Cognitive behavioral therapy (CBT) is a form of psychotherapy that combines basic principles from cognitive psychology and behaviorism. It aims to reduce symptoms of various mental health conditions by challenging and adjusting convictions and assumptions, while helping patients learn better-adapted behavior by trying and training new behaviours. While CBT has philosophical precursors in Stoicism, it developed in three waves in the 20th century.
The first wave consisted of the development of behaviorism in the 1920s and behavioral therapy in the 1950s and 1960s. The second wave focused on the importance of cognitions in the therapeutic process, resulting in the development of cognitive therapy by psychoanalyst Aaron Beck in the 1950s and the establishment of classical CBT, when cognitive and behavioral approaches were combined. The third wave took place in the 1980s and 1990s, when principles originating from Buddhism, especially mindfulness and acceptance, significantly contributed to the development of various new forms of CBT. Over time, cognitive behavior therapy became an umbrella term for all cognitive-based psychotherapies.
CBT is a "problem-focused" and "action-oriented" form of therapy. The therapist's role is to assist the client in finding and practicing effective cognitive and behavioral strategies to address identified obstacles and alleviate symptoms of the disorder. CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of many psychological disorders. CBT focuses on challenging and changing these cognitive distortions (thoughts, beliefs, and attitudes) and their associated behaviors to improve emotional regulation and help the individual develop coping strategies to address problems.
CBT includes a number of cognitive and behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies. These therapies include, but are not limited to, rational emotive behavior therapy (REBT), cognitive therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, eye movement desensitization and reprocessing (EMDR), and multimodal therapy. New forms of CBT specifically influenced by mindfulness approaches include dialectical behavior therapy, mindfulness-based cognitive therapy, acceptance and commitment therapy, and compassion-focused therapy.
Though originally designed to treat depression, CBT is often prescribed as an evidence-informed treatment for many mental health and medical conditions. These include obsessive–compulsive disorder, generalized anxiety disorder, substance use disorders, marital problems, attention deficit hyperactivity disorder, and eating disorders. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice. It is recommended by the American Psychiatric Association, the American Psychological Association, and the British National Health Service. CBT is also recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder.
Criticism of the therapy has focused on its lack of double-blind tested research, relatively high drop-out rates, and tendency to target symptoms rather than the underlying condition.
History The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the late 1950s to early 1960s, and the subsequent merging of the two.
Philosophical precursors Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers". Another example of Stoic influence on cognitive theorists is the influence of Epictetus on Albert Ellis. A key philosophical figure who influenced the development of CBT was John Stuart Mill through his creation of Associationism, a predecessor of classical conditioning and behavioral theory.
First wave: behavioral therapy
Groundbreaking work in behaviorism began with John B. Watson and Rosalie Rayner's studies of conditioning in 1920. Behaviorally-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones' work dedicated to the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s. It was the work of Wolpe and Watson, which was based on Ivan Pavlov's work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioral therapy techniques based on classical conditioning.
During the 1950s and 1960s, behavioral therapy became widely used by researchers in the United States, the United Kingdom, and South Africa. Their inspiration was by the behaviorist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull.
In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization, applied behavioral research to the treatment of neurotic disorders. Wolpe's therapeutic efforts were precursors to today's fear reduction techniques. British psychologist Hans Eysenck presented behavior therapy as a constructive alternative.
At the same time as Eysenck's work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning. Skinner's work was referred to as radical behaviorism and avoided anything related to cognition. However, Julian Rotter in 1954 and Albert Bandura in 1969 contributed to behavior therapy with their works on social learning theory by demonstrating the effects of cognition on learning and behavior modification. The work of Claire Weekes in dealing with anxiety disorders in the 1960s is also seen as a prototype of behavior therapy.
The emphasis on behavioral factors has been described as the "first wave" of CBT.
Second wave: cognitive therapy and classical CBT One of the first therapists to address cognition in psychotherapy was Alfred Adler, notably with his idea of basic mistakes and how they contributed to creation of unhealthy behavioral and life goals.Abraham Low believed that someone's thoughts were best changed by changing their actions. Adler and Low influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy called rational emotive behavioral therapy, or REBT. The first version of REBT was announced to the public in 1956.
Cognitive therapy was developed by psychoanalyst Aaron Beck in the 1950s. In the late 1950s, Aaron Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorized, and that certain types of thinking may be the culprits of emotional distress. It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts "automatic thoughts". He first published his new methodology in 1967, and his first treatment manual in 1979. Beck has been referred to as "the father of cognitive behavioral therapy".
It was these two therapies, rational emotive therapy, and cognitive therapy, that started the "second wave" of CBT, which emphasized cognitive factors and developed into classical CBT in the 1970s.
Although the early behavioral approaches were successful in many so-called neurotic disorders, they had little success in treating depression. Behaviorism was also losing popularity due to the cognitive revolution. The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behavior therapists, despite the earlier behaviorist rejection of mentalistic concepts like thoughts and cognitions. Both of these systems included behavioral elements and interventions, with the primary focus being on problems in the present.
Third wave: mindfulness-oriented CBT A change of orienting assumptions constituted the "third wave" of CBT, in which the focus shifted from the content of one's cognitions to one's stance toward one's cognitions. Principles originating from Buddhism, especially mindfulness and acceptance, have significantly impacted the evolution of various new forms of CBT, including dialectical behavior therapy, mindfulness-based cognitive therapy, acceptance and commitment therapy, and compassion-focused therapy.
Over time, cognitive behavior therapy came to be known not only as a therapy, but as an umbrella term for all cognitive-based psychotherapies. These therapies include, but are not limited to, REBT, cognitive therapy, acceptance and commitment therapy, dialectical behavior therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy.
Despite the increasing popularity of third-wave treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with non-third wave CBT for the treatment of depression.
Guiding principles Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in behavior and affect, but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself.
Basic assumptions
Cognitive therapy Chaloult, Ngo, Cousineau and Goulet have attempted to identify the main assumptions of cognitive therapy used in CBT based on the research literature (Beck; Walen and Wessler; Beck, Emery and Greenberg, and Auger). They describe fourteen assumptions: Human emotions are primarily caused by people's thoughts and perceptions rather than events. Events, thoughts, emotions, behaviors, and physiological reactions influence each other. Dysfunctional emotions are typically caused by unrealistic thoughts. Reducing dysfunctional emotions requires becoming aware of irrational thoughts and changing them. Human beings have an innate tendency to develop irrational thoughts. This tendency is reinforced by their environment. People are largely responsible for their own dysfunctional emotions, as they maintain and reinforce their own beliefs. Sustained effort is necessary to modify dysfunctional thoughts, emotions, and behaviors. Rational thinking usually causes a decrease in the frequency, intensity, and duration of dysfunctional emotions, rather than an absence of affect or feelings. A positive therapeutic relationship is essential to successful cognitive therapy. Cognitive therapy is based on a teacher-student relationship, where the therapist educates the client. Cognitive therapy uses Socratic questioning to challenge cognitive distortions. Homework is an essential aspect of cognitive therapy. It consolidates the skills learned in therapy. The cognitive approach is active, directed, and structured. Cognitive therapy is generally short. Cognitive therapy is based on predictable steps.
These steps largely involve learning about the CBT model; making links between thoughts, emotions, behaviors, and physiological reactions; noticing when dysfunctional emotions occur; learning to question the thoughts associated with these emotions; replacing irrational thoughts with others more grounded in reality; modifying behaviors based on new interpretations of events; and, in some cases, learning to recognize and change the major beliefs and attitudes underlying cognitive distortions.