and interrupting automatic negative thoughts can lead people into a healthier outlook and better understanding of their power over their future reactions.

This therapy has been proven effective in preventing relapse in patients with depression and anxiety. It has also been proven to aid patients with a variety of other psychological problems.

Educating patients with the techniques and strategies of this approach will help them in handling future situations. Equipping patients with these tools give CBT the power for self-motivated emotional and psychological healing.

Before you read on, we thought you might like to download our three Positive CBT Exercises for free. These science-based exercises will provide you with a detailed insight into Positive CBT and will give you the tools to apply it in your therapy or coaching.

Cognitive Behavioral Therapy can be defined as the intentional combination of demonstrated readiness and methodological rigor of behavioral procedures with the cognitive-behavioral processes that influence adjustment (Benjamin et al., 2011). In other words, CBT is utilizing the accurate understanding of our thoughts to purposefully change reactions and behaviors. Our internal thoughts are viewed as mechanisms for change.

This type of therapy is a short-term, goal oriented form of treatment that can be thought of as a combination of behavioral therapy and psychotherapy. The treatment takes a hands-on, practical approach to problem-solving. Psychotherapy focuses on the personal meaning of thought patterns that are believed to have developed in childhood. Behavioral therapy emphasizes the close relationship between personal problems, behavior, and thoughts.

CBT is a way of focusing on the cognitive processes that produce feelings. The approach helps by changing people’s behavior and attitudes with a deeper understanding of thoughts, images, beliefs, and attitudes. The treatment is customized for each patient with regard to differences in personalities and specific needs. CBT can be viewed as an umbrella term for many different forms of therapies aimed at correcting dysfunctional cognition and maladaptive behaviors.

Attitudes grooved in neural pathways during childhood become automatic thoughts. The thoughts resulting in disruption in daily life are negative thoughts around situations that created them.

CBT allows patients to interrupt these thoughts with a deeper understanding of the errors or distortions in the perception of these automatic thoughts. This type of therapy helps patients to correct misinterpretations of the thoughts that have caused disruption in their daily lives.

Cognitive Behavioral Therapy is utilized in treating multiple types of psychiatric problems. The treatment is typically done between 3 and 6 months, depending on the problem. The following is a list of psychological problems where CBT has been utilized.

There are 5 five areas that are believed to be interconnected and affecting one another. For instance, how one feels about a certain situation can cause physical and emotional feelings, resulting in varying behaviors in response.

CBT breaks problems down into smaller pieces to give detailed attention to each part. The techniques aid patients in disrupting negative, automatic thoughts, and replacing them with more helpful ones. The overall goal is to teach the skill of breaking down negative thought patterns and changing them into a more helpful approach to handling daily life.

There is a great deal of overlap in the concepts of positive psychology and cognitive behavioral therapy (Karwoski, Garratt, & Ilardi, 2006). Both approaches see the interaction between client and provider as collaborative. Here are other areas where the conceptual principles overlap.

While positive psychology has developed intervention techniques derived from other therapeutic approaches, several interventions overlap with techniques of CBT.

Cognitive Behavioral Therapy, like other therapies, focuses on reducing the presence of negative emotions. Positive psychology can be presented as the catalyst that CBT needs to endure as a formidable treatment for psychological problems. The reduction of negative emotions does not create the presence of positive emotions.

Introducing positive psychology interventions in addition to reducing negative emotions with CBT has proven to be an effective way to reduce rates of relapse in depressed patients.

While CBT has been proven through various meta-analyses to be an effective treatment for various psychological disorders, it continues to be highly unavailable to those who would most benefit from its introduction (Shafran et al., 2009).

For instance, those suffering from PTSD are most frequently being given supportive counseling, as opposed to the long-term effective strategies provided by cognitive behavioral therapy. There is a widespread lack of training for providers in this type of therapy as well.

There is a gap between research trials and clinical practice. It has much to do with the belief that participants in the trials are suffering from less severe cases of psychological disorders. More and more evidence is being presented for the case that CBT is effective in more severe cases, however. With the increased availability of appropriate training and effective presentation of the techniques, a wider patient base may be reached.

An additional gap in the usage of CBT is within the area of sport psychology (McArdle & Moore, 2012). A strong case can be made for the introduction of the skills of this therapy to athletes. Unthreading negative self-thoughts can, in turn, produce the outcome of improved sports performance.

The patient’s active participation in therapy is a key principle in CBT. Without it, this goal-oriented and problem focused approach would not be effective. Sessions in CBT are well structured and the client’s better understanding of the role of cognition in correcting behavioral dysfunctions is paramount to their success. This educative approach allows the client-therapist relationship to deepen, which is also an important principle in this therapy.

CBT is a time limited approach, and work outside of the therapy office is vital to success. While this approach is initially present focused, an emphasis on adaptive thinking allows for relapse prevention. It allows the patient to be taught techniques to change their thinking, mood, and behavior with the understanding that they will be utilized in their future.

In cognitive behavior therapy, psychological problems are believed to develop through the use of cognitive distortions. Aaron Beck’s work suggests that by correcting these distortions, a more accurate experience of events is created. Through this work, a patient is better able to develop skills to properly process exposure to life events.

Here is a list of Cognitive Distortions (Burns, 1980).

There are many different techniques used in cognitive behavior therapy, which can be practiced with the support of a therapist or individually.

Regardless of whether one practices CBT alone or with a therapist, applying the techniques in real-life situations is key to long-term effectiveness and a reduction of symptoms of psychological problems.

It’s for this reason that CBT therapists are increasingly adopting a blended care approach to conducting CBT that encourages clients to practice interventions in the course of their daily lives with the aid of portable technologies.

For example, using the e-therapy platform Quenza (pictured here), a CBT therapist can assign their client meditations, reflection exercises, and a range of other activities which clients can complete on the go via their smartphone or tablet.

Some of the most common CBT therapists will assign are highlighted here.

Albert Ellis developed the ABC technique that is still utilized in CBT today. The ABC Technique of Irrational Beliefs analyzes the first three steps in which someone might develop an irrational belief: A) Activating event B) Belief C) Consequences (Oltean, Hyland, Vallières, & David, 2017).

Ellis believed that it was not the activating event (A) that causes the negative beliefs and consequences (C), but rather how the patient interprets or misinterprets the meaning of the event (B) that helps cause the consequences (C).

Helping a patient reinterpret their irrational belief system helps to forge new ways for them to interpret their beliefs resulting in alternative behaviors. A person can utilize this technique, even in the absence of a therapist.

Journaling for the awareness of cognitive distortions is a powerful way to better understand personal cognition. A person keeps track of their automatic thoughts and an analysis of the presence of various distortions is detected.

Once better understood, a person can utilize different methods to reevaluate these automatic thoughts with evidence. Well trained practitioners in CBT can aid someone who has difficulty in unraveling these distortions.

Rescripting is a technique used to help patients suffering from nightmares (Davis & Wright, 2006). When the emotion that is brought to the surface from the nightmare is exposed, a therapist can help the patient to redefine the emotion desired and to develop a new image to elicit that emotion.

Exposure therapy is used in OCD and anxiety phobias. Exposing yourself to the trigger reduces the response to the trigger. Many therapists recommend mild exposure 3 times daily. While this may be uncomfortable during the first exposures, the increase in exposure reduces phobic reactions.

The Worst Case/ Best Case/Most Likely Case Scenario technique is used to help people overcome fear or anxiety. Allowing the brain to ruminate to the point of ridiculousness allows the person to “play out” the fear to an unrealistic end. Then the person is brought to the best case and again allowed to let their thoughts “play out” to the ridiculous. Then, a most likely scenario is explored with actionable steps attached, so that control over behavior is realized.

A recent, popular technique being utilized in CBT is called Acceptance and Commitment Therapy. It differs from traditional CBT in that it is not trying to teach people to better control their thoughts around their activating events; instead this approach is teaching people to “just notice,” accept and embrace the feelings around the activating events. This approach utilizes techniques from CBT as well, but ACT focuses on freeing the patient from the grip of the event itself.

Mindfulness techniques like deep breathing and Progressive Muscle Relaxation (PMR) play a big role in CBT. These techniques allow the person to be present in the moment and calmly soothe the unfocused mind. With the relaxation comes the stronger ability to tune in and alter automatic negative thoughts.

Cognitive restructuring is a CBT technique that helps people examine their unhelpful thinking. It helps them to redevelop ways to react in situations that have in the past proven problematic. Keeping a daily record of the automatic negative thoughts creates a way to find the patterns in these thoughts. With an identified pattern, alternative reactions and adaptive thoughts can be forged.

Treating thoughts as guesses is a technique that helps to gather evidence to combat automatic negative thoughts. When a person takes their thoughts to “court” proof of truth must be found for the thought to be held as accurate. If any proof against the thought is found, it must be tossed and replaced with a more accurate thought.

A cognitive pie chart is a fun way for kids to utilize CBT. The first step is identifying the automatic negative thoughts. For example, “I’m dumb because I failed a test.” Step two is devising a list of alternative explanations to those ANTs. Finding as many alternatives as possible is helpful. The third step is giving each explanation a percentage in the contribution to the outcome of failing the test. Step four is placing these explanations in a pie chart.

Activity Scheduling is a powerful technique in CBT. It helps people engage in activities that they are not normally used to doing. It presents as a way to slowly reintroduce rewarding behavior that has been excluded from people’s routines. The technique is helpful in increasing positive emotion when performed incrementally.

Graded exposure is a technique used to help expose anxiety sufferers to contact with what is feared. The underlying theory is that people who avoid situations that induce fear or anxiety will increase the anxiety. The slowly increased exposure aids to decrease that fear.

Many deficits in social skills can be improved through CBT techniques. Modeling, role playing, and instruction can be used to increase social skills like communication and assertiveness. Communication skills, or rather the lack of, are a massive obstacle for many. Improving these skills bolsters confidence and abilities to interact with others, dramatically reducing levels of anxiety inducing situations.

There are advantages and disadvantages to the approach of CBT. Like any therapy, there is always a risk of a negative emotion returning. Let’s have a look at what’s good, and what could hold progress back in treatment.

Here is a list of pros:

Here is a list of cons:

The evolution of cognitive behavioral therapy can be traced back to developments in psychology as early as 1913. The work of behaviorist John B. Watson (1913) laid the foundation for later advancement in the field.

Behaviorism is the theory of learning on the idea that all behaviors are acquired through conditioning. This conditioning happens when people interact with their environment, cueing signals to shape their actions. BF Skinner’s conditioning theories also had foundational influence over the development of cognitive behavioral therapy (Bjork, 1997).

Before cognitive behavioral therapy, there was an approach called behavior therapy that was controversial at the time of its development. One of the first treatments in this approach was done with youth and the correction of enuresis (bed-wetting; Bolla, Sartore, & Correale, 1938). Initial respondent conditioning strategies for better understanding anxiety were also vital in creating theories behind CBT. Extinction, habituation, and counter conditioning were all discovered with respondent conditioning.

Operant learning theory also played a large role in behavioral therapy and childhood CBT development. Out of this theory developed positive and negative reinforcement in children’s development. The deeper understanding of the cognition behind behavior contributed to the deeper understanding of their use in CBT.

In the 1950s, Albert Ellis practiced Rational Emotive Behavior Therapy. The goal was to help patients identify their irrational thoughts. Through this identification, encouragement for the challenge of the thought and a shift to a more rational one would be made. The therapy was thought to give patients a more rational view of the world and their place in it.

The practice of cognitive behavioral therapy was first developed in the 1960s. Dr. Aaron T. Beck at the University of Pennsylvania designed and carried out experiments to test psychoanalytic concepts and found some surprising results. What he found was that in depressed patients, there were consistent instances of a stream of negative thoughts that seemed to emanate spontaneously.

Dr. Beck categorized these automatic negative thoughts into three categories. The patients were having negative ideas about themselves, the world, and/ or the future. With these findings, he began to theorize alternative ways of viewing depression.

The theory of cognitive distortions by Beck and the theory of irrational thinking by Dr. Albert Ellis helped to better explain psychological problems. Beck theorized that in childhood, the development of maladaptive processes led to these problems. His theory was based around the cognitive triad. Dr. Ellis’s theory was based around a set of defined irrational beliefs, also known as common irrational assumptions.

With his approach, Dr. Beck began to help his patients reevaluate their thoughts about themselves. He found that by doing so, his patients were developing a better resilience for handling daily functions of life. Patients found that this therapy resulted in long-lasting change.

The efficacy of this therapy has been examined in many meta-analyses (Butler, Chapman, Forman, & Beck, 2006). Since its introduction, it has grown into a viable treatment modality for a variety of mental health problems. There are therapists who now specialize in this therapeutic approach.

The practice of CBT grew in the mid-1970s to aid in the treatment of higher functioning patients. This transition did not happen automatically, but rather through the trial and error and the development in areas of behavioral therapy and a better understanding of emotional self-control.

As the practice of CBT became stronger over time, new expansions and developments in the field began to emerge. The Tripartite Model (Clark & Watson, 1991) is one of these developments. This model proposes that there is a significant overlap in the negative affect presented in patients with depression and anxiety.

Barlow’s triple vulnerability model of emotional disorders has further expanded work in CBT (Ranjbari, Karimi, Mohammadi, & Norouzi, 2018). The model focuses on children’s perception of control over their environments. In this approach, parents are trained to help children better understand and function in their environments.

The wealth of knowledge of CBT and its application with children is shown throughout psychology. the efficacy of treatment in children and adolescents is far-reaching. This type of therapy helps kids better understand their environment and their role in mastering it.

A new “third” wave of CBT is developing, as a result of various empirical studies failing to prove the hypotheses developed around the efficacy of CBT (Gaudiano, 2008). The shift is within the language of cognition. The approach is acceptance-based strategies. The theory places less stress on altering the cognitive distortions, as the alteration may not be deemed necessary.

With an acceptance-based strategy, the patient is becoming aware of the distortion without trying to control it. The focus is rather on the commitment to the change in behavior.

Development of cognitive behavioral therapy progressed over time. Dr. Albert Ellis was a pioneer in behavior therapy in the 1950s. His work with irrational thinking was foundational in the development of CBT. His ABC technique of Irrational Beliefs is still utilized in CBT today.

The work of Joseph Wolpe and Arnold Lazarus in the 1960s also contributed to the evolution of CBT. Their work in behavior therapy techniques to reduce neuroses is foundational. Their theory of systematic desensitization led to the development of many of the techniques still utilized in this approach today.

Dr. Aaron Beck is the founding father of the cognitive behavior therapy movement. His work began as a clinician in the 1960s. His approach to psychotherapy at that time was radical and groundbreaking. Scientific evidence for his approach has been proven time and again. The efficacy of his theories is far-reaching in the field of psychology.

Dr. Judith Beck has made a significant impact on cognitive behavior therapy as well. She followed her father’s path in research and development of treatments significant in cognitive behavioral therapy. Her work in the area of copping and mechanisms for change advanced the science in a progressive direction.

Dr. Aaron T Beck is given the title of Father of Cognitive Behavior Therapy. He was also named one of the top 5 most influential psychotherapists of all time. Beck is also named as an American in history that shaped the history of psychiatry.

Dr. Beck has published over 600 articles. He has authored or co-authored 25 books. The work he did in developing various scales for measuring depression is still in use today.

His work in cognitive behavioral therapy grew from the work of other psychologists like George Kelly and the vocabulary of Frederic Bartlett and Jean Piaget. The cognitive constructs theory of Kelly and the vocabulary created by Bartlett around the theories of schemas and the vocabulary of Piaget’s theory of cognitive development were very influential in Beck’s initial work in CBT.

As a clinical psychologist, Dr. Beck was noticing a remission of patients’ symptoms. With this realization, came the understanding that his patients were presenting with repeated stories around activating events that he later labeled automatic negative thoughts.

Through his work with depressed patients, Dr. Beck developed the Negative Cognitive Triad. He found 3 types of dysfunctional beliefs, or thoughts, that depressed people were experiencing. His findings suggested that these types of thoughts dominated the thinking of people with depression.

Dr. Beck believed that a close, personal relationship with the patient was crucial. The development of a trusting relationship was necessary to allow for the exploration of automatic negative thoughts. The mere admission of these thoughts was unsettling for some of his patients. The reframing of these thoughts through work with Dr. Beck resulted in significant numbers of patients’ self-reported improvement.

The Beck Institute for Cognitive Behavior Therapy was founded to further investigate the usage of his groundbreaking theory in helping people suffering from various psychological disorders. The institute was founded with his daughter, Dr. Judith Beck, to further investigate and serve a worldwide resource for CBT.

Mental health is a field of study that has come with a tremendous stigma. The rates of psychological disorders are astoundingly high, yet the number of people in treatment for these disorders is astoundingly low because of that stigma. If learning the concepts of cognitive behavioral therapy could help all people, through the examination of their cognitive distortions, an impact on reducing that stigma might be made.

All humans are flawed. There is not a single human alive that doesn’t have cognitive distortion from time to time. Developing a deeper understanding of what these distortions are and creating a way to reframe thoughts, behaviors, and actions can help all humans. What an incredible impact mental well-being training could have on the world! Thanks for reading.

If you are having thoughts of self-harm, please seek help. If depression and anxiety are disrupting your daily life, please seek help. No stigma is worth continued suffering.

We hope you found this article useful. For more information, don’t forget to download our three Positive CBT Exercises for free.

Origins of Cognitive Behavior Therapy

The idea for developing this form of psychotherapy took root when Aaron Beck began to notice that his patients with depression often verbalized thoughts that were lacking in validity and noted characteristic “cognitive distortions” in their thinking. His empirical observations led him to start viewing depression not so much as a mood disorder but as a cognitive disorder. Based on his clinical observations and empirical findings, Beck outlined a new cognitive theory of depression. He published Cognitive Therapy for Depression (Beck, Rush, Shaw, and Emery, 1979) after having published a study that evaluated and demonstrated the efficacy of cognitive therapy. The combination of a detailed treatment protocol manual with outcome research was an innovation in psychotherapy practice that had only previously been attempted by behavior therapists in treating discrete behavioral problems. By accomplishing the same feat with a more complex set of clinical interventions that included cognitive, emotional, and behavioral components, Beck pioneered a model for what psychologists many years later defined as an “empirically validated psychological treatment.”

Other clinicians and researchers became interested and began developing CBT treatment protocols and evaluating their efficacy. Specific treatment protocols were developed for some psychiatric disorders. As behavioral strategies were incorporated, the term cognitive therapy changed to cognitive behavior therapy. Today CBT is the most extensively researched of all psychotherapies with several evidence-based treatment protocols.

Cognitive Model

CBT is based on a straightforward, common-sense model of the relationships among cognition, emotion, and behavior.[4][5][6][7]

Three aspects of cognition are emphasized:

Automatic Thoughts

An individual’s immediate, unpremeditated interpretations of events are referred to as automatic thoughts. Automatic thoughts shape both the individual’s emotions and their actions in response to events. For example, a friend may cross you in the hallway and not say hello to you. If you were to have an automatic thought of “he hates me,” or “I have done something to anger him,” it is likely to impact your mood and cause you to feel upset and also to behave in an avoidant manner when you see him next. On the other hand, if you had the automatic thought, “he is in a hurry,” you would not be too concerned, and you would not be avoidant when you were to see him next.

CBT is based on the observation that dysfunctional automatic thoughts that are exaggerated, distorted, mistaken, or unrealistic in other ways, play a significant role in psychopathology.

Cognitive Distortions

Errors in logic are quite prevalent in patients with psychological disorders. They lead individuals to erroneous conclusions. Below are some cognitive distortions that are commonly seen in individuals with psychopathology:

Underlying Beliefs

Underlying beliefs shape the perception and interpretation of events. Belief systems or schemas take shape as we go through life experiences. They are defined as templates or rules for information processing that underlie the most superficial layer of automatic thoughts. Beliefs are understood at two levels in CBT:

Core Beliefs

Examples of dysfunctional core beliefs:

Intermediate Beliefs

Examples of dysfunctional intermediate beliefs:

Cognitive behavioral therapy (CBT) is a psycho-social intervention[1][2] that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders.[3] CBT focuses on challenging and changing cognitive distortions (such as thoughts, beliefs, and attitudes) and their associated behaviors to improve emotional regulation[2][4] and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of many mental health conditions, including anxiety,[5][6] substance use disorders, marital problems, and eating disorders.[7][8][9] CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.[10][11][12]

CBT is a common form of talk therapy based on the combination of the basic principles from behavioral and cognitive psychology.[2] It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors, and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and to alleviate symptoms of the disorder.[13] CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of many psychological disorders[3] and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.[1][13][14]

When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression,[15] anxiety, post-traumatic stress disorder (PTSD), tics,[16] substance use disorders, eating disorders, and borderline personality disorder.[17] Some research suggests that CBT is most effective when combined with medication for treating mental disorders, such as major depressive disorder.[18] CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder.[1][4] Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults.[19][20] Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice.[1][21]

Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism.[22] Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioral therapists identify cognitive distortions that contribute to depression and anxiety.[23] Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers".[24] Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis.[25] A key philosophical figure who influenced the development of CBT was John Stuart Mill.[26][how?]

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.

Groundbreaking work of behaviorism began with John B. Watson and Rosalie Rayner's studies of conditioning in 1920.[27] Behaviorally-centered therapeutic approaches appeared as early as 1924[28] with Mary Cover Jones' work dedicated to the unlearning of fears in children.[29] These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s.[27] It was the work of Wolpe and Watson, which was based on Ivan Pavlov's work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioral therapy techniques based on classical conditioning.[27][30]

During the 1950s and 1960s, behavioral therapy became widely used by researchers in the United States, the United Kingdom, and South Africa. Their inspiration was by the behaviorist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull.[28]

In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization,[27] applied behavioral research to the treatment of neurotic disorders. Wolpe's therapeutic efforts were precursors to today's fear reduction techniques.[28] British psychologist Hans Eysenck presented behavior therapy as a constructive alternative.[28][31]

At the same time as Eysenck's work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning.[27][30] Skinner's work was referred to as radical behaviorism and avoided anything related to cognition.[27] However, Julian Rotter in 1954 and Albert Bandura in 1969 contributed behavior therapy with their respective work on social learning theory by demonstrating the effects of cognition on learning and behavior modification.[27][30] The work of the Australian Claire Weekes dealing with anxiety disorders in the 1960s is also seen as a prototype of behavior therapy.[32]

The emphasis on behavioral factors constituted the "first wave" of CBT.[33]

One of the first therapists to address cognition in psychotherapy was Alfred Adler (1870–1937), notably with his idea of basic mistakes and how they contributed to creation of unhealthy or useless behavioral and life goals.[34]

Abraham Low (1891–1954) believed that someone's thoughts were best changed by changing their actions.[35]

Adler[34] and Low[36] influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy called rational emotive therapy (contemporarily known as rational emotive behavioral therapy, or REBT).[37] The first version was announced to the public in 1956.

In the late 1950s, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice.[38][39] During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorized, and that certain types of thinking may be the culprits of emotional distress.[39] It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts "automatic thoughts".[39] He first published his new methodology in 1967, and his first treatment manual in 1979.[38] Beck has been referred to as "the father of cognitive behavioral therapy".[40]

It was these two therapies, rational emotive therapy, and cognitive therapy, that started the "second wave" of CBT, which was the emphasis on cognitive factors.[33]

Although the early behavioral approaches were successful in many of the neurotic disorders, they had little success in treating depression.[27][28][41] Behaviorism was also losing in popularity due to the 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.[27] Both of these systems included behavioral elements and interventions, with the primary focus being on problems in the present.

In initial studies, cognitive therapy was often contrasted with behavioral treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US.[28]

Over time, cognitive behavior therapy came to be known not only as a therapy, but as an umbrella term for all cognitive-based psychotherapies.[27] These therapies include, but are not limited to, rational emotive behavior therapy (REBT), cognitive therapy, acceptance and commitment therapy, dialectical behavior therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy.[27] All of these therapies are a blending of cognitive- and behavior-based elements.

This blending of theoretical and technical foundations from both behavior and cognitive therapies constituted the "third wave" of CBT.[42][33] The most prominent therapies of this third wave are dialectical behavior therapy and acceptance and commitment therapy.[33]

Despite the increasing popularity of third-wave treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with non-third wave CBT for the treatment of depression.[43]

Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in behavior and affect,[44] but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself.[45] The goal of cognitive behavioral therapy is not to diagnose a person with a particular disease, but to look at the person as a whole and decide what can be altered.

Therapists or computer-based programs use CBT techniques to help people challenge their patterns and beliefs and replace errors in thinking, known as cognitive distortions, such as "overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior".[44] Cognitive distortions can be either a pseudo-discrimination belief or an overgeneralization of something.[46] CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward cognitive distortions so as to diminish their impact.[45]

Mainstream CBT helps individuals replace "maladaptive ... coping skills, cognitions, emotions and behaviors with more adaptive ones",[47] by challenging an individual's way of thinking and the way that they react to certain habits or behaviors,[48] but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.[49]

CBT can be seen as having six phases:[47]

These steps are based on a system created by Kanfer and Saslow.[50] After identifying the behaviors that need changing, whether they be in excess or deficit, and treatment has occurred, the psychologist must identify whether or not the intervention succeeded. For example, "If the goal was to decrease the behavior, then there should be a decrease relative to the baseline. If the critical behavior remains at or above the baseline, then the intervention has failed."[50]

The steps in the assessment phase include:

The re-conceptualization phase makes up much of the "cognitive" portion of CBT.[47] A summary of modern CBT approaches is given by Hofmann.[52]

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them.[53] Use of the term CBT may refer to different interventions, including "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting".[47] Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven.[54] CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.[55][56]

CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, metacognitive therapy, metacognitive training, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.[57][58] Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.[59]

In adults, CBT has been shown to be an effective part of treatment plans for anxiety disorders,[60][61] body dysmorphic disorder,[62] depression,[63][64][65] eating disorders,[7][66][65] chronic low back pain,[47] personality disorders,[67][65] psychosis,[68] schizophrenia,[69][65] substance use disorders,[70][65] and bipolar disorder.[65] It is also effective as part of treatment plans in the adjustment, depression, and anxiety associated with fibromyalgia,[44] and with post-spinal cord injuries.[71]

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders,[72] body dysmorphic disorder,[73] depression and suicidality,[74] eating disorders[7] and obesity,[75] obsessive–compulsive disorder (OCD),[76] and post-traumatic stress disorder (PTSD),[77] as well as tic disorders, trichotillomania, and other repetitive behavior disorders.[78] CBT has also been applied to a variety of childhood disorders,[79] including depressive disorders and various anxiety disorders. CBT has shown to be the most effective intervention for people exposed to adverse childhood experiences in the form of abuse or neglect.[80]

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners.[81][82] However, evidence supports the effectiveness of CBT for anxiety and depression.[83]

Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.[84][85][86]

The United Kingdom's National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including PTSD, OCD, bulimia nervosa, and clinical depression.[87]

CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age.[88] Of the small number of studies examining CBT for the management of depression in older people, there is currently no strong support.[89]

Cognitive behavioral therapy has been shown as an effective treatment for clinical depression.[63] The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder.[90][page needed]

A 2001 meta-analysis comparing CBT and psychodynamic psychotherapy suggested the approaches were equally effective in the short term for depression.[91] In contrast, a 2013 meta-analyses suggested that CBT, interpersonal therapy, and problem-solving therapy outperformed psychodynamic psychotherapy and behavioral activation in the treatment of depression.[21]

According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either proven or presumed to be an effective therapy on several mental disorders.[65] This included depression, panic disorder, post-traumatic stress, and other anxiety disorders.[65]

CBT has been shown to be effective in the treatment of adults with anxiety disorders.[92]

Results from a 2018 systematic review found a high strength of evidence that CBT-exposure therapy can reduce PTSD symptoms and lead to the loss of a PTSD diagnosis.[93] CBT has also been shown to be effective for post-traumatic stress disorder in very young children (3 to 6 years of age).[94] A Cochrane review found low quality evidence that CBT may be more effective than other psychotherapies in reducing symptoms of posttraumatic stress disorder in children and adolescents.[95]

A systematic review of CBT in depression and anxiety disorders concluded that "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists."[96]

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.[97][98]

One etiological theory of depression is Aaron T. 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, and the negative schema is activated later in life when the person encounters similar situations.[99]

Beck also described a negative cognitive triad. The cognitive triad is made up of the depressed individual's negative evaluations of themselves, the world, and the future. Beck suggested that these negative evaluations derive from the negative schemata and cognitive biases of the person. According to this theory, depressed people 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. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, overgeneralization, magnification, and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.[99]

A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure. CBT-exposure therapy refers to the direct confrontation of feared objects, activities, or situations by a patient. For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears.[100] Likewise, a person with a social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech.[101] This "two-factor" model is often credited to O. Hobart Mowrer.[102] Through exposure to the stimulus, this harmful conditioning can be "unlearned" (referred to as extinction and habituation).

CBT for children with phobias is normally delivered over multiple sessions, but one-session treatment has been shown to be equally effective and is cheaper.[103][104]

CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youths who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable.[105]

Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT[106]). ACT uses mindfulness and acceptance interventions and has been found to have a greater longevity in therapeutic outcomes. In a study with anxiety, CBT and ACT improved similarly across all outcomes from pre- to post-treatment. However, during a 12-month follow-up, ACT proved to be more effective, showing that it is a highly viable lasting treatment model for anxiety disorders.[107]

Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders,[61][64][96][108][83][109] including children.[110] Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.[111][112] CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety.[113]

Studies have provided evidence that when examining animals and humans, that glucocorticoids may lead to a more successful extinction learning during exposure therapy for anxiety disorders. For instance, glucocorticoids can prevent aversive learning episodes from being retrieved and heighten reinforcement of memory traces creating a non-fearful reaction in feared situations. A combination of glucocorticoids and exposure therapy may be a better-improved treatment for treating people with anxiety disorders.[114]

For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes.[83][115][116] In another study, 3% of the group receiving the CBT intervention developed generalized anxiety disorder by 12 months postintervention compared with 14% in the control group.[117] Individuals with subthreshold levels of panic disorder significantly benefitted from use of CBT.[118][119] Use of CBT was found to significantly reduce social anxiety prevalence.[120]

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older.[121] Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles.[122] A further study also saw a neutral result.[123] A meta-study of the Coping with Depression course, a cognitive behavioral intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.[124]

Many studies show CBT, combined with pharmacotherapy, is effective in improving depressive symptoms, mania severity and psychosocial functioning with mild to moderate effects, and that it is better than medication alone.[125][126][127]

INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including bipolar disorder.[65] This included schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.[65]

In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses.[68] Meta-analyses confirm the effectiveness of metacognitive training (MCT) for the improvement of positive symptoms (e.g., delusions).[128][129]

For people at risk of psychosis, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT.[130][131]

INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including schizophrenia.[65]

A Cochrane review reported CBT had "no effect on long‐term risk of relapse" and no additional effect above standard care.[132] A 2015 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia and determined that there is no clear advantage over other, often less expensive, interventions but acknowledged that better quality evidence is needed before firm conclusions can be drawn.[133]

CBT is also used for pathological and problem gambling. The percentage of people who problem gamble is 1–3% around the world.[134] Cognitive behavioral therapy develops skills for relapse prevention and someone can learn to control their mind and manage high-risk cases.[135] There is evidence of efficacy of CBT for treating pathological and problem gambling at immediate follow up, however the longer term efficacy of CBT for it is currently unknown.[136]

CBT looks at the habit of smoking cigarettes as a learned behavior, which later evolves into a coping strategy to handle daily stressors. Since smoking is often easily accessible and quickly allows the user to feel good, it can take precedence over other coping strategies, and eventually work its way into everyday life during non-stressful events as well. CBT aims to target the function of the behavior, as it can vary between individuals, and works to inject other coping mechanisms in place of smoking. CBT also aims to support individuals with strong cravings, which are a major reported reason for relapse during treatment.[137]

In a 2008 controlled study out of Stanford University School of Medicine suggested CBT may be an effective tool to help maintain abstinence. The results of 304 random adult participants were tracked over the course of one year. During this program, some participants were provided medication, CBT, 24-hour phone support, or some combination of the three methods. At 20 weeks, the participants who received CBT had a 45% abstinence rate, versus non-CBT participants, who had a 29% abstinence rate. Overall, the study concluded that emphasizing cognitive and behavioral strategies to support smoking cessation can help individuals build tools for long term smoking abstinence.[138]

Mental health history can affect the outcomes of treatment. Individuals with a history of depressive disorders had a lower rate of success when using CBT alone to combat smoking addiction.[139]

A Cochrane review was unable to find evidence of any difference between CBT and hypnosis for smoking cessation. While this may be evidence of no effect, further research may uncover an effect of CBT for smoking cessation.[140]

Studies have shown CBT to be an effective treatment for substance use disorders.[70][141][142] For individuals with substance use disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimizing and catastrophizing thought patterns, with healthier narratives.[143] Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication.[144]

INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including alcohol dependency.[65]

Research has identified Internet addiction as a new clinical disorder that causes relational, occupational, and social problems. Cognitive behavioral therapy (CBT) has been suggested as the treatment of choice for Internet addiction, and addiction recovery in general has used CBT as part of treatment planning.[145]

Though many forms of treatment can support individuals with eating disorders, CBT is proven to be a more effective treatment than medications and interpersonal psychotherapy alone.[66][7] CBT aims to combat major causes of distress such as negative cognitions surrounding body weight, shape and size. CBT therapists also work with individuals to regulate strong emotions and thoughts that lead to dangerous compensatory behaviors. CBT is the first line of treatment for bulimia nervosa, and Eating Disorder Non-Specific.[146] While there is evidence to support the efficacy of CBT for bulimia nervosa and binging, the evidence is somewhat variable and limited by small study sizes.[147] INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including bulimia and anorexia nervosa.[65]

Emerging evidence for cognitive behavioral interventions aimed at reducing symptoms of depression, anxiety, and obsessive-compulsive disorder in autistic adults without intellectual disability has been identified through a systematic review.[148] While the research was focused on adults, cognitive behavioral interventions have also been beneficial to autistic children.[149]

A Cochrane review in 2022 found that adults with dementia and mild cognitive impairment (MCI) who experience symptoms of depression may benefit from CBT, whereas other counselling or supportive interventions might not improve symptoms significantly. [150] Across 5 different psychometric scales, where higher scores indicate severity of depression, adults receiving CBT reported somewhat lower mood scores than those receiving usual care for dementia and MCI overall.[150] In this review, a sub-group analysis found clinically significant benefits only among those diagnosed with dementia, rather than MCI.[150][151]

The likelihood of remission from depression also appeared to be 84% higher following CBT, though the evidence for this was less certain. Anxiety, cognition and other neuropsychiatric symptoms were not significantly improved following CBT, however this review did find moderate evidence of improved quality of life and daily living activity scores in those with dementia and MCI. [150]

Evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD),[152] hypochondriasis,[153] and bipolar disorder,[125] but more study is needed and results should be interpreted with caution. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter,[154] but not in reducing stuttering frequency.[155][156]

There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.[157] Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating insomnia.[158] Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.[111][112] CCBT was found to be equally effective as face-to-face CBT in insomnia.[158]

A Cochrane review of interventions aimed at preventing psychological stress in healthcare workers found that CBT was more effective than no intervention but no more effective than alternative stress-reduction interventions.[159]

Cochrane Reviews have found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youths under their care,[160] nor was it helpful in treating people who abuse their intimate partners.[161]

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality disorders and behavioral problems.[162] INSERM's 2004 review found that CBT is an effective therapy for personality disorders.[65]

In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management.[163] A 2015 Cochrane review also found that CBT for symptomatic management of non-specific chest pain is probably effective in the short term. However, the findings were limited by small trials and the evidence was considered of questionable quality.[164] Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition.[165] CBT combined with hypnosis and distraction reduces self-reported pain in children.[166]

There is limited evidence to support its use in coping with the impact of multiple sclerosis,[167] sleep disturbances related to aging,[168] and dysmenorrhea,[169] but more study is needed and results should be interpreted with caution.

Previously CBT has been considered as moderately effective for treating chronic fatigue syndrome,[170] however a National Institutes of Health Pathways to Prevention Workshop stated that in respect of improving treatment options for ME/CFS that the modest benefit from cognitive behavioral therapy should be studied as an adjunct to other methods.[171] The Centres for Disease Control advice on the treatment of ME/CFS[172] makes no reference to CBT while the National Institute for Health and Care Excellence[173] states that cognitive behavioral therapy (CBT) has sometimes been assumed to be a cure for ME/CFS, however, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness."

A typical CBT programme would consist of face-to-face sessions between patient and therapist, made up of 6–18 sessions of around an hour each with a gap of 1–3 weeks between sessions. This initial programme might be followed by some booster sessions, for instance after one month and three months.[174] CBT has also been found to be effective if patient and therapist type in real time to each other over computer links.[175][176]

Cognitive-behavioral therapy is most closely allied with the scientist–practitioner model in which clinical practice and research are informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and the attainment of goals. These are often met through "homework" assignments in which the patient and the therapist work together to craft an assignment to complete before the next session.[177] The completion of these assignments – which can be as simple as a person with depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change.[177] The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment.[177] Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance.[2][178] Unlike many other forms of psychotherapy, the patient is very involved in CBT.[177] For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first.[177] The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.[177]

Computerized cognitive behavioral therapy (CCBT) has been described by NICE as a "generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system",[179] instead of face-to-face with a human therapist. It is also known as internet-delivered cognitive behavioral therapy or ICBT.[180] CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist.[181][182] In this context, it is important not to confuse CBT with 'computer-based training', which nowadays is more commonly referred to as e-Learning.

Although improvements in both research quality and treatment adherence is required before advocating for the global dissemination of CCBT,[183] it has been found in meta-studies to be cost-effective and often cheaper than usual care,[184][185] including for anxiety[186] and PTSD.[187][188] Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods.[189] A study assessing an online version of CBT for people with mild-to-moderate PTSD found that the online approach was as effective as, and cheaper than, the same therapy given face-to-face.[187][188] A review of current CCBT research in the treatment of OCD in children found this interface to hold great potential for future treatment of OCD in youths and adolescent populations.[190] Additionally, most internet interventions for post-traumatic stress disorder use CCBT. CCBT is also predisposed to treating mood disorders amongst non-heterosexual populations, who may avoid face-to-face therapy from fear of stigma. However presently CCBT programs seldom cater to these populations.[191]

In February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication,[179] and CCBT is made available by some health systems.[192] The 2009 NICE guideline recognized that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product.[193]

Another new method of access is the use of mobile app or smartphone applications to deliver self-help or guided CBT. Technology companies are developing mobile-based artificial intelligence chatbot applications in delivering CBT as an early intervention to support mental health, to build psychological resilience, and to promote emotional well-being. Artificial intelligence (AI) text-based conversational application delivered securely and privately over smartphone devices have the ability to scale globally and offer contextual and always-available support. Active research is underway including real-world data studies[194] that measure effectiveness and engagement of text-based smartphone chatbot apps for delivery of CBT using a text-based conversational interface. Recent market research and analysis of over 500 online mental healthcare solutions identified 3 key challenges in this market: quality of the content, guidance of the user and personalisation.[195]

Enabling patients to read self-help CBT guides has been shown to be effective by some studies.[196][197][198] However one study found a negative effect in patients who tended to ruminate,[199] and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional).[200]

Patient participation in group courses has been shown to be effective.[201] In a meta-analysis reviewing evidence-based treatment of OCD in children, individual CBT was found to be more efficacious than group CBT.[190]

Brief cognitive behavioral therapy (BCBT) is a form of CBT which has been developed for situations in which there are time constraints on the therapy sessions and specifically for those struggling with suicidal ideation and/or making suicide attempts.[202] BCBT was based on Rudd's proposed "suicidal mode", an elaboration of Beck's modal theory.[203] BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed with soldiers on active duty by Dr. M. David Rudd to prevent suicide.[202]

Breakdown of treatment[202]

Cognitive emotional behavioral therapy (CEBT) is a form of CBT developed initially for individuals with eating disorders but now used with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. It combines aspects of CBT and dialectical behavioral therapy and aims to improve understanding and tolerance of emotions in order to facilitate the therapeutic process. It is frequently used as a "pretreatment" to prepare and better equip individuals for longer-term therapy.[204]

Structured cognitive-behavioral training (SCBT) is a cognitive-based process with core philosophies that draw heavily from CBT. Like CBT, SCBT asserts that behavior is inextricably related to beliefs, thoughts, and emotions. SCBT also builds on core CBT philosophy by incorporating other well-known modalities in the fields of behavioral health and psychology: most notably, Albert Ellis's rational emotive behavior therapy. SCBT differs from CBT in two distinct ways. First, SCBT is delivered in a highly regimented format. Second, SCBT is a predetermined and finite training process that becomes personalized by the input of the participant. SCBT is designed to bring a participant to a specific result in a specific period of time. SCBT has been used to challenge addictive behavior, particularly with substances such as tobacco,[205] alcohol and food, and to manage diabetes and subdue stress and anxiety. SCBT has also been used in the field of criminal psychology in the effort to reduce recidivism.

Moral reconation therapy, a type of CBT used to help felons overcome antisocial personality disorder (ASPD), slightly decreases the risk of further offending.[206] It is generally implemented in a group format because of the risk of offenders with ASPD being given one-on-one therapy reinforces narcissistic behavioral characteristics, and can be used in correctional or outpatient settings. Groups usually meet weekly for two to six months.[207]

This type of therapy uses a blend of cognitive, behavioral, and certain humanistic training techniques to target the stressors of the client. This usually is used to help clients better cope with their stress or anxiety after stressful events.[208] This is a three-phase process that trains the client to use skills that they already have to better adapt to their current stressors. The first phase is an interview phase that includes psychological testing, client self-monitoring, and a variety of reading materials. This allows the therapist to individually tailor the training process to the client.[208] Clients learn how to categorize problems into emotion-focused or problem-focused so that they can better treat their negative situations. This phase ultimately prepares the client to eventually confront and reflect upon their current reactions to stressors, before looking at ways to change their reactions and emotions to their stressors. The focus is conceptualization.[208]

The second phase emphasizes the aspect of skills acquisition and rehearsal that continues from the earlier phase of conceptualization. The client is taught skills that help them cope with their stressors. These skills are then practised in the space of therapy. These skills involve self-regulation, problem-solving, interpersonal communication skills, etc.[208]

The third and final phase is the application and following through of the skills learned in the training process. This gives the client opportunities to apply their learned skills to a wide range of stressors. Activities include role-playing, imagery, modeling, etc. In the end, the client will have been trained on a preventive basis to inoculate personal, chronic, and future stressors by breaking down their stressors into problems they will address in long-term, short-term, and intermediate coping goals.[208]

A newly developed group therapy model based on CBT integrates knitting into the therapeutical process and has been proven to yield reliable and promising results. The foundation for this novel approach to CBT is the frequently emphasized notion that therapy success depends on the embeddedness of the therapy method in the patients' natural routine. Similar to standard group-based CBT, patients meet once a week in a group of 10 to 15 patients and knit together under the instruction of a trained psychologist or mental health professional. Central for the therapy is the patient's imaginative ability to assign each part of the wool to a certain thought. During the therapy, the wool is carefully knitted, creating a knitted piece of any form. This therapeutical process teaches the patient to meaningfully align thought, by (physically) creating a coherent knitted piece. Moreover, since CBT emphasizes the behavior as a result of cognition, the knitting illustrates how thoughts (which are tried to be imaginary tight to the wool) materialize into the reality surrounding us.[209][210]

Mindfulness-based cognitive behavioral hypnotherapy (MCBH) is a form of CBT focusing on awareness in reflective approach with addressing of subconscious tendencies. It is more the process that contains basically three phases that are used for achieving wanted goals.[211]

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a form of CBT, developed by David H. Barlow and researchers at Boston University, that can be applied to a range of and anxiety disorders. The rationale is that anxiety and depression disorders often occur together due to common underlying causes and can efficiently be treated together.[212]

The UP includes a common set of components:[213]

The UP has been shown to produce equivalent results to single-diagnosis protocols for specific disorders, such as OCD and social anxiety disorder.[214] Several studies have shown that the UP is easier to disseminate as compared to single-diagnosis protocols.

The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments,[97] many other researchers[21][215][19][98][216] and practitioners[217][218] have questioned the validity of such claims. For example, one study[97] determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers[19] responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e., measures of general functioning) no significant differences have been typically found between CBT and other treatments.[19][219]

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., either the subjects or the therapists in psychotherapy studies are not blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.[220]

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in.[221] Pooled data from published trials of CBT in schizophrenia, major depressive disorder (MDD), and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low.[222][223][224]

Additionally, a 2015 meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Additional sub-analysis revealed that CBT studies where therapists in the test group were instructed to adhere to the Beck CBT manual had a steeper decline in effect sizes since 1977 than studies where therapists in the test group were instructed to use CBT without a manual. The authors reported that they were unsure why the effects were declining but did list inadequate therapist training, failure to adhere to a manual, lack of therapist experience, and patients' hope and faith in its efficacy waning as potential reasons. The authors did mention that the current study was limited to depressive disorders only.[225]

Furthermore, other researchers write that CBT studies have high drop-out rates compared to other treatments. One meta-analysis found that CBT drop-out rates were 17% higher than those of other therapies.[98] This high drop-out rate is also evident in the treatment of several disorders, particularly the eating disorder anorexia nervosa, which is commonly treated with CBT. Those treated with CBT have a high chance of dropping out of therapy before completion and reverting to their anorexia behaviors.[226]

Other researchers analyzing treatments for youths who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youths who self-injure. The researchers concluded that none of them were found to be efficacious.[216]

The methods employed in CBT research have not been the only criticisms; some individuals have called its theory and therapy into question.[227]

Slife and Williams write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states: nowhere in CBT theory is agency, or free will, accounted for.[217]

Another criticism of CBT theory, especially as applied to major depressive disorder (MDD), is that it confounds the symptoms of the disorder with its causes.[220]

CBT is generally regarded as having very few if any side effects.[228][229] Calls have been made by some for more appraisal of possible side effects of CBT.[230] Many randomized trials of psychological interventions like CBT do not monitor potential harms to the patient.[231] In contrast, randomized trials of pharmacological interventions are much more likely to take adverse effects into consideration.[232]

A 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications.[233] Nevertheless, CBT therapists do sometimes report 'unwanted events' and side effects in their outpatients with "negative wellbeing/distress" being the most frequent.[234]

The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with "the parallel rise of neoliberalism, with its focus on marketization, efficiency, quantification and managerialism", and he questions the scientific basis of CBT, suggesting that "the 'science' of psychological treatment is often less a scientific than a political contest".[235] In his book, Dalal also questions the ethical basis of CBT.[236]

The UK's National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense[237] as part of an initiative called Improving Access to Psychological Therapies (IAPT).[238] The NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed.[237] Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes "a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money ... Everyone has been seduced by CBT's apparent cheapness."[237][239]

The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT's policies were undermining traditional psychotherapy and criticized proposals that would limit some approved therapies to CBT,[240] claiming that they restricted patients to "a watered down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff".[240]

The NICE also recommends offering CBT to people with schizophrenia, as well as those at risk of a psychotic episode.[241][242]

In the 1960s, Aaron Beck developed cognitive behavior therapy (CBT) or cognitive therapy.