Cognitive Behavioral Therapy

1. Introduction to CBT

Cognitive Behavioral Therapy (CBT) is a branch of psychotherapy which aims to improve

the health of its patients (Beck, 2011) by helping them to regulate their emotions (Benjamin
et al., 2001) The practice has been called as a ‘psycho-social intervention’ (Beck, 2011), as it
operates by making patients focus on obstructive cognitive distortions (negative habits,
beliefs, attitudes and thinking patterns) (Benjamin et al., 2001). CBT therapy helps patients
who are going through a mentally challenging time develop coping mechanisms. Originally
developed to combat depression, CBT has since evolved and developed overtime to treat a
number of different diagnosed psychopathologies and psychological conditions (Mckay D. et
al., 2015). CBT is now a well-recognized medical practice that is a mandatory part of training
and curriculum for for psychiatry residents in the US (Lambert, 2013). It utilizes ‘evidence
based techniques’ to treat a number of different diagnosed psychopathologies using many
different types of cognitive and behavioral psychotherapies. (Hofmann, et al., 2013)

What is different about CBT is that, whereas historically, psychotherapy has leaned more
towards a psychoanalytical approach where psychological analyses behaviors to look for
subconscious explanations behind them for formulating a diagnosis, CBT takes a radically
different more conscious approach. It is highly action oriented and problem focused to
developing effective strategies for managing and reducing symptoms of already diagnosed
psychological disorders (Schacter, et al., 2010)

Psychoactive medications that are prescribed to treat psychological illnesses in a clinical

manner operate with a similar goal as CBT – the reduction of symptoms in the patient,
however, they often introduce a host of side effects and complications in patients, especially
when multiple different drugs are being taken (Hilt et al., 2014). Comparatively CBT is a lot
safer, and recent studies show that when properly administered, CBT have been found to be
as effective as medication in treating several psychological disorders such as substance abuse
and personality disorders

2. The development of CBT

Historical influence of CBT has been traced all the way back to the teachings of the ancient
philosophy of stoicism (Beck, et al., 1979). The problem based approach of CBT is
influenced by the belief of stoicism that psychological illness and beliefs that lead to
destructive emotions and thinking can be mitigated by logical thinking and dialectics
(Mathews, 2015).

Behavioral therapy, which is the study of how the environment interacts with the mental
states of a person to affect a person’s behavior (O’Leary, et al, 1975) forms the roots of
modern CBT practice. The origins of behavioral therapy began in the early 1920s with the
studies of John B. Watson and Rosalie Rayner on mental conditioning, which later went on to
influence Joseph Wolfe’s work in 1950s on desensitization which is the major influence of
the fear reduction techniques used in CBT today (Rachman, 1997). Other notable
contributions. Other notable influences include Hans Eysenck and Arnold Lazarus’s work on
classic condition, B.F. Skinner’s work on operant condition, Julian Rotter and Albert
Bandura’s work on social learning theory (Corsini & Wedding, 2008).

Cognitive theory is the second major contributor to CBT. It is based on the theory that the
person’s reaction to an event dictates their emotional state. One of the earliest works is Alfred
Alder’s seminal theory of how ‘basic mistakes’ results in the developing of major unhealthy
behaviors that affect life goals, that went to be a major influence for the work of Albert Ellis
(Mosak & Maniacci, 2008) which in modern times been developed in the rational emotive
behavioral therapy (REBT).

Undoubtedly the greatest influence behind the development of cognitive therapy is work of
renowned psychologist Dr. Aaron T. Beck – called the Father of cognitive behavioral therapy
(Folsom, et al., 2016). Before he was so, a major part of Dr. Beck’s psychoanalytic practice
involved Freudian methodologies, such as free association sessions developed by Sigmond
Freud where patient is let to express anything and everything without any censorship, filters
or judgment (Lothane, 2018). While conducting these sessions Dr. Beck noticed, that the act
of thinking, and thoughts themselves, are not as much of a product of the unconscious as
Freud theorized them to be; further that some specific kinds of thoughts contribute the most
towards developing a psychological disorder. It was on the base of this observation that Dr.
Beck developed cognitive therapy. The interaction between REBT and cognitive therapy
started what is known as the second wave of CBT (Wilson, 2008).

The third wave of CBT – which resulted in the formation of modern CBT as we know it
today, resulted from the blending of behavioral and cognitive therapy (Hayes & Hofmann,
2017). Even though “mentalist” concepts like thoughts and cognition was in fact rejected by
early behaviorists, cognitive therapy methodologies gained popularity with behaviorists
because behavioral therapy did not have much success in treating disorders like depression
(Trull, 2007). Gradually CBT became an umbrella term under which was developed many
different types of therapies such as cognitive processing therapy, choice theory, EMDR,
acceptance and commitment therapy and multimodal therapy (Trull, 2007).

3. Principles and concepts of CBT

The basic principles and assumptions under which CBT operates are as follows -

 Symptoms arising from psychological disorders can be managed through developing

new coping mechanisms and information processing abilities in patients (Schacter et
al., 2010).
 Behavioral interventions are highly effective in developing social and coping skills
amongst patients (Wright et al., 2006).
 Making a person confirm an unpleasant situation such as exposure therapy can lead to
desensitization which can lead to developing coping mechanisms and reducing phobia
(Wright, 2006).
 CBT is administered in a structured manner, to go to the root of the problem and
prevent relapse (Beck, 2006).

Dr. Beck and his colleagues distinguished between three levels of cognition (Wright, 2006).
The first level – full consciousness, is when all rational decisions are undertaken in full
awareness. The second level – automatic thoughts, are more autonomous and private that
occur in the head of the patient in a constant stream; in patients with major psychological
disorders such as depression or extreme anxiety automatic thoughts are filled with errors and
logical fallacies, and center around themes of low elf-esteem negativity and ineffectiveness
(Wright et al, 2003).. The third and deepest level of cognition, and also the most autonomous
are schemas, which are subconscious fundamental rules that govern out thought processes
and way of thinking, formed by upbringing and life experiences (Wright et al, 2003).

Cognitive distortions’ or “exaggerated or irrational thought pattern”(Helmond et al., 2015)

such as such as overreacting, magnifying the negatives, diminishing positives, and
catastrophizing, Hasset & Gevirtz, 2009) for e.g. wanting to commit suicide after failing a
test due, and ‘maladaptive behaviors’, i.e. negative habits and behaviors developed from
childhood or resulting in the aftermath of a traumatic event prevent a person from adapting
and evolving play a major role in the development and persistence of psychological disorders
(Field et al, 2015). The primary goal of CBT is to gradually phase out cognitive distortions
and maladaptive behaviors replace them with more effective and realistic thought processes
to minimize emotional distress and self-sabotaging behavior (Hasset & Gevirtz, 2009)

4. Anatomy of a CBT session

CBT is meant to be administered in a very systematic and structure manner over a period of
time, usually 8-10 weeks. Each session of CBT has to be planned in advance by the therapist,
the specifics of which will actually depend on the kind of therapy being conducted and the
nature of the illness. Broadly, a CBT session consists of the following steps and phases –

 Before the CBT sessions begin, a therapist should perform a diagnostic interview with the
patient, which is a friendly chat to build rapport with the patient, and also inform him
about cognitive models, what CBT is and how it is administered, setting broad but
specific end goals and also enquiring about the expectations of the patient from the
sessions. This is called the assessment period (Wexbrook, 2011).
 The beginning of every session should consist of a general mood check to gangue the
intensity of symptoms at that time, and whether they appear to have bettered or worsened
since the last session. If the patient has been prescribed medication, it should be enquired
as to whether they are experiencing any side effects or whether the medicine is working
correctly (Wexbrook, 2011).
 The next step is to set the agenda for the session. It can be initiated by discussing the
problems at hand and being aware of specific indicators, such as how the patient actually
feels when describing the stressor, that types of thoughts are evoked, and the degree of
irrationality of those thoughts (Wexbrook, 2011).
 The penultimate step is to discuss a review of the session with the patient. A therapist
should encourage a patient to ask question as it gives them confident and makes them feel
that they are in control (Wexbrook, 2011).
 A session should end by assigning homework which helps to keep the patient on the right
track and not fall back on their maladaptive behaviors when they are not under the direct
supervision of the therapist and also provides the therapist a measure to gauge progress.
(Wexbrook, 2011).
5. An overview of techniques utilized in CBT

Early CBT worked on the principle of reducing maladaptive thinking to effect a change in a
person’s behavior however modern CBT theory is more nuanced and instead recognizes that
eliminating maladaptive thinking as the first step itself might be difficult, so instead the focus
is now more on changing a person’s relationship and reaction to maladaptive thinking to cope
with adverse effects (Hayes, et al., 2011). As the name suggests CBT is an amalgamation of
cognitive and behavioral techniques.

A primary concept of the cognitive side of CBT is the concept of guided discovery derived
from Socratic questioning which requires the therapist to under the patient’s perspective and
then help them become aware their thinking patterns and underlying assumption, to effect
long term change by themselves (Padesky, 1993). The therapist should pose questions to the
patient such as “what do you think causes this?” or “why is this important to you” to set them
on a path to guided self-discovery. Patients can also be asked to keep a positive data log to
manage maladaptive practices and form a new more adaptive (positive) schema (Padesky,
1994), or fill out a seven column thought record (Greenberger and Padesky, 1995).

Behavioral techniques aim to help the patient by regulating his day to day behavior to form
positive habits. Activity scheduling for patients, reduces the requirement of decision making
by the patients, and helps them constantly engage in effective behaviors. This type of therapy
can prove to be very fruitful for people afflicted with anxiety (Fenn & Byrne, 2013). It can
also help patients be aware of the urges to indulging in ‘safety behaviors’ (Salkovskis, 1996)
or escapist tendencies.

6. Who can benefit the most out of CBT?

A comparative study of 269 meta-analyses of CBT use across different patient populations
with a variety of the psychological disorders was conducted by Hofmann, et al. (2012) to find
out areas where CBT is most effective.

Referring to Hoffman’s study, for addiction related disorders such as nicrotine (Song, et al.,
2010), marijuana CBT was found to be very effective when performed over multiple sessions
with a low drop-out rate (Dutra et al., 2008). However for harder drugs like opiods and even
alcohol, CBT was not found to be the most effective. (Powers, et al., 2008). CBT was also
found to be effective to reduce gambling (Oakley-Browne et al., 2000).

For psychotic disorders such as schizophrenia CBT was found to be effective for chronic
patients (Gould et al., 2001) in reducing hallucinogenic symptoms and in combination with
pharmaceutical drugs for acute patients. (e.g., Zimmerman et al., 2005). CBT was found to be
the highly effective for depression (van Straten, et al., 2010), insomnia (Okajima, Komada, &
Inoue, 2011), and as a first line response in anxiety disorders (Hofmann & Smits, 2008). It
was found moderately effective in reducing bipolar disorder (Gregory, 2010a), anger and
aggression (Del Vecchio & O’Leary, 2004), criminal behaviors (Lösel & Schmucker, 2005).

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