What is cognitive-behavioral psychotherapy?

Cognitive-behavioral psychotherapy, or cognitive-behavioral psychotherapy, or cognitive-behavioral therapy is a widespread comprehensive form of psychotherapy that combines cognitive therapy with behavioral therapy. Cognitive behavioral therapy is effective for a wide variety of mental disorders and is a short-term, skills-focused treatment that aims to change maladaptive emotional responses by changing the patient's thoughts, changing behavior, or changing both. CBT is the therapy of choice for many mental disorders.

The cognitive approach proceeds from the assumption that psychological problems and neuropsychiatric disorders are caused by illogical or inappropriate human thoughts and beliefs, as well as dysfunctional thought patterns, by changing which emotions and behavior can be changed and thereby solve problems. The behavioral approach, based on behaviorist theory, involves changing a person's behavior by encouraging and reinforcing desirable behaviors and not reinforcing undesirable behaviors, and changing emotions and thought patterns as a consequence of behavioral change.

Cognitive-behavioral exercises are therapeutic and preventive means of psychotherapy, which are cognitive means of self-impact.

Cognitive behavioral psychotherapy is based on a combination of the basic principles of behavioral and cognitive psychology and differs from historical approaches to psychotherapy, such as the psychoanalytic approach, in which the therapist searches for the unconscious meaning of behavior and then formulates a diagnosis on this basis. In contrast to psychoanalysis, CBT is a "problem-oriented" and "action-oriented" form of therapy, which means that it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to help the client find and practice effective strategies to achieve their goals and alleviate the symptoms of the disorder. CBT is based on the belief that distorted thinking and inappropriate behavior play a role in the development and maintenance of many mental disorders and that symptoms and associated distress can be reduced by teaching new information processing skills and coping mechanisms.

Review studies have shown that compared to psychopharmacological medications, CBT alone is as effective for treating non-serious forms of depression, anxiety, post-traumatic stress disorder (PTSD), tics, substance use disorders, eating disorders and borderline personality disorder. Some studies show that cognitive behavioral therapy is most effective when combined with medications to treat certain psychiatric disorders, such as major depressive disorder. CBT is recommended as a first-line treatment for most psychiatric disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that otherbona fide therapeutic interventions have been equally effective in treating some conditions in adults. Along with interpersonal psychotherapy (IPT), cognitive behavioral therapy is recommended as the preferred psychosocial treatment.

The premise of some fundamental aspects of CPT was found in various ancient philosophical teachings, especially in Stoicism. Stoic philosophers, especially Epictetus, believed that logic could be used to identify and discard false beliefs that lead to destructive emotions, and these Stoic beliefs have influenced the way modern cognitive behavioral therapists identify cognitive distortions that contribute to depression and anxiety. For example, Aaron T. Beck's original guide to treating depression states, "The philosophical origins of cognitive therapy go back to the Stoic philosophers." Another example of the Stoics' influence on CPT is Epictetus' influence on Albert Ellis. A key philosophical figure who influenced the development of CPT was also John Stuart Mill.

The modern roots of cognitive behavioral therapy can be traced to the development of behavioral therapy in the early 20th century, the development of cognitive therapy in the 1960s, and their subsequent merger. The pioneering developments in behaviorism began with the study of conditioning byJohn B. Watson and Rosalie Rayner in 1920. Behavioral oriented therapeutic approaches were described as early as 1924 in Mary Cover Jones' work on relieving children's fears. These were the forerunners of Joseph Wolpe's behavioral therapy, which emerged in the 1950s. It was the views of Wolpe and Watson, based on Ivan Pavlov's discoveries of conditioned reflexes, that influenced Hans Eiseneck and Arnold Lazarus in developing new methods of behavior therapy based on classical conditioning.

In the 1950s and 1960s behavioral therapy became widely used by researchers in the United States, Britain and South Africa. They were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull. In Britain, Joseph Wolpe, who applied the results of animal experiments as part of his method of systematic desensitization, used the results of behavioral research in the treatment of neurotic disorders. Wolpe's therapeutic work was the forerunner of current methods of fear reduction. The British psychologist Hans Eysenck introduced behavioral therapy as a constructive alternative to Wolpe's methods.

At the same time that Eiseneck's research was being conducted, B.F. Skinner and his colleagues began developments in the field of operant conditioning. Skinner's method was called radical behaviorism. Julian Rotter in 1954 and Albert Bandura in 1969 contributed to behavior therapy with developments in social learning theory, demonstrating the influence of cognitions on learning and behavior modification. The work of Australian Claire Weeks in the 1960s on anxiety disorders is also considered a prototype for behavioral therapy. The emphasis on behavioral factors defined the "first wave" of CBT.

One of the first therapists to address cognitions in psychotherapy was Alfred Adler. In particular, his notion of basic errors, which contribute to the creation of unhealthy or unhelpful behavioral and life goals, played a major role. Adler's views influenced those of Albert Ellis, who developed the earliest form of cognitive-oriented psychotherapy called rational-emotional therapy (now known as rational-emotional behavioral therapy, or REPT). Ellis also considers Abraham Lowe to be the founder of cognitive-behavioral therapy.

Around the same time that rational-emotional-behavioral therapy was being developed, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck observed that thoughts were not as unconscious as Freud had previously suggested, and that certain types of thinking could lead to emotional distress. Based on this hypothesis, Beck developed cognitive therapy and called such thoughts "automatic thoughts. Beck is considered "the father of cognitive-behavioral therapy.

It was these two types of psychotherapy, rational-emotional therapy and cognitive therapy, that gave rise to the "second wave" of cognitive-behavioral therapy, which emphasized cognitive factors.

Fusion of behavioral and cognitive therapy

Although early behavioral approaches were successful for many neurotic disorders, they proved ineffective in treating depression. Behaviorism also began to lose popularity because of the cognitive revolution. The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behavioral therapists despite the behaviorists' earlier rejection of mentalist concepts such as thought and cognition. Both of these systems included behavioral elements and interventions, with a focus on the patient's problems in the present.

In the original studies, cognitive therapy was often contrasted with behavioral therapies to see which type of treatment was more effective. In the 1980s and 1990s, cognitive and behavioral methods were merged into cognitive-behavioral therapy. Key to this merger was the successful development of treatments for panic disorder by David M. Clarke in the United Kingdom and David H. Barlow in the United States.

Over time, cognitive-behavioral therapy has become known not only as a specific type of psychotherapy, but also as a general term for all types of cognitive-oriented psychotherapy. These modalities include, but are not limited to, rational-emotional-behavioral therapy (REPT), cognitive therapy, acceptance and commitment therapy, dialectical behavioral therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy. All of these treatments are a mixture of cognitive and behavioral elements.

The combination of the theoretical and practical foundations of behavioral and cognitive therapy formed the basis of the "third wave" of CBT. The best known types of therapy in this third wave are dialectical behavioral therapy and acceptance and commitment therapy.

Despite the growing popularity of third-wave treatment approaches, reviews of studies suggest that there may be no difference in effectiveness in treating depression compared to traditional cognitive-behavioral therapy.

Usually cognitive-behavioral therapy assumes that changing maladaptive thinking leads to changes in behavior and affect, but recent modifications emphasize changes in the person's attitude toward maladaptive thinking, rather than changes in thinking itself. The goal of cognitive-behavioral therapy is not to identify a specific disorder in a person, but to look at the person as a whole and draw conclusions as to what can be changed in him or her.

Therapists or computer programs use cognitive behavioral therapy techniques to help people challenge their patterns and beliefs and replace thinking errors known as cognitive distortions, that is, "overgeneralization, exaggeration of negativity, minimization of positivity and catastrophization," with more realistic thoughts, thereby reducing emotional distress and the potential for self-destructive behavior. Cognitive distortions can be either pseudo-discriminatory beliefs or overgeneralization of something. CBT techniques can also be used to help people take a more open and aware stance on cognitive distortions and thus reduce their consequences.

CBT can be conducted in conjunction with various but related techniques such as exposure therapy, stress inoculation, cognitive processing, cognitive therapy, metacognitive therapy, metacognitive training, relaxation training, dialectical behavioral therapy, and acceptance and commitment therapy. Some practitioners promote a form of conscious cognitive therapy that includes a greater emphasis on self-awareness as part of the therapeutic process.

There is evidence that in adults, cognitive behavioral therapy is an effective component of treatment for anxiety disorders, dysmorphobia, depression, eating disorders, chronic low back pain, personality disorders, psychosis, schizophrenia, substance use disorders, and bipolar disorder. CBT is also effective as part of treatment for adjustment, depression and anxiety associated with fibromyalgia, and after spinal cord injuries.

In children and adolescents, CBT is an effective component of treatment for anxiety disorders, body dysmorphic disorder, depression and suicidal tendencies, eating disorders and obesity, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and tic disorder, trichotillomania and other repetitive behavior disorders.

Criticism of cognitive-behavioral therapy sometimes refers to shortcomings in its practical application, i.e. touches on such topics as low-quality therapy conducted by poorly trained practicing psychotherapists. But this does not cancel out the effectiveness of cognitive-behavioral therapy for depression, anxiety disorders and a number of other mental disorders.

Evidence suggests that the use of hypnotherapy as an adjunct to cognitive-behavioral therapy increases the effectiveness of treatment for a variety of clinical problems.

The UK National Institute for Health and Care Excellence (NICE) recommends CBT as a treatment for a number of mental health disorders, including post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa and clinical depression.

There is some evidence that CBT is superior to benzodiazepines and other medications in the treatment of insomnia in the long term. The effectiveness of computerized cognitive behavioral therapy (CCBT) in treating insomnia has been proven by randomized controlled trials and other studies. Some studies have shown similar efficacy for the intervention of informational websites and therapy in the form of weekly phone calls. CBT has been found to be as effective as face-to-face CBT for insomnia.

Many studies show that cognitive behavioral therapy in combination with pharmacotherapy is effective in treating depressive manifestations of bipolar disorder, reduces the severity of mania and improves psychosocial functioning with mild to moderate effects, and that this combination is more effective than psychopharmacotherapy used without psychotherapeutic intervention.

In long-term psychosis, cognitive-behavioral therapy is used as an adjunct to treatment and is easily adapted to the individual needs of patients. Interventions related to these conditions include reality exploration, modification of delusions and hallucinations, exploration of triggers for relapse, and treatment of relapses. Observations confirm the effectiveness of metacognitive training (MCT) in controlling productive psychopathological symptomatology (e.g., delirium).

A 2004 INSERM review found high effectiveness of CBT in treating several types of mental disorders, including schizophrenia.

The Cochrane review reported that CBT "does not affect long-term risk of relapse" and has no additional effect beyond standard treatment. A 2015 systematic review examined the effects of CBT compared to other psychosocial treatments for schizophrenia and found that there were no clear advantages of CBT over other, often less costly, treatments.

Pathological and gaming addiction

CPT is used in the treatment of pathological gambling addiction. The percentage of people with pathological gambling addiction is 1-3%. Cognitive-behavioral therapy develops relapse prevention skills, thanks to it a patient can learn to control himself and cope with situations when the risk of relapse is especially high. There is evidence of the effectiveness of CBT in the treatment of pathological gambling addiction, however whether this method is effective in its long-term treatment is currently not clarified.

CBT views the habit of smoking as an acquired behavior that later becomes a coping strategy for everyday stressors. Because smoking is often readily available and makes the smoker feel good quickly, it often takes precedence over other coping strategies and eventually becomes habitual in a person's daily life even in the absence of stress-inducing events. CBT targets behavioral function, as it can vary from person to person, and allows smoking to be replaced by other coping mechanisms for stress. CBT also helps patients learn how to cope with strong cravings for smoking, which is a major cause of relapse during treatment.

A 2008 controlled study conducted by Stanford University School of Medicine suggested that CBT may be an effective means of abstaining from smoking. The 304 randomly selected adult participants were monitored for one year. During this program, some participants received medication, some underwent cognitive behavioral therapy, some received 24-hour telephone support, and some were treated with a combination of the three. After 20 weeks, participants exposed to CBT had an abstinence rate of 45% compared to participants not exposed to CBT, who had an abstinence rate of 29%. Overall, the study concluded that emphasizing cognitive and behavioral strategies to support smoking cessation can help people develop long-term abstinence habits.

Substance use disorders

Research has shown that cognitive behavioral therapy is an effective treatment for substance use disorders. In these cases, CBT aims to correct maladaptive thoughts with healthier narratives. Specific techniques include identifying potential triggers and developing strategies for coping with high-risk relapse situations. Studies have shown that cognitive behavioral therapy is particularly effective when combined with other psychotherapeutic techniques and medications.

Research characterizes Internet addiction as an emerging clinical disorder causing interpersonal relationship problems, work problems, and social problems. CBT has been proposed as the treatment of choice for Internet addiction.

Although there are many therapies that can provide relief for people with eating disorders, cognitive behavioral therapy has been shown to be more effective than medication and interpersonal psychotherapy. CBT targets the underlying causes of distress, such as patients' negative beliefs about body weight, shape and size. CBT therapists also train patients to regulate strong emotions and thoughts that lead to dangerous compensatory behaviors. CBT is a first-line therapy for bulimia nervosa and nonspecific eating disorder, but the evidence regarding its effectiveness in these two disorders is mixed and limited by the small size of the studies. In particular, a 2004 INSERM review found that CBT is an effective treatment for several psychiatric disorders, including bulimia and anorexia nervosa.

Evidence suggests a possible role for CBT in treating attention deficit hyperactivity disorder (ADHD), hypochondria, and bipolar disorder, but more research is needed and results should be interpreted with caution. CBT may help reduce symptoms of anxiety and depression in people with Alzheimer's disease. CPT has been studied as an adjunctive treatment for anxiety associated with stuttering. Initial studies have shown that cognitive behavioral therapy reduces social anxiety in adults who stutter, but does not reduce the frequency of stuttering.

Cochrane reviews have found no conclusive evidence that cognitive behavioral therapy training helps foster parents cope with problem behaviors in the children and adolescents in their care, and that CBT is useful in treating people who abuse their intimate partners.

CPT is used to treat personality disorders and behavioral problems.

A typical cognitive-behavioral therapy program consists of 6-18 individual sessions of about an hour each, with 1-3 weeks between sessions. This initial program may be followed by several additional sessions, for example, one or three months later. Cognitive behavioral therapy has also been found to be effective when the patient and therapist communicate with each other in real time via an Internet connection.

Mobile apps for self-help or guided cognitive behavioral therapy can also be used. Technology companies are developing applications for mobile chatbots with artificial intelligence that allow the use of CBT to maintain mental health, increase psychological resilience, and enhance emotional well-being.

REPT is a rigidly structured and goal-oriented form of psychotherapy aimed at getting rid of unpleasant thoughts about a particular situation and replacing them with safer and more useful alternatives.

Moral recovery therapy

Moral redress therapy, a type of cognitive-behavioral therapy used to help offenders overcome manifestations of antisocial personality disorder, has been shown to slightly reduce the risk of further offending. Usually implemented in a group format because of the risk that in offenders with antisocial personality disorder, individual therapy may reinforce narcissistic tendencies. Groups usually meet weekly for two to six months.

Position of state agencies and medical organizations regarding CPT

The UK National Health Service announced in 2008 that the number of therapists being trained in CBT at public expense would be increased. NICE said that CBT would be the mainstay of treatment for non-severe depression, and that medication would only be used when success was not achieved.

NICE also recommends offering cognitive behavioral therapy to people with schizophrenia and those who have ever experienced a psychotic episode.