Defining the Cognitive-Behavioral Approach

Cognitive therapy (CT) and cognitive-behavioral therapy (CBT) are closely related; however CBT is an umbrella category of therapies that includes cognitive therapy. CBT is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors, and cognitive processes through a number of goal-oriented, systematic procedures. The category refers to behavior therapy, cognitive therapy, and therapies based on a combination of basic behavioral and cognitive principles and research, including dialectical behavior therapy.

Basic tenets of CBT

The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs relate to themselves, others, or the future. Centered around that is a feedback loop between behavior, thoughts, and feelings, all of which are the target of CBT. 

Cognitive Therapy

Cognitive therapy seeks to help the client overcome difficulties by identifying and changing dysfunctional thinking and behavior, as well as emotional responses. This involves helping patients to develop skills for modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. Treatment is based on collaboration between the patient and therapist and on testing beliefs.

At the core of cognitive therapy is the idea of cognitive biases, or irrational beliefs that cause distress in a person's life. Some examples include:

• Over-generalization: drawing general conclusions from a single (usually negative) event, such as thinking that making a single bad grade makes you a failure of a student.
• Minimization and magnification: either grossly underestimating one's own positive performance or overestimating the importance of a negative event.
• Selective abstraction: occurs when a detail is taken out of context and believed while everything else in the context is ignored.

Cognitive biases

Cognitive biases are maladaptive patterns of judgment, whereby inferences about other people and situations may be drawn in an illogical fashion. The example in this image depicts a common cognitive bias known as black-and-white thinking, in which someone may think in terms of false dichotomies of always/never or right/wrong with no room for grey areas in between.

These irrational beliefs take the form of automatic thoughts; cognitive therapy believes that patients suffering from mental illness can be helped if therapists challenge these irrational beliefs. In this way, cognitive therapy encourages people to see that some of their thoughts are mistaken. It has been found that by adjusting these thoughts people's emotional distress can be reduced.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) works to solve current problems and change unhelpful thinking and behavior. The basic tenet of CBT is that emotions (both adaptive and maladaptive) occur because of our interpretation of an event, not because of the event itself. At its most basic level, it is a combination of cognitive therapy and behavioral therapy. While rooted in rather different theories, these two therapy types have been characterized by a constant reference to experimental research to test hypotheses. Common features of CBT procedures are a focus on the here and now, a directive or guidance role of the therapist, structured psychotherapy sessions, and alleviating patients' symptoms as well as vulnerabilities.

CBT is one of the most widely researched and most effective treatments for depression, anxiety disorders, eating disorders, and substance abuse disorders. When someone is distressed or anxious, the way they see and evaluate themselves can become negative. CBT therapists and clients work together to see the link between negative thoughts and mood. This empowers people to assert control over negative emotions and to change the way they behave. CBT assumes that changing maladaptive thinking leads to change in affect and behavior. Therapists help individuals to challenge maladaptive thinking and help them replace it with more realistic and effective thoughts, or encourage them to take a more open, mindful, and aware posture toward those thoughts.

Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT), which is discussed in more detail below. 

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a form of psychotherapy that was originally developed to treat people with borderline personality disorder (BPD). DBT involves a combination of standard cognitive-behavioral techniques (e.g., reframing, emotion regulation testing) with acceptance approaches (e.g., distress tolerance,  mindful awareness).

DBT research suggests that maladaptive behaviors (such as self-harm or attention-seeking) function to regulate negative emotions in individuals who lack emotion-regulation skills. Thus, from a DBT perspective, the behaviors that are considered maladaptive in BPD, in people with eating disorders, and in sexual abuse survivors, are negatively reinforced, as they function to regulate emotions and decrease feelings of distress. Consequently, helping clients to develop more adaptive strategies to cope with their emotions should help patients improve their maladaptive behaviors.

DBT includes learning a number of strategies that are directly focused on increasing patients' skills to adaptively cope with strong urges and emotions. These strategies include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

History of Cognitive-Behavioral Therapy

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. Groundbreaking work of behavioralism began with Watson's and Rayner's studies of conditioning in 1920. Behavioral-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones's work on the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s. During the 1950s and 1960s, behavioral therapy became widely utilized by researchers in the United States, the United Kingdom, and South Africa, who were inspired by the behaviorist learning theories of Ivan Pavlov, John B. Watson, and Clark L. Hull.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979). One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US. Over time, cognitive-behavioral therapy came to be known not only as a therapy, but as an umbrella category for all cognitive-based psychotherapies.

DBT is a modified form of cognitive-behavioral therapy that was originally developed in the late 20th century by psychology researcher Marsha Linehan to treat people who are chronically suicidal and those with borderline personality disorder (BPD).

Efficacy of Cognitive-Behavioral Therapy 

In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders, depression, eating disorders, chronic low back pain, personality disorders, psychosis, substance use disorders, and in the adjustment, depression, and anxiety associated with fibromyalgia and post-spinal-cord injuries. Evidence has shown CBT is effective in helping treat schizophrenia, and it is now offered in most treatment guidelines. Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression. However, psychodynamic therapy may provide better long-term outcomes.

In children and adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive-compulsive disorder, and post-traumatic stress disorder, as well as tic disorders, trichotillomania, and other repetitive-behavior disorders.

Criticisms of Cognitive-Behavioral Therapy

The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments, many other researchers and practitioners have questioned the validity of such claims. A recent meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Some critics argue that CBT studies have high drop-out rates compared to other treatments. At times, the CBT drop-out rates can be more than five times higher than those of other treatment groups. 

Critics argue that one of the hidden assumptions in CBT is that of determinism, or the absence of free will, because CBT invokes a type of cause-and-effect relationship with cognition. Specifically, critics argue that since CBT holds that external stimuli from the environment enter the mind, causing different thoughts that lead to emotional states, there is no room in CBT theory for agency, or free will.