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Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

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Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy BETH-00620; No of Pages 19; 4C: Available online at www.sciencedirect.com ScienceDirect Behavior Therapy xx (2016) xxx–xxx www.elsevier.com/locate/bt Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy Lorenzo Lorenzo-Luaces John R. Keefe Robert J. DeRubeis University of Pennsylvania there is any kind of contribution of the “cognitive” in Since the introduction of Beck’s cognitive theory of emotional cognitive-behavioral therapy. disorders, and their treatment with psychotherapy, cognitive- Despite debate regarding their active treatment behavioral approaches have become the most extensively components as well as working mechanisms, CBTs researched psychological treatment for a wide variety of continue to be the most widely studied forms of disorders. Despite this, the relative contribution of cognitive to therapy (Hofmann, Asmundson, & Beck, 2013). A behavioral approaches to treatment are poorly understood uniquely appealing aspect of CBTs is that their theo- and the mechanistic role of cognitive change in therapy is ries of therapeutic change comport well with most widely debated. We critically review this literature, focusing modern conceptualizations of psychopathology. In on the mechanistic role of cognitive change across cognitive this review, we attempt to reconcile skepticism and behavioral therapies for depressive and anxiety disorders. regarding the relative contribution of CT strategies to BT, as well as the mechanisms that account for their efficacy. First, we provide a very brief historical over- Keywords: cognitive-behavioral therapy; cognitive theory; view of the origins of CBT and discuss the support for psychotherapy processes; depression; anxiety the cognitive vulnerability models to depression and anxiety disorders. We discuss methodological chal- THE ORIGIN OF COGNITIVE-BEHAVIORAL THERAPIES lenges in psychotherapy research that have impeded (CBTs) as a family of interventions can be traced to a more thorough understanding of the relative con- the advent of behavioral treatments for psychopa- tributions of cognitive to behavioral techniques. We thology in the 1950s and, later, the so-called “ ” – then focus most of our discussion on research on the cognitive revolution of the 1950 1960s (Dobson, cognitive mechanisms of change in CT, BT, and CBTs 2009). Consequently, CBTs blend techniques that are for depression and anxiety disorders. emphasized in behavioral therapies (BTs) and cogni- We use the terms cognitive therapy (CT) and tive therapies (CTs). However, there remains skepti- cognitive techniques to refer to behaviors therapists cism regarding the relative contributions of CT engage in that are targeted towards changing the strategies to BT strategies in promoting symptom content or process of thoughts, inferences, inter- change within the CBTs (Longmore & Worrell, pretations, cognitive biases, and cognitive schemas.1 2007). Additionally, critics have asserted that changes in thinking are not mechanisms of change in CBTs (e.g., Kazdin, 2007), calling into question whether 1 The terms “cognitive therapy” (CT) and “cognitive-behavioral therapy” (CBT) are often used interchangeably. We believe this is Correspondence regarding this article should be addressed to somewhat unfortunate in that it might be informative to reserve the Lorenzo Lorenzo-Luaces, University of Pennsylvania, Department of Psychology, 3720 Walnut Street D20, Philadelphia PA 19104; term CT to a set of interventions within the broader family of CBTs “ ” e-mail: [email protected]. that are more purely cognitive in nature. However, throughout the article, when we refer to findings in studies of CT or CBT, we are 0005-7894/© 2016 Association for Behavioral and Cognitive Therapies. adhering to the label the study authors use. Additionally, we use CBTs, Published by Elsevier Ltd. All rights reserved. in plural, to refer to the family of cognitive-behavioral therapies. Please cite this article as: Lorenzo Lorenzo-Luaces, et al., Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy, Behavior Therapy (2016), http://dx.doi.org/10.1016/j.beth.2016.02.012 2 lorenzo-luaces et al. These interventions can include Socratic question- CT emerged in the context of the so-called cogni- ing, examining the evidence for and against beliefs, tive revolution (Beck, 1991; O’Donohue, Ferguson, cognitive restructuring, and adopting alternative & Naugle, 2003) from the writings of Ellis (1962), core beliefs. We use the terms behavior therapy who described a form of therapy known as rational- (BT) and behavioral techniques to refer to behav- emotive therapy, and Beck (1963). The cognitive iors therapists engage in that are targeted towards models of Ellis and Beck focused on inferential errors a change in observable behavior, including in vivo leading to maladaptive views of one’s self, world, exposure, imaginal exposure, and activity sched- and the future. According to Beck, cognitive biases uling. We use cognitive-behavioral therapies in the and maladaptive cognitive content are the product of plural (CBTs) to refer to the family of interventions the activation of cognitive schemas that typically to which CT and BT belong, and in the singular, develop early in life. Unlike BTs, which were initially CBT, to refer to a treatment package that combines successful in specific phobias and circumscribed cognitive and behavioral techniques. By cognitive anxieties, CTs were focused on depressotypic pre- change, we refer to changes in the content of sentations and more generalized anxiety. Early in thoughts, inferences, interpretations, and cognitive his writing, Beck recognized that his cognitive theory biases. By behavioral change, we refer to changes of psychopathology, which gave a central role to in behavior, such as increasing the frequency of cognition in the etiology of disorder, contrasted selected behaviors (e.g., approaching feared stimuli, with behavioral theories of psychopathology. In his engaging with pleasurable activities) or decreasing highly cited article, “Cognitive Therapy: Nature the frequency of other behaviors (e.g., safety and Relation to Behavioral Therapy,” Beck (1970) behaviors). We include in our paper a discussion of described important differences between the theories issues related to the conceptualization and measure- that underlie BT and CT while recognizing areas of ment of cognitive vs. behavioral interventions as well overlap in the performance of the therapies. Similar- as cognitive vs. behavioral mechanisms of change ities include that both therapies deal with issues in and conclude with a summary and with recommen- the present, are symptom-focused, and require active dations for future research. therapist contribution. Cognitive Therapy: Nature and Relation to Beck (1970) recognized differences between behavioral and cognitive approaches. He applied Behavioral Therapy the principles of his then nascent cognitive theory to Behavioral therapies emerged in the 1950s–1960s account for the mechanisms of action of systematic (O’Donohue & Noll, 1995). The behavioral desensitization, a BT. He concluded that the cog- models emphasized maladaptive learning and self- nitive model “provides a greater range of concepts sustaining behaviors as key to the maintenance of for explaining psychopathology as well as the psychopathology. This made behavioral change mode of action of therapy.” That is, Beck made a the obvious target of treatment, an approach that distinction between the nature of the therapeutic was in stark contrast to the previously dominant interventions (i.e., cognitive vs. behavioral) and psychoanalytic models. Under psychoanalysis, their working mechanisms in providing a cognitive pathological behavior was seen to reflect dysfunc- account of the effects of a behavioral intervention. tion in underlying psychic structures. Behavioral Beck’s paper would become one of the early reflec- change was thus seen as surface-level “symptom tions on the relative contributions of cognitive to reduction” that did not address underlying prob- behavioral strategies and the relevant mechanisms lems. BTs proved very effective, particularly in the of change. Although Beck has provided two up- treatment of phobias and more circumscribed dates to his cognitive model (Beck, 1996; Beck & states of anxiety. Principles of associative learning Haigh, 2014), its basic tenets remain largely intact: were used to account for the efficacy of these that the distinction between different forms of psy- interventions. To the behaviorists, learning had chopathology can be traced to differences in the a specific meaning: an overt change in behavior locus of the cognitive pathology and that cognitive (e.g., approaching a previously avoided stimulus) change, regardless of how this change is achieved, is in the absence of symptoms (e.g., without display- integral to symptom change. ing the fear reaction). This definition avoided “mentalistic” terms. Although early behavioral Cognitive Vulnerability to Depression models featured theoretical accounts focused on and Anxiety associative learning, nonassociative learning, in- Basic research supports the notion that cognitive cluding habituation, was also seen as important. vulnerabilities confer risk to the onset and main- Newer behavioral models also focus on inhibitory tenance of psychopathology (see Mathews & learning (Craske et al., 2008). MacLeod, 2005). Attentional biases to threatening Please cite this article as: Lorenzo Lorenzo-Luaces, et al.,
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