Cognitive Behaviour Therapy (CBT)
CBT is currently seen as being the most effective psychological method of treating depression. Originally devised by Aaron T. Beck it combines primarily the cognitive model with aspects of psychoanalysis and behaviour therapy.
The basic aim of CBT is ‘cognitive restructuring’ designed to bring about ‘lasting changes in target emotions and behaviour’ (Wessler 1986). To this end the therapist and the patient (from here on in referred to as ‘the client’) form a relationship in which the irrational and overly negative beliefs of the client are recognised and challenged by the therapist.
CBT has been widely used by many therapists for many years. During that time it has undergone many revisions with each therapist tailoring the procedure to their own needs. As a result there are many forms of CBT in use. However, they all have various characteristics in common and Beck and Weishaar (1989) suggest the following five common elements:
Patients are taught to:
Making the client aware of the way cognitive and behavioural aspects feed into mood is referred to as the educational phase.
Thought catching (cognitive element)
Considers the link between irrational thinking and low mood. Typically the therapist will set homework in which the client is set clear and achievable goals such as talking to a member of the opposite sex or a stranger or perhaps recognising their automatic thoughts and challenging these. Homework extends the therapy into everyday life. However, the therapist needs to be certain that the homework set is realistic. Setting a task that cannot be achieved is likely to reinforce the client’s negative thinking still further.
Behavioural activation (behaviourist element)
The client is encouraged to take part in enjoyable activities. It is common for patients with depression to cut themselves off and stop socialising. Here the therapist encourages the client to get out and engage in activities that they enjoyed before the depression. For example, play sports, go to the cinema, socialise with friends..
Exercise is seen as being particularly beneficial:
Babyak et al (2006) randomly allocated 156 depressed patients into one of three groups:
After the four months all showed significant improvement. Six months later when the patients were revisited the groups taking exercise had a significantly lower level of relapse.
With CBT there are usually about 20 sessions followed by ‘boosters’ in the first year to help prevent relapse.
Does CBT work?
An early study by Rush et al (1977) showed CBT to be more effective in reducing low mood than the drug imimprimine (a tricyclic). However, in this particular study the most striking feature was the lack of success of the drug!
Elkin (1994) made a similar comparison and found that both CBT and imiprimine resulted in ‘almost complete removal’ of depressed symptoms in 55% of patients. Both were significantly better than placebo, but the drug did work faster.
Hollon et al (2005)
This will sound familiar because we’ve looked at it as evidence for the effectiveness of drugs, but here it is again. Depressed patients were treated for 16 weeks. They received either:
An SSRI (paroxetine) or Cognitive therapy
Similar numbers of each group (about 60%) showed considerable improvement. These successes were then followed up for a further 12 months. They were broken down as follows:
CBT is currently seen as being the most effective psychological method of treating depression. Originally devised by Aaron T. Beck it combines primarily the cognitive model with aspects of psychoanalysis and behaviour therapy.
The basic aim of CBT is ‘cognitive restructuring’ designed to bring about ‘lasting changes in target emotions and behaviour’ (Wessler 1986). To this end the therapist and the patient (from here on in referred to as ‘the client’) form a relationship in which the irrational and overly negative beliefs of the client are recognised and challenged by the therapist.
CBT has been widely used by many therapists for many years. During that time it has undergone many revisions with each therapist tailoring the procedure to their own needs. As a result there are many forms of CBT in use. However, they all have various characteristics in common and Beck and Weishaar (1989) suggest the following five common elements:
Patients are taught to:
- Monitor their negative and automatic cognitions
- Recognise the link between cognitions, affect (mood) and behaviour
- Consider evidence for and against these automatic thoughts
- Replace biased thoughts with more realistic ones
- Learn to identify and then change the beliefs that predispose the client to distorted thinking.
Making the client aware of the way cognitive and behavioural aspects feed into mood is referred to as the educational phase.
Thought catching (cognitive element)
Considers the link between irrational thinking and low mood. Typically the therapist will set homework in which the client is set clear and achievable goals such as talking to a member of the opposite sex or a stranger or perhaps recognising their automatic thoughts and challenging these. Homework extends the therapy into everyday life. However, the therapist needs to be certain that the homework set is realistic. Setting a task that cannot be achieved is likely to reinforce the client’s negative thinking still further.
Behavioural activation (behaviourist element)
The client is encouraged to take part in enjoyable activities. It is common for patients with depression to cut themselves off and stop socialising. Here the therapist encourages the client to get out and engage in activities that they enjoyed before the depression. For example, play sports, go to the cinema, socialise with friends..
Exercise is seen as being particularly beneficial:
Babyak et al (2006) randomly allocated 156 depressed patients into one of three groups:
- Four months of aerobic exercise
- Drug treatment
- Combination of exercise and drug treatment
After the four months all showed significant improvement. Six months later when the patients were revisited the groups taking exercise had a significantly lower level of relapse.
With CBT there are usually about 20 sessions followed by ‘boosters’ in the first year to help prevent relapse.
Does CBT work?
An early study by Rush et al (1977) showed CBT to be more effective in reducing low mood than the drug imimprimine (a tricyclic). However, in this particular study the most striking feature was the lack of success of the drug!
Elkin (1994) made a similar comparison and found that both CBT and imiprimine resulted in ‘almost complete removal’ of depressed symptoms in 55% of patients. Both were significantly better than placebo, but the drug did work faster.
Hollon et al (2005)
This will sound familiar because we’ve looked at it as evidence for the effectiveness of drugs, but here it is again. Depressed patients were treated for 16 weeks. They received either:
An SSRI (paroxetine) or Cognitive therapy
Similar numbers of each group (about 60%) showed considerable improvement. These successes were then followed up for a further 12 months. They were broken down as follows:
|
Initial 16 weeks
Cognitive Therapy Drug Therapy (SSRI) Drug Therapy |
Continuation Period
No treatment No treatment Drug therapy |
Relapse Rate
31% 76% 47% |
What this tells us
When CBT was stopped and no further treatment was received, relatively few suffered relapse into depression. This suggests that cognitive therapy has dealt with the cause of the depression.
When drug therapy is given and maintained relapse rate is relatively low (though not as low as therapy) which suggests the drugs are working provided they are maintained.
The most telling figure however, is the 76% that relapse when the drugs are withdrawn. This confirms that drugs are fine until medication stops. During the prescribed period the drugs are reducing the symptoms but not dealing with the causes. If they were then the patient would be fine when medication stopped. In fact three quarters of patients become depressed again. Drugs appear to be palliative. This suggests that CBT is to be preferred to drugs.
Further evidence for the curative nature of CBT was produced by Segal et al (2005). Groups of patients were treated with either CBT or drugs. As with the Hollon study, both were similarly successful.
Later the recovered patients were ‘made to feel sad.’* Those who had been treated with drugs returned to their negative and dysfunctional thinking (evidence for palliative) whereas those who had received CBT remained more positive and rational (evidence for curative).
*Was intrigued as to how they did this… here’s the answer: ”Patients listened through headphones to a piece of music presented on a CD player while following instructions to recall a time in their lives when they felt sad. The piece of music was “Russia under the Mongolian Yoke,” composed by Sergei Prokofiev. This piece was re-mastered at half speed and runs for approximately 8 min. This piece, played at half speed, has been shown to be very effective in inducing a negative or depressed mood.”
Appropriateness of CBT
On the face of it, it seems to be the most appropriate given that so many symptoms of depression are cognitive in nature. It is also worth mentioning that CBT also tackles the behavioural components such as seeking to encourage greater contact and interactions with others and seeking more pleasurable activities.
CBT might not be suitable for everyone. It does require a certain level of intelligence and an ability to be introspective as well as to be able to communicate your thoughts adequately.
Note: a lot is made in the literature about the competence of the therapist in ensuring a positive outcome. However, there have been recent and successful attempts to produce more automated forms of CBT that can be delivered online. This would seem to negate the need for a therapist at all!
One of the biggest issues with CBT is the cost, particularly in the UK where health care is delivered by the NHS at the taxpayer’s expense. Whitfield and Williams (2003) found evidence that the NHS was struggling to provide CBT on a weekly basis to the many patients that would clearly benefit from the procedure.
|
Recently there have been attempts to train other health care workers in the basics of CBT so it can be administered more widely. One such initiative is SPIRIT (Structured Psychosocial InteRvention In Teams). Their acronym not mine!
This is a training programme designed to run for just under 40 hours together with 5 hours of clinical supervision in the administering of the therapy. Medical professionals are taught how to build relationships with their clients and how to use Beck’s techniques to alter distorted thinking. This does illustrate however, how popular the therapy has become. The initiative, running in Glasgow, is still in its early days. |
Rational Emotive (Behaviour) Therapy
Albert Ellis developed RET, later to become REBT in the 1950s based upon cognitive behavioural principles and ideas. Basically it assumes, as all such therapies do, that irrational and faulty thinking leads to self-defeating and maladaptive behaviours. REBT enables the client to understand in what way their thoughts are irrational and encourages them to replace such ideas with healthier and more realistic thoughts.
Easy as ABC
Activating Event leads to Irrational Beliefs that causes Consequences
With depression:
Activating event (failing a test) leads to overly negative beliefs about failing everything which results in negative emotions
Ellis suggests a 'D' for his A,B,C... DISPUTING, or questioning the A, B, C at the root of the depression.
The therapy suggests the following:
Words you often see associated with this approach are ‘catastrophizing’ and the truly awful ‘awfulizing.’ Very American but quite descriptive of the mental states involved. Always expecting the very worst. Another word you sometimes see is ‘mustabation’ since irrational thinkers can put too much pressure on themselves and forever be thinking I must... succeed etc.
Other forms of CBT
Beck’s homework
Aaron Beck was one of the first to adopt a form of CBT back in the 1970s. He would set his clients the homework of behaving in a way that they found difficult or uncomfortable. For example a person suffering from social phobia would be told to go to work and during the week approach each co-worker and hold a conversation with them.
Before doing this they’re asked to make a prediction (hypothesis) about how well it will go and then go out and put this hypothesis to the test and hopefully disprove it.
Exposure therapy
Like exposure therapy discussed in the behaviourist section this gets the patient to face up to their fears by tackling safe-seeking behaviour. This is the tendency for people with a phobia for example to avoid the fear provoking situation. Unlike with the behaviourist approach it encourages the patient to produce and then test and hopefully disprove a hypothesis about their situation and thinking. For example a social phobe will be told to give a public talk (ie avoid safe-seeking behaviour). This should act as an ‘effective disconfirmation of negative views’ which is a nice phrase if you can fit it into an essay!
Evaluation of CBT
Evidence
Butler et al (2006) in a huge study collated the results from 16 meta-analyses (a meta-meta analysis if you like) which covered the results from over 10,000 patients. It found that CBT was effective in treating:
They also found that CBT was effective in treating schizophrenia when used in conjunction with antipsychotic drugs.
CBT is a combination of treatments from both behaviourist and cognitive psychology and is seen as offering a more effective treatment than either approach in isolation. Similarly since it combines decades of mostly scientific research into two different approaches to psychology it is very securely grounded and well respected.
However
As we’ve already seen CBT is most effective in treating a certain category of disorder, particularly those involving anxiety and low mood. To date it as proved less effective in treating psychotic disorders such as schizophrenia although recently Butler et al (2006) have reported some successes (see notes above).
Some have argued that CBT over emphasises the importance of cognitive processes. Perhaps for example people’s negative emotions are not maladaptive but simply realistic interpretations of their situation.
As with all treatments based on the approaches it is reductionist. It concentrates on behaviour interpretation of environment and maladaptive thinking but does not consider biological issues such as genetics or brain chemistry which have been shown to play a crucial role in some forms of psychopathology.
Albert Ellis developed RET, later to become REBT in the 1950s based upon cognitive behavioural principles and ideas. Basically it assumes, as all such therapies do, that irrational and faulty thinking leads to self-defeating and maladaptive behaviours. REBT enables the client to understand in what way their thoughts are irrational and encourages them to replace such ideas with healthier and more realistic thoughts.
Easy as ABC
Activating Event leads to Irrational Beliefs that causes Consequences
With depression:
Activating event (failing a test) leads to overly negative beliefs about failing everything which results in negative emotions
Ellis suggests a 'D' for his A,B,C... DISPUTING, or questioning the A, B, C at the root of the depression.
The therapy suggests the following:
- Logical Disputing: the client is asked to question the basis for their illogical ideas; do they really make sense?
- Empirical Disputing: how do their ideas match with the evidence; what empirical proof is there that their ideas are right? Can a spider really be that harmful?
- Pragmatic Disputing: emphasises how damaging these ideas are to the person. In what way is a fear of spiders useful? Consider the harm it’s doing to my gardening hobby J
Words you often see associated with this approach are ‘catastrophizing’ and the truly awful ‘awfulizing.’ Very American but quite descriptive of the mental states involved. Always expecting the very worst. Another word you sometimes see is ‘mustabation’ since irrational thinkers can put too much pressure on themselves and forever be thinking I must... succeed etc.
Other forms of CBT
Beck’s homework
Aaron Beck was one of the first to adopt a form of CBT back in the 1970s. He would set his clients the homework of behaving in a way that they found difficult or uncomfortable. For example a person suffering from social phobia would be told to go to work and during the week approach each co-worker and hold a conversation with them.
Before doing this they’re asked to make a prediction (hypothesis) about how well it will go and then go out and put this hypothesis to the test and hopefully disprove it.
Exposure therapy
Like exposure therapy discussed in the behaviourist section this gets the patient to face up to their fears by tackling safe-seeking behaviour. This is the tendency for people with a phobia for example to avoid the fear provoking situation. Unlike with the behaviourist approach it encourages the patient to produce and then test and hopefully disprove a hypothesis about their situation and thinking. For example a social phobe will be told to give a public talk (ie avoid safe-seeking behaviour). This should act as an ‘effective disconfirmation of negative views’ which is a nice phrase if you can fit it into an essay!
Evaluation of CBT
Evidence
Butler et al (2006) in a huge study collated the results from 16 meta-analyses (a meta-meta analysis if you like) which covered the results from over 10,000 patients. It found that CBT was effective in treating:
They also found that CBT was effective in treating schizophrenia when used in conjunction with antipsychotic drugs.
CBT is a combination of treatments from both behaviourist and cognitive psychology and is seen as offering a more effective treatment than either approach in isolation. Similarly since it combines decades of mostly scientific research into two different approaches to psychology it is very securely grounded and well respected.
However
As we’ve already seen CBT is most effective in treating a certain category of disorder, particularly those involving anxiety and low mood. To date it as proved less effective in treating psychotic disorders such as schizophrenia although recently Butler et al (2006) have reported some successes (see notes above).
Some have argued that CBT over emphasises the importance of cognitive processes. Perhaps for example people’s negative emotions are not maladaptive but simply realistic interpretations of their situation.
As with all treatments based on the approaches it is reductionist. It concentrates on behaviour interpretation of environment and maladaptive thinking but does not consider biological issues such as genetics or brain chemistry which have been shown to play a crucial role in some forms of psychopathology.