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A Cognitive Behavioral Therapy ('''CBT''') is a Psychotherapy based on modifying cognitions, assumptions, beliefs and behaviors, with the aim of influencing disturbed emotions. The general approach developed out of Behavior Modification , Cognitive Therapy and Rational Emotive Behavior Therapy , and has become widely used to treat Neurosis Psychopathology , including Mood Disorders and Anxiety Disorders . The particular therapeutic techniques vary according to the particular kind of client or issue, but commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation and distraction techniques are also commonly included. CBT is widely accepted as an evidence and empirically based, cost-effective psychotherapy for many disorders and psychological problems. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages. THE BASICS An example will illustrate this process. Someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on mood, making the person feel Depressed ; the problem may be worsened if the individual reacts by avoiding activities and then behaviorally confirming his negative belief to himself. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a Self-fulfilling Prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client cognitize and behaves in response to similar situations and by developing more flexible ways to think and respond, including reducing the avoidance of activities. If, as a result, the client escapes the negative thought patterns and destructive behaviors, the feelings of depression may over time be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression. In therapy the objective is often to identify irrational or maladaptive thoughts, assumptions and beliefs that is related to debilitating negative emotions and identify what it is about them that is dysfunctional or just not helpful; this is done in an effort to reject the distorted tendencies and replace them with more realistic and self-helping alternatives. Cognitive Behavioral Therapy is not an overnight process. Even after patients have learned to recognize when and where their mental processes go awry, it can take months of concerted effort to replace any dysfunctional cognitive-affective-behavioral processes or habit with a more reasonable, salutary one. The cognitive model especially empathized in Aaron Becks Cognitive Therapy says that a person's core beliefs (often formed in childhood) contribute to 'automatic thoughts' that pop up in every day life in response to situations. Cognitive Therapy practitioners hold that Clinical Depression is typically associated with negatively biased thinking and Irrational Thoughts . Cognitive Behavioral Therapy is often used in conjunction with Mood Stabilizing medications to treat Bipolar Disorder . Its application in treating Schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS. COGNITIVE BEHAVIORAL THERAPY Concurrently with the pioneering contributions of Ellis and Beck, starting in the late 1950s and continuing through the 1970s, Arnold A. Lazarus developed what was arguably the first form of "Broad-Spectrum" Cognitive-Behavior Therapy. Indeed, in 1958, Arnold Lazarus was the first person to introduce the terms "behavior therapy" and "behavior therapist" into the professional literature. He later broadened the focus of behavioral treatment to incorporate cognitive aspects (e.g., see Arnold Lazarus' 1971 landmark book "Behavior Therapy and Beyond," perhaps the first clinical text on CBT). When it became clear that optimizing therapy's effective and effecting durable treatment outcomes often required transcending more narrow focused cognitive and behavioral methods, Arnold Lazarus expanded the scope of CBT to include physical sensations (as distinct from emotional states), visual images (as distinct from language-based thinking), Interpersonal Relationships , and biological factors. The final product of Arnold Lazarus' approach to psychotherapy is called Multimodal Therapy and is, perhaps, the most comprehensive form of CBT in addition to REBT that also shares much of the same assumptions and theorizing. A sub-field of Cognitive Behavior Therapy used to treat Obsessive Compulsive Disorder makes use of Classical Conditioning through Extinction (a type of conditioning) and Habituation . (The specific technique, Exposure With Response Prevention (ERP) has been demonstrated to be more effective than the use of medication—typically SSRI s—alone). CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder , Health Anxiety , Social Phobia and Panic Disorder . In recent years, CBT has been used to treat symptoms of Schizophrenia , such as Delusions and Hallucinations . This use has been developed in the UK by Douglas Turkington and David Kingdon. CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse. It has been clinically demonstrated in over 400 studies to be effective for many Psychiatric Disorders and medical problems for both children and adolescents. It has been recommended in the UK by the National Institute For Health And Clinical Excellence as a treatment of choice for a number of Mental Health difficulties, including Post-traumatic Stress Disorder , OCD , Bulimia Nervosa and Clinical Depression . Cognitive Behavioral Therapy most closely allies with the Scientist-Practitioner Model Of Clinical Psychology , in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment. DEPRESSION Negative thinking dominates when a person experiences depression. The depressed person can experience negative thoughts as being beyond their control, that can then become automatic and self-perpetuating. Negative thinking can be categorized into a number of common patterns called " Cognitive Distortion s." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called Cognitive Restructuring . Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad." Attributional style An approach to depression based upon theory. In 1989 , this theory was challenged by Hopelessness Theory .Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989. This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions. The ABCs of Irrational Beliefs A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. The first three steps ''analyze'' the process by which a person has developed irrational beliefs and may be recorded in a three-column table.
For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she ''must'' have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.
From the example above, a therapist would help Gina realize that there is no evidence that she ''must'' have good grades to be worthwhile, or that getting bad grades is ''awful''. She desires good grades, and it would be good to have them, but it hardly makes ''her'' worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on. Effectiveness of CBT with or without drugs for depression A large-scale study in 2000Keller, M. et al. ''A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression'' . New England Journal of Medicine Volume 342:1462-1470 May 18, 2000. showed substantially higher results of response and remission when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either method was used alone. The effectiveness of combination therapy is endorsed by the Australian depressioNet group: : The typical short-term success rate for CBT is about 50%. In other words, if 100 people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work. CBT WITH CHILDREN AND ADOLESCENTS The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression, anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder . Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago .
COMPUTERIZED CBT As the name suggests, this is a computerised form of CBT, in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face-to-face with a therapist. Computerised CBT is not a replacement for face-to-face therapy but can provide an option for patients, especially in light of the fact that there are not always therapists available, or the cost can be prohibitive. Computerised CBT is clinically proven and drug-free. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their deepest problems can be off-putting. In this respect, CCBT (especially if delivered online) can be a good option. It has been proven to be effective in Randomised Controlled Trials, and in February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that CCBT should be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for medication (i.e. anti-depressant pills).National Institute for Health and Clinical Excellence. (2006). '' Depression and anxiety - computerised cognitive behavioural therapy .'' A new Government initiative for tackling Mental Health issues has recently been launched by the Care Services Improvement Partnership.[http://www.csip.org.uk/ This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE[http://www.medicine.manchester.ac.uk/staff/LouisAppleby] has confirmed that by 31st March 2007 PCTs should have ST Solutions' "FearFighter" and Ultrasis' "Beating the Blues" CCBT products in place and the NICE Guidelines should be met. NOTABLE BEHAVIORAL THEORISTS NOTABLE CONTRIBUTORS TO MODERN COGNITIVE BEHAVIORAL THERAPY
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