41. cognitive-behavioral therapy

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210 Cognitive-Behavioral Therapy4. Jacobson AM , Parmelee DX: Psychoanalysis: Critical Explorations in Contem porary Theory and Practice.5 . Klerman G, Weissman M Rovsanville B, Chevron E: Interpersonal Psychotherapy of Depression. New York,6. Luborsky L: Theories of cure in psychoanalytic psychotherapies and the evide nce for them. Psychoanalytic7. Mann J : Time-Limited Psychotherapy. Cambridge,MA Harvard University Press, 1973.8. Sloane RB, Staples FR, Cristol AH, et al: Psychotherapy Versus Behavior Therapy. Cambridge, MA9. Wachtel PL: Psychoanalysis and Behavior Therapy. New York, Basic B ooks, 1977.10. Stem DN: T he Interpersonal World of the Infant. New York, Basic Books, 1985.I I . Rothstein A: Models of the Mind. New York, International Universities Press, 1985.12. Vaillant G E ed): Ego Mechanisms of Defense: Guide for Clinicians and Researchers. Washington, DC,

New York, Brunn erM azel, 1982.Basic Books, 1984.Inquiry 16 2):257-264, 1996.Harvard University Press, 1975.

American P sychiatric P ress, 1992.

4 1. COGNITIVE-BEHAVIORAL THERAPYJ acq u eh eA. Samson, Ph.D

1. What is cognitive behavioral therapy?Cognitive-behavioral therapy (CBT) combines treatment approaches of both cognitive and be-havioral therapy. The principles were first outlined in a treatment manual specifically targeted to de-pression by Beck et aL3The basis of cognitive therapy is the observation that negative feelings result from faulty cog-nitive processing. Incoming information is selectively filtered so that perceptions are distortedtoward negative conclusions. Faulty processing is identified by examining a patients spontaneousthoughts occurring throughout the day or after specific events. These automatic thoughts are keyto understanding a patients core system of assumptions and beliefs about the self and the world.CBT treatments first help a patient become aware of automatic thoughts and underlying assumptionsand beliefs. The patient is then encouraged to seek evidence by which to support or refute the as-sumptions, and to modify beliefs based on a more balanced view of all available information.Behavioral techniques are integrated throughout CBT treatment to facilitate change. Specificexercises for thought stopping, relaxation, and impulse control may be combined with monitoring

and adjusting daily activities to increase mastery and pleasure experiences. Graded task assignmentsand systematic graded exposures also may be used.2. Give an example of cognitive distortion.

A depressed patient reported to her cognitive therapist that she felt sad over the weekend. In re-constructing the events of the weekend, she noted that the sadness began during a telephone call onSaturday morning from an old friend. The therapist then encouraged her to remember the conversa-tion and the point at which she first felt sadness. She remembered that her friend Sarah was dis-cussing her plans to take a vacation but did not invite the patient to come along. Her first automaticthought was: Sarah doesnt want me along because Im no fun. Her next thought was, Nobodywants to be with me. I have no friends. She then thought, 1 will be alone for the rest of my life.Gloomy thoughts indeedThe patients faulty processing began with her first reaction to the news of Sarahs vacation.When the therapist asked the patient to examine the evidence for her assumption that Sarah did notwant to be in her company, she had to say that there was no evidence; the fact that Sarah called indi-cated that Sarah enjoyed her company. Once the distortion i n the automatic thought was workedthrough, the patient felt more hopeful about the future and was able to say that she might ask Sarahif they could plan to do something together soon .


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Cogni t ive-Behaviora l Therapy 21 I3. What is the cognitive triad?

Th e cognitive triad refers to negative biase s that are characteristic of depress ed patients. Th e pa-t ient tends to: 1 ) view him - o r herself in a negat ive l ight and assume excessive responsibi li ty fo rfai lures or negative experiences; 2) view the world in a negative light and as presenting ob staclestha t cannot be overcome; 3) view the future negatively, consist ing only of m ore fai lure and insur-mountable obstacles.4. What are the main cognitive processing errors that contribute to maintaining negative

biases?In general, cog nitive erro rs involve: I ) mak ing predict ions a bout the future or how o thers willbehave withou t sufficient evidence; 2) selectively focusing only o n informa tion that is consistentwith ones expectat ions and ignoring information that runs counter to expectat ions; 3 ) assumingtoo much re spons ib i li ty fo r nega tive even t s wi thou t acknowledg ing the con t r ibu t ions mad e byothers o r the si tuat ion; and (4) seeing si tuat ions as al l-or-nothing and fai ling to acknow ledge part ialsuccess o r progress.

Cognitive Processing ErrorsEmotional reasoning: A conclusion or inference based on an emotional state; e.g., I feel this way; there-fore, I ur this way.Overgeneralization: Evidence drawn from one experience or a small set of experiences to reach an un-warranted conclusion with far-reaching implications.Catastrophic thinking: An extreme example of overgeneralization, in which the impact of a clearly neg-ative event or experience is amplified to extreme proportions; e.g., If I have a panic attack I will lose llcontrol and go crazy or die).All-or-nothing black-or-white; absolutistic) thinking:An unnecessary division of complex or continu-ous outco mes into polarized extremes; e.g., Either Im a success a t this, or Im a total failure.Shoulds and musts: Imperative statements about self that dictate rigid standards or reflect an unrealisticdegree of presum ed control over external events.Negative predictions: Use of pessimism or earlier experiences of failure to prematurely or inappropri-ately predict failure in a new situation; also known as fortune telling.Mind reading: Negatively toned inferences abou t the thoughts, intentions, or motives of another person.Labeling: An undesirable characteristic of a person or event is made definitive of that person or event;e.g., Because Ifuiled to be selected for ballet, I am afuilure.Personalization: Interpretation of an event, situation, or behavior as salient or personally indicative of anegative aspect of self.Selective negative focus selective abstraction): Focusing on undesirable or negative events, memories,or imp lications at the expense of recalling or identifying other, more neutral or positive information. Infact, positive information m ay be ignored or disqualified as irrelevant, atypical, o r trivial.Cognitive avoidance: Unpleasant thoughts, feelings, or events are misperceived as overwhelming and/orinsurmountable and are actively suppressed or avoided.Somatic mis) focus: Th e predisposition to interpret internal stimuli e.g., heart rate, palpitations, short-ness of breath, dizziness, or tingling) as definite indications of impending catastrophic events heart attack,suffocation, collapse).Adapted from Thase ME, Beck A T Overview of cogn ition therapy. In Wright JG, Thase ME, Beck AT LudgateJW eds): Cognitive Therapy with Inpatien ts. New York, Guilford, 1993,pp 3-34.5. How do patients learn to correct cognitive processing errors?By w orking with a therapist wh o que stions their logic. Th e therapist may use the so cratic method

and en courage the patient to identify erro rs in rational thinking by asking question s such as: What isthe eviden ce that this is true? Wh at is the evide nce that this is not true? Is there another way of look-ing at this? On ce alternative explanation s have bee n generated, the therapist may co llaborate with


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212 Cognitive-Behavioral Therapythe patient to design a mini-experiment in which the patient gathers information to confirm, refute,or m odify the assumption.6. How does correction of cognitive errors result in mood change?Although the exact mechanisms involved in clinical change are not known, it is hypothesizedthat the tendency to filter incoming information through a negative lens systematically excludes thepositive information needed to maintain a balanced perspective. Th e process of cha nge involvescompleting homework assignments. Th is is a critical ste p because it requires that the patient takeconcrete action to gather data i.e., fill out daily activity monitoring form s). Patients are more likelyto follow through o n such assignm ents when they understand the rationale of the treatment, and evi-dence of its usefulness has been demonstrated in the initial therapy sessions see Question 2). Thisbehavioral component increases the patients activity level and, usually, sense of self-efficacy. Oncethe patient becomes m ore active and is feeling so mew hat empowered, opp ortunities for positivefeedback from others increase. Mood improves as the negative cognitive biases are refuted by expe-rience or evidence, and the patient begins to see mo re options.7. How is the role of the cognitive-behavioral therapist different from more psychodynami-

cally oriented therapists?Th e cognitive-behavorial th erapist takes an active, problem-oriented,and directive stance inthe therapy relationship. Early i n the relationship, the therapist assumes a direct teaching role andconveys the basic principles of cognitive therapy to the patient. In later sessions, the therapist as-sumes the role of coach, as the patient takes on m ore responsibility. Sessions are structured: the ther-apist and patient 1 ) jointly set an agenda, 2) briefly review the previous se ssion , 3) reviewhomew ork completed since the last session, (4) work on additional topics spurred by the homeworkor events of the week, 5 ) set up homework for the following week, and (6) end with a summ ary ofthe key points from the session. Thro ughou t the session the therapist actively sum marizes and high-lights points as they occur and selectively pursues issu es for further w ork.

Structure o a Typical CBT Session1. Mood check2. Set the agenda3. Weekly items

Examination of symptom severity score e.g., Beck Depression Inventory)

Review of events since last sessionFeedback on reactions to previous session and review of key pointsHomework review4. Todays major top ic

5. Set homework for next week6. Summ arize key points of todays session7. Feedback on reactions to todays session

8. How many sessions typically are involved?Protocols for CBT of depression and anxiety disorders are relatively brief typically 12-20 ses-sions). The patient is expected to gradually master the skills of this method so that he or she maycontinue to monitor automatic thoughts and test assumptions independently after therapy termina-tion. For patients w ith multiple d iagnoses or como rbid personality d isorders, m ore sessions may beneeded to address target problems.9. To what degree is early developmental experience examined inCBT?

In general, cognitive-behavioral therapists are oriented toward the present and encourage pa-tients to exam ine how prese nt thoughts affect specific behaviors. Exam ination of a numb er of auto-matic thoughts may reveal recurring themes. Such themes can then be examined in more detail to


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Cogni t i ve Behavi oral Therapy 213understand core beliefs or schemas about oneself or the world that may be driving the thoughts.Although core beliefs are likely to have developed as a result of early experience, it is not neces-sary to spend a great deal of therapy time exploring such experiences. Rather, the patient may beencouraged to write a brief autobiography outside the session from which likely links betweenschemas and early experiences can be drawn with the therapist in the next session. The therapistcan help the patient to trace how the core belief m ay have evolved from painful early exp eriencesand to see how they are understand able in that light. However, the emph asis is primarily o n exam-ining the ways in which o ld beliefs distort present thinking and behaviors and on developing anaction plan for change.10. Is there research evidence that CBT works?Yes. A growing number of well-designed studies demonstrate that CB T is effective for patientswith depression or anxiety disorders. Studies also show C BT to be as effective as antidepressantmedication in mildly to mo derately depressed patients; in patients with severe depression, this evi-dence is mixed. For both disorders, there is no clear evidence that a combination of C BT and med-ication is superior to either alone, or that the combination is less effective than either alone.Stud ies comparing C BT to psychodynamically oriented therapies have not been conclusive,partly because of differences in the length of the treatmen ts and difficulties in establishing standard-ized treatment protocols.11. How do relapse rates for CBT and pharmacotherapy compare?Follow-up studies find that 70-80 of depressed patients treated with CBT alone continue to bewell 2 years later. These rates are significantly higher than the maintenance rates in patients who arewithdrawn from antidepressant medication after a com parable initial trial, and equal t o the rate inpatients who continue on antidepressant medications.12. Which disorders are responsive to CBT?Efforts to apply CB T techniques to various types of patients have expanded rapidly in the pastdecade. Included among the disorders shown to be responsive to CBT are panic disorder, general-ized anxiety disorder, social phobia, and bulimia nervosa. Preliminary studies show som e prom iseapplying C BT techniques to post-traumatic stress disorder, obsessive compulsive disorder, and dys-thymia. There are guidelines for applying CBT techniques to personality d isorders, but efficacy hasnot been estab lished across all diagn ostic gro ups. Such application m ay require mo re extensivelonger) treatment, and may explain why so me depressed and anx ious patients with comorb id per-sonality disorder do not show com plete response to a brief trial of CB T. Cluster C personality disor-ders are likely to be most responsive.13. Are there patients for whom CBT does not work?Studies predicting outcome based on patient characteristics are only now being completed. Astrong predictor of positive outcome is whether a patient completes homework assignments be-tween sessions. Preliminary work suggests that patients w ho have borderline personality disorder ora great deal of difficulty forming a work alliance with the therapist are likely to show a poor re-sponse to a brief trial of cognitive therapy. However, these patients also are likely to show poor re-sponse to other forms of brief therapy. Historically, patients with bipolar depression or psychoticfeatures have been excluded from research trials and assumed to be less responsive to interventionwith CBT alone. CBT recently has had som e success in relapse prevention in bipolar patients; it alsohas decreased the conviction of psychotic beliefs in patients with delusional features.

BIBLIOGRAPHY1. Beck AT: Depression, Causes and Treatment. Philadelphia, Uuiversity of Pennsylvania Press, 1967.2. Beck AT Emery G:Anxiety Disorders and Phobias: A Cognitive Perspective. New York, Basic Books, 1985.3. Beck AT Rush AJ Shaw BF, Emery G: Cognitive Therapy of Depression. New York, Guilford Press, 1979.4. Beck JS:Cognitive Therapy: Basics and Beyond. New York, Guilford Press, 1995.


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214 Behavior Therapy5 . Beutler LE, Engle D, Mohr D, et al: Predictors of differential response to cognitive, experiential and self-di-rected psychotherapeutic procedures. J Co nsult Clin Psychol 59:333-340, 1991.6. Dobson K: A meta-analysis of the efficacy of cognitive therapy fo r depression. J Consult Clin Psychol57:414419, 1989.7. Elkins I, SheaT,Watkins J, et al: National Institute of Mental Health Treatment of Depression Collaborative

Research Program . Arch Gen Psychiatry 46:971-982, 1989.8. Evans M, H ollon SD , DeR ubeis RJ, et al: Differential relapse following cognitive therapy and pharma-cotherapy for depres sion. Arch Gen Psychiatry 49:774-78 1 1992.9. Fennel1 MJ : Depression. In Hawton K, Salkovskis PM, Kirk J, Clark DM eds): Cognitive Behavior Therapyfor Psychiatric Problems. Practical Guide . New York, Oxfo rd Unive rsity Press, 1989 , pp 169-234.10. Hollon SD, Beck AT: Cognitive and cognitive-behavioral therapies. In Bergin AE, Garfield SL eds):Handbook of Psych otherapy and Behavior Change, 4th ed. New York John W iley Sons, 1994, pp4 2 8 4 6 6 .1 I . Hollon SD, DeRubeis RJ, Evans M D, et al: Cognitive therapy and pharmacotherapy for depression: Singlyand in combination. Arch Gen Psychiatry 49:774-781, 1992.12. Hollon SD, Shelton R C, Loosen PT: Cognitive therapy and pharmacothei-apy for depression. J Consult ClinPsychol 59:88-99, 1991.13. Thase ME, Beck AT: Overview of cognitive therapy. In Wright JG , Thase M E, Beck AT, Ludgate JW eds):Cogn itive Therapy with Inpatients. New York, Guilford, 1993, pp 3-34.

42. BEHAVIOR THERAPYCarry Welch Ph .D. , and Jacqueline A. Samson, Ph.D.

1. What is behavior therapy?Behavior therapy is a scientifically based approach to the understanding and treatment of hum anproblems. It arose from laboratory exp eriments of animal behavior conducted in the early 1900s andhas developed since from a larg e body of clinical research an d experience. T he goals of behaviortherapy are:Improve daily functioningReduce emotional distressBehavior therapy first came into com mo n use in the 1960s and is now applied to a wide range ofhuman problems. Originally the emphasis was on overt, measurable behavior and the applicationof classical and operant conditioning p rinciples. However, since the 1980 s it has been expand ed toinclude cognitive aspects that emphasize the role of inner m ental processes and em otional states. Inaddition, a new consideration of the broader social context of behavior has developed. The currentfocus of behavior therapy is not only what we o vertly do , but also w hat we think and feel; all of theseelements are influenced by the fundam ental principles of learning.

Enhan ce relationshipsMax imize human potential

2. Which patients are most likely to benefit from behavior therapy?Behavior therapy has been proven effective for the treatment of specific health problems requir-ing behavior change, such as sm oking cessation, weight loss, stress, and pain m anagem ent. In addi-tion, treatment protocols for anxiety disorders and phobias such as obsessive-compulsive disorder(OCD), agoraphobia, and panic disord er show success equivalent to or exceeding medication alone.Behavior therapy and token economy systems see Question 15)have been used with good outcomein patients with develop men tal disabilities and severely disturbed psychotic patients. It is the treat-ment of cho ice for severely ill patients w ho cannot p articipate in standard insight-oriented or cogni-tive therapies.3. How do operant and classical conditioning differ?Behavior therapy draws heavily on principles derived from classical or Pavlovian) and operant(or instrumental) conditioning. Both forms of conditioning are im portant influences in daily life

41. cognitive-behavioral therapy

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