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132 Medical Journal of Dr. D.Y. Patil University | April-June 2013 | Vol 6 | Issue 2
Address for correspondence:
Dr. Daniel Saldanha, Department of Psychiatry, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune – 411 018, India.
E-mail: d_saldanha@rediffmail.com
Cognitive behavior therapy
Labanya Bhattacharya, Bhushan Chaudari, Daniel Saldanha, Preethi Menon
Department of Psychiatry, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
ABSTRACT
Cognitive behavior therapy (CBT) is one of the most extensively
researched psychotherapeutic modalities which is being used
either in conjunction with psychotropic drugs or alone in various
psychiatric disorders. CBT is a short-term psychotherapeutic
approach that is designed to inuence dysfunctional emotions,
behaviors, and cognitions through a goal-oriented, systematic
procedure. Recent advances in CBT suggest that there is a
fresh look on a “third wave” CBT that has a greater impact and
newer application that may mitigate the sufferings of mentally
ill patients.
Key words: Cognitive behavior therapy, cognitive psychology,
third wave
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DOI:
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Review Article
in the early 20th century and the development of Cognitive
School of thought in the 1960s, and subsequent integration
of the two.[6]
Since early 1920s, inspired works of Ivan Pavlov, John B.
Watson, Joseph Wolpe and B. F. Skinner, the science of
behavior therapy came into practice to treat neurotic disorders.
In behaviorism, learning theory played a signicant role.
e behaviorists shifted from science to technology and did
not show much interest in theory building. Although the
early behavioral methods successfully treated many neurotic
disorders like anxiety disorders, it had little success in treating
depression. All this led to a shift in focus of therapeutic
approaches from behaviorism to “cognitive theory” of mental
disorders.
e so-called cognitive revolution was pioneered by the works
of Aaron T. Beck, psychiatrist at the University of Pennsylvania,
and Albert Ellis, Psychologist in 1960s. Aaron T. Beck, within
the course of his psychoanalytical treatment, observed the
fact that traditional psychoanalytical concepts for depression
“aggression directed inwards” could not be validated and
certain patterns were evident in the thoughts of depressed
individuals. He observed that their symptoms were the result
of negative bias in their cognitive processing. is led to the
development of “cognitive therapy.” Concurrently, “Rational
Emotive Behavior erapy” was developed by Albert Ellis,
stating the same notion that faulty cognition leads to emotional
disturbances.
Development of Cognitive Behavior
Therapy
e term cognitive behavior therapy (CBT) can be seen as
an umbrella term, generally used to refer a group of related
therapies that have theoretical basis in behavioristic learning
and cognitive psychology and are derived from scientically
proven theoretical models from these theories,[1] and is
currently a treatment of choice for various psychiatric disorders
including mood disorders, anxiety disorders, personality
disorders (PDs), eating disorders, substance abuse disorders,
and psychotic disorders.[2,3]
e origin of cognitive behavior therapies can be traced back
to various ancient philosophical traditions and thinkers of
the pre-classical and classical periods, particularly Stoicism.[4]
Epictetus, a Greek philosopher and stoic stated that “It is not
things themselves that disturb men, but their judgments about
these things.” It has been mentioned in Aaron T. Beck’s original
treatment manual for depression that “e philosophical
origins of cognitive therapy can be traced back to the Stoic
philosophers.”[5] However, the modern roots of CBT can be
traced to the development of Behavioral School of thought
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Earlier studies compared cognitive therapy and behavior
therapy to see which was more eective. Later cognitive
therapists started blending cognitive and behavior therapies
into a coherent whole to form CBT. us, the importance of
cognition was incorporated in behaviorism, while behavioristic
characteristics, like empiricism and conduction of outcome
research, were incorporated in cognitive therapy. It can be said
that the earliest form of CBT was observed in Ellis’ work in
early 1960s,[7] but the rst major texts on cognitive behavior
modication appeared in 1970s.[8-10]
Basic Principles of Cognitive
Behavior Therapy
Although the actual theoretical mechanism behind eectiveness
of CBT in various clinical disorders is not well understood,
CBT operates under the assumption that psychological
disorders are mediated by distorted cognitions and maladaptive
behaviors. To explain in simple terms, the distorted cognitions
lead to faulty emotions which in turn lead to maladaptive
behaviors and these behaviors will have negative impact on
cognitions as depicted in Figure 1.
CBT uses two basic approaches to bring about changes, i.e. (i)
restructuring the cognitive event which is based on cognitive
theory and (ii) social and interpersonal skill training which is
a behavioral arm of cognitive behavior theory.
Cognitive principle
Although dierent cognitive therapists use dierent theoretical
models of cognitive processes which may dier according to
psychological disorder, some basic cognitive structures and
processes have been described by early cognitive therapists.[5,11,12]
Automatic thoughts
Automatic thoughts are short-term cognitive events which
appear as a response to external events “without thought” or
“automatically.” Aaron T. Beck rst described these automatic
thoughts which he observed, in patients of depressive disorders,
as often negatively tinged.[13,14] ese “Negative Automatic
oughts” or “Cognitive Distortions” are thought to exert a
direct inuence over mood and they are therefore of central
importance to any CBT therapy. ese cognitive distortions
can be classied according to their typical bias or illogic.
Examples include: “She thinks I’m an idiot” (Mind-reading),
“I’ll fail the test” (Fortune-telling), “I’m a loser” (Labeling),
“I can’t stand it—it’s awful” (Catastrophizing), “My successes
are trivial” (Discounting positives), “I fail at everything” (All-
or-nothing thinking), “If I fail at this, I’ll fail at other things
too” (Overgeneralizing), and “e divorce was all my fault”
(Personalizing).[15]
Underlying assumptions and core beliefs
ese are long-term cognitive processes and are less available
to an individual’s consciousness than automatic thoughts.[16]
Underlying assumptions and core beliefs are more durable and
stable organizational system, that doesn’t change over a range
of situations or time. ese represent person’s basic rules or
values. Typical rules are “I should be perfect,” “I should be liked
by everyone,” “My worth depends on others’ approval,” “I need
to be certain,” and “My partner should understand and meet
my needs without my having to tell him.” ese underlying
assumptions and core beliefs structure a person’s automatic
thinking.[13] Most cognitive approaches start with helping the
client to identify automatic thoughts and cognitive distortions
and then addressing the long-term underlying core beliefs that
are associated with them.[7,14,17]
This represents the basic cognitive model of emotional
disorders underlying CBT. Over the years, generic models for
various psychiatric disorders, i.e. depression,[5] panic disorder,[18]
post-traumatic stress disorder (PTSD),[19] hypochondriasis,[20]
obsessive-compulsive disorder (OCD),[21] generalized anxiety
disorder,[22] and social phobia[23] have been developed.
Behavioral principle
e theoretical principle which is inherited from behavioral
theory assumes that person’s behavior is crucial in maintaining
– or in changing – psychological states of his mind. It states
that the person having cognitive distortions behave in such a
way that the subsequent behavior has negative impact on the
emotional states and further cognition. us, changing the
behavior of a person is a powerful way of changing thoughts
and emotions. ese behavioral methods include various
strategies of coping and social skill training. ese behavioral
techniques have proven to be an essential part for successful
therapy in various research studies.[24]
Event
Thought/ Belief /
Cognition
Feelings/ Emotion
Action/ Behavior
Figure 1: Distorted cognitions leading to maladaptive behaviors
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134 Medical Journal of Dr. D.Y. Patil University | April-June 2013 | Vol 6 | Issue 2
At the beginning of each session, review information is
gathered from the patient about events that occurred since
the previous session that is relevant to the patient’s goals for
treatment. Along with this, some part of treatment session
is also dedicated for diculties that may occur before next
treatment session. ese diculties then are discussed in
the context of problem solving and the implementation of
necessary cognitive and behavioral skills. Although the specic
intervention used during CBT may vary, the interventions
are based on cognitive and learning theories. rough these
cognitive and behavioral techniques, generally rst patient’s
negative automatic thoughts and dysfunctional beliefs
are identied and tested in reality. ere are a number of
specic cognitive and behavioral techniques used in the CBT
procedure, some of which are enumerated bellow although
they are not exclusive.[15]
Cognitive techniques
• Identifyingandmonitoringnegativethoughts
• Ratingthedegreethebeliefinsuchnegativethoughts
anddegreeofemotionassociatedwiththoughts
• Categorizingthenegativethoughtsinspeciccognitive
distortions
• Verticaldescent (Whatwoulditmean ifthethought
weretrue?)
• Whatistheunderlyingassumption?
• Whatarethecostsandbenetsofthethought?
• Listing the evidences supporting and refuting his
thoughts
• Placing the event in perspective by examining its
consequencesinpatient’sview
• Doublestandard(askingpatientifhewouldapplythe
samestandardsifeventoccurswithothers
• Roleswitchingandarguingbackatnegativethoughts
bypatient
• Patientisaskedtoexaminemanyalternativecausesand
consequencesofthethought,especiallylessnegative
alternatives
• Acceptance (Is there a reality that the patient can learn to
accept, rather than trying to x or struggle with it?)
Behavioral techniques
• Exposureorconfrontingthefearedstimuli
• Gradedexposure
• Modeling (e.g. therapist demonstrates in session an
appropriate assertive response that the patient then
imitates.)
• Imitation(e.g.patient“copies”andenactsthebehavior
thatheobservesinanotherperson.)
• Behavioralrehearsal(patientenactsthebehaviorwhich
heplanstoconductoutsideoftherapy.)
• Relaxationtechniques
• Activity scheduling (listing activities throughout the
day and rating them for various emotions associated
The “here and now” principle
In modern CBT, the main focus of therapy is on what is
happening in the present and main concerns of the therapy is
the processes currently maintaining the problem, rather than
the processes that might have led to its development years ago.
The empirical principle
CBT believes in evaluating the theories and treatment
outcomeasrigorouslyaspossibleusingscienticevidence.
Thisisimportantforseveralreasons:
• Scientically– sothatthetreatmentscan befounded
onsound,well-establishedtheories
• Economically – so that the cost–benefit ratio of
treatmentisbenecialfortheclient
• Ethically – so that the clientsareprovidedwithsound
treatment.
Technique
Modern form of CBT includes variety of techniques
and approaches. These are exposure therapy, stress
inoculation training,cognitive processing therapy, cognitive
therapy,relaxation training,dialectical behavior therapy,
andacceptance and commitment therapy.[25] Therapeutic
techniques vary according to specic issues that have to be
dealt with. e current form of CBT targets core components
of a given disorder. CBT is typically delivered over the course
of 12 to 20 sessions; each session typically lasts from 45 min
to 1 h duration.
A key feature of CBT is the establishment of a strong,
collaborative working relationship with the patient. is will
be facilitated if there is a warm and trusting atmosphere.
Empathy and unconditional positive regard toward patient is
of utmost importance. e role of therapist in CBT should be
as a guide, catalyst, and teacher. e initiation of this working
relationship is done with psycho education of patient about
the nature of the disorder, explaining the CBT model of the
etiology and maintenance of the disorder and the intervention
derived from the model.
In initial few sessions, thorough evaluation of the presenting
problem of a patient is done and initial hypothesis and
treatment plan is formulated. is phase of treatment is called
“Cognitive Behavioral Assessment.” Patient’s current problem
is assessed through self-monitoring of symptoms of the patient,
behavioral interviewing, and direct observation of behavior
or objective assessment of patient’s symptoms through a
self-report questionnaire. e therapist helps to identify and
dierentiate between problems so the challenges are reduced
to manageable goals.
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withthem)
• Gradedtask assignments (planning and enacting
behaviorsthatareexpectedtoproducereward)
• Assertivenesstraining
• Communicationtraining
• Self reward to increase desirable behaviors
Homework is an essential part of CBT treatment, as patient
is not only transformed during sessions but a lot of change
in patient’s cognitive structuring and behavior is happening
between the sessions. This is catalyzed by a homework
assignment which usually follows from the problem solving
process in the treatment session. Successful completion
of homework assignment is a good predictor of success of
therapy. is inter-session practice also encourages the patient
to generalize skills learned in sessions to tackle problems
encountered in everyday life.
Group cognitive behavioral therapy
CBT can also be given in group therapy settings, in which
therapeutic benets of both CBT and group therapy can be
combined. is technique is found to be useful in patients with
substance use disorders,[26] depression,[27] anxiety disorders[28]
social phobia,[29] and also in children.[30] e group CBT
is cost eective, as well as it allows patients to learn about
their cognitive distortions by observing other patients and
it also provides a safe environment for them to learn and
practice communication and social learning skills as in real
life situations.
Computer-based cognitive behavior therapy
Computerized Cognitive Behavioral erapy (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,”[31]
instead of face-to-face with a human therapist. It can be
used by patients where direct face-to-face CBT is dicult
to obtain because of unavailability of expert therapist or cost
issues. Studies have proved eectiveness of this computer based
therapy in mild to moderate depression and anxiety disorders.
[32] e usefulness of this method in our setting is questionable.
Application of CBT to Various
Disorders
After the development of CBT, in the initial few years it
primarily gained recognition as a treatment method for mood
disorders and anxiety disorders.[33] As CBT started gaining
popularity, the indications for its use was found in various
psychiatric as well as medical disorders by various workers.
Today some claim that CBT is probably the rst line of
psychological treatment for many disorders.[34]
Depression
Initially, CBT was considered a treatment of choice for mild
to moderate depression among psychological treatment
options. e ecacy of CBT in depression has been shown
by many empirical evidences in which it has been stated to
be superior or at least equally eective with other treatments
including antidepressants.[35,36] Studies have also shown that
combining CBT with medications shows greater eect than
medications alone.[36] CBT can be of particular importance
in chronic and recurrent depression in preventing relapses.[37]
Even in severe depression, CBT is shown to be as ecacious as
antidepressants[38] but this is questionable. CBT is also shown to
be eective in dealing with depressive symptoms in children.[39]
Anxiety disorders
Numerous studies have shown that CBT is eective in reducing
information processing biases and avoidance behaviors which
are characteristic of anxiety disorders and also that with CBT
stronger eects are observed for treatment of anxiety disorders
as compared to other disorders.[40] Several meta-analysis studies
have shown eectiveness of CBT across the range of anxiety
disorders including panic disorder,[41] specic phobia,[42] social
phobia,[43] and generalized anxiety disorder.[44]
Psychotic conditions
e current evidence from multiple randomized controlled
trials and meta-analyses suggests that CBT is a potent adjunct
to pharmacotherapy in psychotic conditions.[45,46] CBT is
eective in dealing with persistent positive as well as negative
symptoms of schizophrenia and also it improve medication
adherence. CBT has also shown its eectiveness in treatment
of acute psychoses.[47]
Obsessive-compulsive disorder
CBT is considered as eective psychological treatment for
OCD,[48] particularly in obsessional problems where intrusive
thoughts are considered as personal responsibility. CBT can
change responsibility beliefs and appraisals and thereby reduce
distress and neutralizing behaviors.[49] However, in compulsive
behaviors, behavioral component of exposure seems to be the
active component of therapy,[50] but cognitive component can
make patient more compliant to behavioral measures.
Post-traumatic stress disorder and acute stress
disorder
Various meta-analyses have shown eectiveness of CBT in
treatment and prevention of PTSD.[51] e most studied
CBT approaches being prolonged exposure[52] and cognitive
processing therapy.[53] In acute stress disorder CBT is found
to be superior to supportive counseling[54] and also prevents
progression to PTSD.
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Substance use disorders
Numerous large-scale trials and quantitative reviews have
shown the efficacy of various CBT interventions in the
treatment of alcohol and other drug use disorders.[55,56]
Various CBT interventions used for substance use disorders
include contingency management, motivational interventions,
relapse prevention which can be given in individual as well as
group settings.
Personality disorders
CBT oers various specic therapeutic techniques which
depend on the core psychopathological symptoms of the
PD. Although there are supporting evidences for ecacy of
CBT interventions in PDs, most studied and widely adopted
technique is dialectical behavior therapy which is used in
patients of borderline personality disorder.[57]
Behavioral medicine
CBT can help variety of ill and at risk population by modifying
health and illness behavior and developing eective coping
skills, including patients suering from bulimia nervosa,[58]
cancer,[59] chronic pain,[60] cardiovascular diseases,[61] HIV
and AIDS.[62]
“New Wave” of Cognitive
Behavioral Therapy
Also called as a “ird Wave” of behavior and CBT, this new
wave of CBT has been described recently. It defers from
traditional CBT in a way that the focus of therapy is to change
the function of psychological events that people experience and
promote emotion regulation strategies, rather than to change
the perception of the event.[63] is therapeutic eect is achieved
through various approaches like acceptance, cognitive diusion,
or mindfulness. Psychotherapeutic interventions which are
included in this category include Acceptance and Commitment
erapy (ACT)[64] and Mindfulness-Based Cognitive erapy
(MBCT).[65] Although the present empirical evidence allows
these third wave therapies to be ecacious, further research is
warranted to prove their usefulness over the traditional ones.[66]
Conclusion
Cognitive therapy rst proposed by Beck in early 1960s
for depression has rapidly evolved into one of the major
psychotherapeutic methods in modern psychiatric treatment.
Its ecacy of treatment for depression, generalized anxiety
disorder, panic disorder, eating disorders, and other psychiatric
conditions has been well established by numerous outcome
studies. Most psychiatric illnesses now have well-organized
treatment guidelines based on cognitive therapy. e goals of
cognitive therapy include immediate relief from symptoms and
to acquire cognitive and behavioral skills that reduce the risk
for relapses. With fast-paced modern gadgets, future challenges
for this therapy include computer-assisted models of learning
that is easy and economically viable. In conclusion, it will not
be incorrect to state that whatever method of therapy one
uses it should address the relief of symptoms in that respect
cognitive behavior therapy has proved its utility in varieties of
mental disorders.
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How to cite this article: Bhattacharya L, Chaudari B, Saldanha D, Menon P.
Cognitive behavior therapy. Med J DY Patil Univ 2013;6:132-8.
Source of Support: Nil. Conict of Interest: None declared.
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