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, has become widely used to treat various kinds of
neuroses and 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 empiricism-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.

An example will illustrate the process: Having made a mistake, a
person believes, "I'm useless and can't do anything right." This, in
turn, worsens the mood, leading to feelings of depression; 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 thinks 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.

The objectives of CBT typically are to identify irrational or
maladaptive thoughts, assumptions and beliefs that are related to
debilitating negative emotions and to identify how they are
dysfunctional, inaccurate, or simply not helpful. This is done in an
effort to reject the distorted cognitions and to 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 effort to replace a
dysfunctional cognitive-affective-behavioral process or habit with a
more reasonable, salutary one.

The cognitive model especially emphasized in psychiatrist Aaron Beck's
cognitive therapy says that a person's core beliefs (often formed in
childhood) contribute to "automatic thoughts" that pop up in everyday
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.

Contents [hide]
1 Cognitive Behavioral Therapy
2 Depression
2.1 Causes of depression according to cognitive theory
2.2 Attributional style
2.3 The ABCs of Irrational Beliefs
2.4 Effectiveness of CBT with or without drugs for depression
3 CBT with children and adolescents
4 Computerized CBT
5 Notable Behavioral Theorists
6 Notable Contributors to Modern Cognitive Behavioral Therapy
7 Related Techniques & Therapies
8 References
9 Further reading
10 External links
10.1 Professional Organizations & Institutes

[edit] Cognitive Behavioral Therapy
CBT can be seen as an umbrella term for many different therapies that
share some common elements.[1] While similar views of emotion have
existed for millennia, the earliest form of Cognitive Behavior Therapy
was developed by Albert Ellis (1913-2007) in the early 1950s. Ellis
eventually called his approach Rational Emotive Behavioral Therapy, or
REBT, as a reaction against popular psychoanalytic methods at the time.
[2] Aaron T. Beck independently developed another CBT approach, called
Cognitive Therapy, in the 1960s.[3] Cognitive therapy rapidly became a
favorite intervention to study in psychotherapy research in academic
settings. In initial studies, it was often contrasted with behavioral
treatments to see which was most effective. However, in recent years,
cognitive and behavioral techniques have often been combined into
cognitive behavioral treatment. This is arguably the primary type of
psychological treatment being studied in research today.

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 (i.e., Lazarus, A. A. "New
methods in psychotherapy: a case study". South African Medical
Journal, 1958, 32, 660-664).[citation needed] 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 effectiveness and effecting durable treatment
outcomes often required transcending more narrowly 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 many of the same assumptions and
theorizing.

Cognitive Behavioral Group Therapy (CBGT) is a similar approach in
treating mental illnesses, based on the protocol by Richard Heimberg.
[4] In this case, clients participate in a group and recognize they
are not alone in suffering from their problems.

A sub-field of cognitive behavioral 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
SSRIs—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.

Other types of Cognitive Behavioral Therapy include Dialectical
Behavior Therapy, Self-Instructional Training, Schema-Focused Therapy
and many others.[5]

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.

[edit] Depression
See also Clinical Depression

Negative thinking dominates when a person experiences depression. The
depressed person can experience negative thoughts as being beyond
their control, thereby allowing them to become automatic and self-
perpetuating.

Negative thinking can be categorized into a number of common patterns
called "cognitive distortions." 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.

[edit] Causes of depression according to cognitive theory
One etiological theory of depression is the Aaron Beck cognitive
theory of depression. His theory is regarded as the most verified
psychological theory of depression. His theory states that depressed
people think the way they do because their thinking is biased towards
negative interpretations. According to Beck’s theory of the etiology
of depression, depressed people acquire a negative schema of the world
in childhood and adolescence. (Children and adolescents who suffer
from depression acquire this negative schema earlier.) Depressed
people acquire such schemas through a loss of a parent, rejection of
peers, criticism from teachers or parents, the depressive attitude of
a parent and other negative events. When the person with such schemas
encounters a situation that resembles in some way, even remotely, the
conditions in which the original schema was learned, the negative
schemas of the person are activated. [6]

Beck also included a negative triad in his theory. A negative triad is
made up of the negative schemas and cognitive biases of the person. A
cognitive bias is a view of the world. Depressed people, according to
this theory, have views such as “I never do a good job.” A negative
schema helps give rise to the cognitive bias, and the cognitive bias
helps fuel the negative schema. This is the negative triad. Also, Beck
proposed that depressed people often have the following cognitive
biases: arbitrary inference, selective abstraction,
overgeneralization, magnification and minimization. These cognitive
biases are quick to make negative, generalized, and personal
inferences of the self, thus fueling the negative schema.[7]

Another cognitive theory of depression is the Hopelessness Theory of
depression. This is the latest theory of the helpless/hopeless
theories of depression. According to this theory, hopelessness
depression is caused by a state of hopelessness. A state of
hopelessness obtains when the person believes that no good outcomes
will happen and that bad ones will happen instead. Also, the person
feels that he or she has no ability to change the situation so that
good things will happen. Stressors (negative life events) are thought
to interact with a diathesis (in this case, a predisposing factor to
depression) to create a sense of hopelessness.[8]

Some proposed diatheses are attributing negative events to stable and
global factors, low self-esteem, and a tendency to believe that
negative life events will have severe negative consequences. Such
diatheses increase the possibility that a person will experience
hopelessness depression.

[edit] Attributional style
An approach to depression based upon attribution theory in social
psychology is related to the concept of attributional style. First
advanced by Lyn Abramson and her colleagues in 1978, this approach
argues that depressives have a typical attributional style —they tend
to attribute negative events in their lives to stable and global
characteristics of themselves.[9] This theory is sometimes known as a
revised version of learned helplessness theory.

In 1989, this theory was challenged by Hopelessness Theory.[10] This
theory emphasized attributions to global and stable factors, rather
than, as in the original model, internal attributions. Hopelessness
Theory also emphasizes that beliefs about the consequences of events,
and rated importance of events, may be at least as important as causal
attributions in understanding why some people react to negative events
with clinical depression.

[edit] The ABCs of Irrational Beliefs
A major aid in cognitive therapy is what Albert Ellis called the ABC
Technique of Irrational Beliefs.[2] The first three steps analyze the
process by which a person has developed irrational beliefs. They may
be recorded in a three-column table.

A - Activating Event or objective situation. The first column records
the objective situation, that is, an event that ultimately leads to
some type of high emotional response or negative dysfunctional
thinking.
B - Beliefs. In the second column, the client writes down the negative
thoughts that occurred to him or her.
C - Consequence. The third column is for the negative disturbed
feelings and dysfunctional behaviors that ensued. The negative
thoughts of the second column are seen as a connecting bridge between
the situation and the distressing feelings. The third column C is next
explained by describing emotions or negative thoughts that the client
believes are caused by A. These could be anger, sorrow, anxiety, etc.
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.

Reframing. After irrational beliefs have been identified, the
therapist will often work with the client in challenging the negative
thoughts on the basis of evidence from the client's experience by
reframing it, meaning to re-interpret it in a more realistic light.
This helps the client to develop more rational beliefs and healthy
coping strategies.
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 more effectively from then on.

[edit] Effectiveness of CBT with or without drugs for depression
A large-scale study in 2000[11] showed substantially higher results of
response and remission (73%% for combined therapy vs. 48%% for either
CBT or a particular discontinued antidepressant alone) when a form of
cognitive behavior therapy and that particular discontinued anti-
depressant drug were combined than when either modality was used
alone.

The effectiveness of combination therapy is endorsed by the Australian
depressioNet group:

Currently the most effective treatment for major (clinical) depression
is considered to be a combination of antidepressant medication and
Cognitive Behavioral Therapy.[12]
For more general results confirming that CBT alone can provide lower
but nonetheless valuable levels of relief from depression, and result
in increased ability for the patient to remain in employment, see The
Depression Report,[13] which states:

The typical short-term success rate for CBT is about 50 percent. 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.
The American Psychiatric Association Practice Guidelines (April 2000)
indicated that among psychotherapeutic approaches, cognitive
behavioral therapy and interpersonal psychotherapy had the best-
documented efficacy for treatment of major depressive disorder,
although they noted that rigorous evaluative studies had not been
published.[14]

[edit] 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. Paula Barrett and her colleagues have also
validated CBT as effective in a group setting for the treatment of
youth and child anxiety using the Friends Program she authored. This
CBT program has been recognized as best practice for the treatment of
anxiety in children by the World Health Organization.Combining the
Biofeedback method with the CBT process is very effective.(( cite-book
Biofeedback You Are In Control Editor Dr.Yigal Gliksman,))
((www.lulu.com/content/1800043)) date 2008. CBT has been used with
children and adolescents to treat a variety of conditions with good
success.[15][16]

CBT is also used as a treatment modality for children who have
experienced Complex Post Traumatic Stress Disorder, chronic
maltreatment, and Post Traumatic Stress Disorder.[17] It would be one
component of treatment for children with C-PTSD, along with a variety
of other components, which are discussed in the Complex Post Traumatic
Stress Disorder article.

[edit] Computerized CBT
As the name suggests, this is a computerized 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.

Computerized 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. Computerized 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 innermost problems can be off-putting.
In this respect, CCBT (especially if delivered online) can be a good
option.

Randomized controlled trials have proven its effectiveness, and in
February 2006 the UK's National Institute of Health and Clinical
Excellence (NICE) recommended that CCBT 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. antidepressant pills).[18]

A new UK government initiative for tackling Mental Health issues[1]
has recently been launched by the Care Services Improvement
Partnership.[2] This confirms Primary Care Trust (PCT)
responsibilities in delivering the NICE Technology Appraisal on CCBT.
National Director for Mental Health, Professor Louis Appleby CBE[3]
has confirmed that by 31 March 2007 PCTs should have ST Solutions'
"FearFighter" and Ultrasis' "Beating the Blues" CCBT products in place
and the NICE Guidelines should be m