Cognitive-Behavioural Therapy ( CBT) is a psychotherapeutic approach that aims to influence problematic and dysfunctional emotions, behaviours and cognitions through a goal-oriented, systematic procedure. CBT can be seen as an umbrella term for therapies that share a theoretical basis in Behaviourist learning theory and Cognitive Psychology and that use methods of change derived from these theories.

CBT treatments have received empirical support for efficient treatment of a variety of clinical and non-clinical problems, including mood disorders, anxiety disorders, personality disorders, eating disorders, psychotic illnesses and substance abuse. It is often brief and time-limited. It is used in individual therapy as well as group settings, and the techniques are also commonly adapted for self-help applications. Some CBT therapies are more oriented towards predominately cognitive interventions while some are more behaviourally-oriented. In cognitive-oriented therapies, the objective is typically to identify and monitor thoughts, assumptions, beliefs and behaviours that are related to and accompanied by debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace or transcend them with more realistic and useful ones.

CBT was primarily developed through a merging of  behavioural therapies with cognitive therapies. While rooted in rather different theories, these two approaches found common ground in focusing on the here-and-now and symptom removal. Many CBT treatment programmes for specific disorders have been developed and evaluated for efficacy and effectiveness; as a result CBT tends to generate better results more consistently than any other form of Psychotherapy. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends CBT as the treatment of choice for a number of mental health difficulties, including Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Bulimia Nervosa and mild to moderate Depression.

How CBT works...

CBT includes a variety of approaches and therapeutic systems, having effectively absorbed Aaron Beck’s Cognitive Therapy and led Albert Ellis to reformat Rational Emotive Therapy as Rational Emotive Behaviour Therapy. Defining the scope of what constitutes a cognitive–behavioural therapy is a difficulty that has persisted throughout its development. American psychologists Keith Dobson & David Dozois define cognitive–behavioural therapies as sharing the theoretical assumption that behavioural change is mediated by cognitive events.

The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviours; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly included. CBT is often also used in conjunction with mood stabilising medications to treat conditions like Bipolar Disorder. Its application in treating Schizophrenia along with medication and Family Therapy is recognised by NICE.

CBT interventions are structured with clear goals and measurable outcomes.

The Cognitive element

The therapist encourages the client to become aware of beliefs which might contribute to anxiety or Depression or are associated with a general dysfunction in daily life. This can involve direct questioning such as: “Tell me what you think about....”

The therapist does not usually challenge the beliefs outrightly but treats them as hypotheses to be tested for validity. Therapist and client may also work together to conduct a cost-benefit analysis, examining the advantages and disadvantages of particular beliefs. The therapist may draw diagrams to show clients the links between their thoughts, behaviour and emotions.

The Behavioural element

Therapist and client decide together how to test out hypotheses through experimentation. Experiments can be conducted through role play or homework assignments. The intention is that, by actively testing out possibilities, clients themselves come to recognise the consequences of their faulty cognitions.

Therapist and client then work together to set new goals for the client in order that more realistic and rational beliefs are incorporated into ways of thinking.

These are usually in graded stages of difficulty so that clients can build upon their own success.

Going through CBT generally is not an overnight process for clients. Even after clients have learned to recognise when and where their mental processes go awry,  in some cases it can take considerable time of effort to replace a dysfunctional cognitive-affective-behavioural process or habit with a more reasonable and adaptive one.

For Depression

 According to the British Association for Behavioural & Cognitive-Behavioural Psychotherapies (BABCP), the aim of CBT in treating Depression should be to:-

• re-establish previous levels of activity
• re-establish a social life
• challenge patterns of negative thinking
• learn to spot the early signs of recurring Depression

Evaluating CBT

For Depression

In a study by Giovanni Fava, Chiara Rafanelli, Silvana Grandi, Sandra Conti & Piera Belluardo (1998) 40 patients with recurrent Depression were allocated to one of two groups. In the first they received drug treatment alone; in the second they received drugs and CBT. The second group showed a greater reduction in symptoms. In a follow-up two years later, 75% of the second group were still free of symptoms (compared to just 25% of the first group). A study by Robin Jarrett, Martin Schaffer, Donald McIntire, Amy Witt-Browder, Dolores Kraft & Richard Risser (1999) found CBT and MAOI antidepressants to be equally effective with 108 patients with severe Depression in a 10-week trial - although CBT obviously had the benefit of no physical side effects! S D Hollon,  R J DeRubeis, M D Evans, M J Weimer, M J Garvey, M W Grove & V B Tuason 1992 found no difference between CBT and tricyclic antidepressants with 107 patients in a 12-week trial. They also found no difference between CBT alone and CBT combined with the tricyclics. Moreover Hollon’s team claimed that relapse often occurred when medication was terminated but, with CBT, the effect was maintained beyond the end of the therapy sessions. (They did, however, concede that only about 40% of those who began treatment - either drugs or psychological therapy - completed it.) Earlier Martin Seligman, Lyn Abramson, A Semmell & C von Baeyer (1979) had actually found a mix of cognitive and behavioural therapies to be more effective than medication alone. D David & M Avellino (2003) looked at a number of studies into different forms of Psychotherapy and concluded that overall CBT had the highest success rate.

Probably the most significant investigation into the efficacy of CBT in treating Depression was that of Andrew Butler, Jason Chapman, Evan Forman & Aaron T Beck (2006) who reviewed 16 meta-analyses of studies into CBT. They found CBT to very effective for treating Depression.

Not all investigators have endorsed CBT. J Holmes (2002) identified several limitations in the evidence:-

• The National Institutes of Mental Health (1994) conducted the single largest investigation into effective treatments for Depression and found that CBT was less effective than antidepressant drugs and other psychological therapies
• There is insufficient evidence for the long-term effectiveness of CBT (and other treatments).
• The evidence for the effectiveness of CBT comes from trials of highly-selected patients with only Depression and no presenting symptoms of any other mental health problems – there is less evidence of effectiveness in real patient populations where the majority have more complex problems.

It should be noted that CBT does not benefit all patients.

NICE (2004) recommended Psychodynamic therapies and medication for more complex cases of Depression. CBT is recommended for mild to moderate Depression.

General

There may be bias in some of the reports on the effectiveness of CBT.  Richard Harrington, Fiona Campbell, Philip Shoebridge & Jane Whittaker (1998) have questioned why several reviews of studies of CBT have failed to mention studies in which CBT was found not to be effective. Additionally, Bruce Wampold, Takuya Minami, Thomas Baskin & Sandy Tierney (2002) re-evaluated the data on a number of studies and found that, after removing therapeutic interventions without a theoretical base, CBT was no more effective than other forms of Psychotherapy.

It also appears that, in some cases, other forms of therapy can be more effective. Christer Sandahl, Kristina Herlitz & Goran Ahlin (1998) reported that, at 15-month follow-up into treatment of alcohol abusers, significantly more patients were abstaining from alcohol after Psychodynamic therapy than were patients treated with CBT.

CBT appeals to clients who find ‘insight therapies’ (which delve into inner emotional conflicts) too threatening. Although CBT can be subject to the criticism that it does not address the underlying causes, it does attempt to empower clients by educating them into self-help strategies. However, despite this, many clients do become dependent on their therapist.