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16 and Cognitive Therapy Cognitive-behavioral Therapy, Behavioral Therapy, 16 and Cognitive Therapy Susan E. Sprich, PhD, Bunmi O. Olatunji, PhD, Hannah E. Reese, PhD, Michael W. Otto, PhD, Elizabeth Rosenfield, BA, and Sabine Wilhelm, PhD KEY POINTS Background • There is an increasing focus on the dissemination of empirically-supported treatments, such that clinicians in • Cognitive-behavioral therapy (CBT) is one of the most the community are trained in the use of these extensively researched forms of psychotherapy that is treatments. increasingly recognized as the treatment of choice for many disorders. • The question of whether or not to combine pharmacotherapy and CBT may not be straightforward. History • The decision to provide combined treatment must • Cognitive-behavioral therapies represent an integration include a careful examination of the disorder, the ofo tw strong traditions within psychology: behavioral severity and chronicity of the disorder, the patient’s therapyT) (B and cognitive therapy (CT). treatment history, and the stage of treatment. • BT employs principles of learning to change human • There is an increasing emphasis on research that behavior.T B techniques include exposure, relaxation, is focused on dimensions of observable behavior assertion training, social skills training, problem-solving and on neurobiological measures, with the goal of training, modeling, contingency management, and leading to an improved understanding of behavioral activation. psychopathology. • CT, initially developed as a treatment for depression, is Practical Pointers based on the understanding that thoughts influence behavior and that maladaptive thinking styles lead to • CBT is a collaborative treatment. maladaptive behaviors and emotional distress. CT is • CBT is an active treatment. now widely used for a range of disorders. • CBT is a structured treatment. Clinical and Research Challenges • CBT is evidence-based. • A common concern is whether the results found in • CBT is a short-term treatment. well-controlled randomized controlled trials (RCTs) of CBT translate well to routine practice in the community. OVERVIEW cally consistent relationship between CBT techniques and the disorders that they are designed to treat.15 Depending on the Cognitive-behavioral therapy (CBT) is one of the most exten- disorder, interventions may be directed toward eliminating sively researched forms of psychotherapy that is increasingly cognitive and behavioral patterns that are directly linked to 1 recognized as the treatment of choice for many disorders. Find- the development or maintenance of the disorder, or they may ings from randomized controlled trials (RCTs) typically suggest be directed toward maximizing coping skills to address the thatT CB is better than wait-list control groups, as well as sup- elicitation or duration of symptoms from disorders driven by portive treatment and other credible interventions, for specific other (e.g., biological) factors. disorders. Early implementations of CBT were largely indicated for anxiety and mood disorders.2 However, more recent clinical research efforts have begun to develop CBT for an increasingly BEHAVIORAL THERAPY, COGNITIVE THERAPY, 3,4 widery arra of problems (including bipolar disorder, eating AND COGNITIVE-BEHAVIORAL THERAPY disorders,5 body dysmorphic disorder,6 attention-deficit/hyper- activity disorder,7,8 and psychotic disorders9). Cognitive-behavioral therapies represent an integration of two The empirical evidence for the use of CBT for a broad range strong traditions within psychology: behavioral therapy (BT) of conditions is promising.10 However, there remains a notice- and cognitive therapy (CT). BT employs principles of learning able gap between encouraging reports from clinical trials and to change human behavior. BT techniques include exposure, the widespread adoption of CBT interventions among general relaxation, assertion training, social skills training, problem- practitioners.11 Moreover, questions remain regarding the solving training, modeling, contingency management, and limits of, and indications for, the efficacy of CBT in general behavioral activation. Many of these interventions are a direct practice.12 Nevertheless, it is clear that CBT represents the best outgrowth of principles of operant and respondent condition- of what the psychotherapy community currently has to offer ing. Operant conditioning is concerned with the modification in terms of evidence-supported treatment options. of behaviors by manipulation of the rewards and punish- CBT generally refers to a treatment that uses behavioral and ments, as well as the eliciting events. For example, in the treat- cognitive interventions; it is derived from scientifically- ment of substance dependence, the use of specific contingencies supported theoretical models.13,14 ,Thus there exists a theoreti- between drug abstinence (as frequently confirmed by urine or 152 Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 21, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. Cognitive-behavioral Therapy, Behavioral Therapy, and Cognitive Therapy 153 saliva toxicology screens) and rewards (e.g., the chance to win future (e.g., the presence of the therapist). Effective application a monetary reward) has proven to be a powerful strategy for of exposure therapy also requires prevention of safety behav- 16 achieving abstinence among chronic drug abusers.16 Included iors that may undermine what is learned from exposure. Safety as an operant strategy are also the myriad of interventions that behaviors refer to those behaviors that individuals may use to use stepwise training to engender needed new skills for reassure themselves in a phobic situation. For example, a problem situations. For example, assertiveness training, relaxa- patient with panic disorder may carry a cell phone or a water tion training, and problem-solving training are all core behav- bottle for help or perceived support during a panic attack. ioral strategies for intervening with skill deficits that may be These safety behaviors, while providing reassurance to patients, manifest in disorders as diverse as depression, bipolar disor- appear to block the full learning of true safety.21,22 , That is der, or hypochondriasis. One approach to treating depression, when such safety behaviors are made unavailable, better behavioral activation, emphasizes the return to pleasurable extinction (safety) learning appears to result.23,24 and productive activities, and the specific use of these activities CT was initially developed as a treatment for depression to boost mood. Interventions involve the step-by-step pro- with the understanding that thoughts influence behavior and gramming of activities rated by patients as relevant to their it is largely maladaptive thinking styles that lead to maladap- personal values and likely to evoke pleasure or a sense of tive behavior and emotional distress.25,26 ,Currently however, personal productivity. Behavioral activation will typically CT includes approaches to a wider range of disorders.27,28 consist of construction of an activity hierarchy in which up to As applied to depression, the cognitive model posits that (approximately) 15 activities are rated, ranging from easiest to intrusive cognitions associated with depression arise from most difficult to accomplish. The patient then moves through a synthesis of previous life experiences. The synthesis of the hierarchy in a systematic manner, progressing from the such experiences is also described as a schema, a form of easiest to the most difficult activity.17 Depending on the semantic memory that describes self-relevant characteristics. patient, additional interventions or skill development may be For example, the cognitive model of depression posits that needed. For example, assertion training may include a variety negative “schemas” about the self that contain absolute beliefs of interventions, such as behavioral rehearsal, which is acting (e.g., “I am unlovable” or “I am incompetent”) may result in out appropriate and effective behaviors, to manage situations dysfunctional appraisals of the self, the world, and the future. in which assertiveness is problematic. On exposure to negative life events, negative schemas and Respondent conditioning refers to the changing of the dysfunctional attitudes are activated that may produce symp- meaning of a stimulus through repeated pairings with other toms of depression. Thus, maladaptive cognitive patterns and stimuli, and respondent conditioning principles have been negative thoughts may also be considered risk or maintaining particularly applied to interventions for anxiety disorders. For factors for depression.29 eNegativ automatic thoughts can be example, influential theories such as Mowrer’s18 two-factor categorized into a number of common patterns of thought theory of phobic disorders emphasized the role of respondent referred to as cognitive distortions. As outlined in Table 16-1, conditioning in establishing fearful responses to phobic cues, cognitive distortions often occur automatically and may mani- and the role of avoidance in maintaining the fear. Accordingly, fest as irrational thoughts or as maladaptive interpretations of BT focuses on the role of exposure to help patients re-enter relatively ambiguous life events. phobic situations and to eliminate (extinguish) learned fears CT,30 and a similar
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