Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a psycho-social intervention[1][2] that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders.[3] Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions (such as thoughts, beliefs, and attitudes) and their associated behaviors to improve emotional regulation[2][4] and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety,[5][6] substance use disorders, marital problems, ADHD, and eating disorders.[7][8][9][10] CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.[11][12][13]
This article is about therapy to improve mental health. For the journal, see Cognitive Behaviour Therapy (journal). For other uses of the acronym 'CBT', see CBT.Cognitive behavioral therapy
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CBT is a common form of talk therapy based on the combination of the basic principles from behavioral and cognitive psychology.[2] It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and to alleviate symptoms of the disorder.[14] CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of many psychological disorders[3] and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.[1][14][15]
When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression,[16] anxiety, post-traumatic stress disorder (PTSD), tics,[17] substance use disorders, eating disorders, and borderline personality disorder.[18] Some research suggests that CBT is most effective when combined with medication for treating mental disorders, such as major depressive disorder.[19] CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder.[1][4] Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults.[20][21] Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice.[1][22]
History[edit]
Early roots[edit]
The prevailing body of research consistently indicates that maintaining a faith or belief system generally contributes positively to mental well-being.[23] Religious institutions have proactively established charities, such as the Samaritans, to address mental health issues.[24] Cognitive behavioral therapy has undergone scrutiny as studies investigating the impact of religious belief and practices have gained prominence. Numerous randomized controlled trials have explored the correlation of CBT within diverse religious frameworks, including Judaism,[25] Taoism,[26] and predominantly, Christianity.[27][28][29][30]
Buddhism[edit]
Principles originating from Buddhism have significantly impacted the evolution of various new forms of CBT, including dialectical behavior therapy, mindfulness-based cognitive therapy, spirituality-based CBT, and compassion-focused therapy.[31]
Philosophy[edit]
Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism.[32] Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioral therapists identify cognitive distortions that contribute to depression and anxiety. Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers".[33] Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis.[34] 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.[35][36]
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 1960s, and the subsequent merging of the two.
Methods of access[edit]
Therapist[edit]
A typical CBT program would consist of face-to-face sessions between patient and therapist, made up of 6–18 sessions of around an hour each with a gap of 1–3 weeks between sessions. This initial program might be followed by some booster sessions, for instance after one month and three months.[200] CBT has also been found to be effective if patient and therapist type in real time to each other over computer links.[201][202]
Cognitive-behavioral therapy is most closely allied with the scientist–practitioner model in which clinical practice and research are informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and the attainment of goals. These are often met through "homework" assignments in which the patient and the therapist work together to craft an assignment to complete before the next session.[203] The completion of these assignments – which can be as simple as a person with depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change.[203] The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment.[203] Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance.[2][204] Unlike many other forms of psychotherapy, the patient is very involved in CBT.[203] For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first.[203] The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.[203]
Computerized or Internet-delivered (CCBT)[edit]
Computerized cognitive behavioral therapy (CCBT) has been described by NICE as a "generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system",[205] instead of face-to-face with a human therapist. It is also known as internet-delivered cognitive behavioral therapy or ICBT.[206] CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist.[207][208] In this context, it is important not to confuse CBT with 'computer-based training', which nowadays is more commonly referred to as e-Learning.
Although improvements in both research quality and treatment adherence is required before advocating for the global dissemination of CCBT,[209] it has been found in meta-studies to be cost-effective and often cheaper than usual care,[210][211] including for anxiety[212] and PTSD.[213][214] Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods.[215] A study assessing an online version of CBT for people with mild-to-moderate PTSD found that the online approach was as effective as, and cheaper than, the same therapy given face-to-face.[213][214] A review of current CCBT research in the treatment of OCD in children found this interface to hold great potential for future treatment of OCD in youths and adolescent populations.[216] Additionally, most internet interventions for post-traumatic stress disorder use CCBT. CCBT is also predisposed to treating mood disorders amongst non-heterosexual populations, who may avoid face-to-face therapy from fear of stigma. However presently CCBT programs seldom cater to these populations.[217]
In February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication,[205] and CCBT is made available by some health systems.[218] The 2009 NICE guideline recognized that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product.[219]
Smartphone app-delivered[edit]
Another new method of access is the use of mobile app or smartphone applications to deliver self-help or guided CBT. Technology companies are developing mobile-based artificial intelligence chatbot applications in delivering CBT as an early intervention to support mental health, to build psychological resilience, and to promote emotional well-being. Artificial intelligence (AI) text-based conversational application delivered securely and privately over smartphone devices have the ability to scale globally and offer contextual and always-available support. Active research is underway including real-world data studies[220] that measure effectiveness and engagement of text-based smartphone chatbot apps for delivery of CBT using a text-based conversational interface. Recent market research and analysis of over 500 online mental healthcare solutions identified 3 key challenges in this market: quality of the content, guidance of the user and personalisation.[221]
A study compared CBT alone with a mindfulness-based therapy combined with CBT, both delivered via an app. It found that mindfulness-based self-help reduced the severity of depression more than CBT self-help in the short-term. Overall, NHS costs for the mindfulness approach were £500 less per person than for CBT.[222][223]
Reading self-help materials[edit]
Enabling patients to read self-help CBT guides has been shown to be effective by some studies.[224][225][226] However one study found a negative effect in patients who tended to ruminate,[227] and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional).[228]
Types[edit]
Brief cognitive behavioral therapy[edit]
Brief cognitive behavioral therapy (BCBT) is a form of CBT which has been developed for situations in which there are time constraints on the therapy sessions and specifically for those struggling with suicidal ideation and/or making suicide attempts.[230] BCBT was based on Rudd's proposed "suicidal mode", an elaboration of Beck's modal theory.[231][232] BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed with soldiers on active duty by Dr. M. David Rudd to prevent suicide.[230]
Breakdown of treatment[230]
Society and culture[edit]
The UK's National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense[266] as part of an initiative called Improving Access to Psychological Therapies (IAPT).[267] The NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed.[266] Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes "a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money ... Everyone has been seduced by CBT's apparent cheapness."[266][268]
The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT's policies were undermining traditional psychotherapy and criticized proposals that would limit some approved therapies to CBT,[269] claiming that they restricted patients to "a watered-down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff".[269]
