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Section 17
The History of Cognitive-Behavioral Therapy

Question 17 | Answer Booklet | Table of Contents

Definition of Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) represents a unique category of psychological interventions based on scientific models of human behavior, cognition, and emotion (Dobson, 2000). It includes a wide range of treatment strategies that take the current knowledge about the etiology and maintenance of the different mental disorders into account (Beck, 1995; Beck, 2005; Cutler, Goldyne, Markowitz, Devlin, & Glick, 2004; Hayes, Follette, & Linehan, 2004; Kanfer & Phillips, 1970; Masters, Burish, Hollon, & Rimm, 1987). Patients and therapists work together to identify and understand problems in terms of the relationship between thoughts, feelings, and behavior. The focus lies in the here and now. Individualized, usually time-limited therapy goals are formulated. CBT intends to directly target symptoms, reduce distress, re-evaluate thinking and promote helpful behavioral responses. The therapist supports the patient to tackle problems by harnessing his or her own resources. Specific psychological and practical skills are acquired (e.g., reflecting and reevaluating the meaning attributed to a situation with subsequent behavior changes) and the therapist actively promotes change with an emphasis on putting what has been learned into practice between sessions ("homework"). The patient learns to attribute improvement to his or her own efforts (self-efficacy). A trusting and safe therapeutic alliance is viewed as an essential ingredient, but not as the main vehicle of change.

Behavioral interventions are considered as clinical applications of learning theory (Kana et al., 1970; Masters et al., 1987). The most frequently used methods are classical and operant conditioning, often combined with observational learning ("modeling"). For example, patients learn to reward themselves systematically whenever they have been successful in showing new and adequate reactions to crucial situations. Behaviors such as avoidance or reduced activity are problematic because they can act to keep the problems going or worsen. If patients avoid situations that trigger phobias (e.g., crowds, traveling in bus or train), therapists help them feel safe enough to face the feared situation as a means of reducing anxiety and learning new behavioral skills with which they may tackle problems.

Cognitive interventions refer to how patients create meaning about symptoms, situations, and events in their lives, as well as beliefs about themselves, others, and the world (Beck, 1995; Beck, 2005; Dobson, 2000). The therapist assists the patient to become more aware of maladaptive automatic thoughts that spring to mind and evoke negative personal interpretations (e.g., "I'm in danger"). A style of trained questioning (called "Socratic dialogue" or "guided recovery") gently probes for patient meanings and stimulates alternative viewpoints or ideas. Based on these alternatives, patients carry out behavioral experiments to test the accuracy of alternative behaviors, and thus they adopt new and more realistic ways of perceiving and acting. It should be emphasized that CBT is not about trying to prove the client wrong and the therapist right, but about moving toward a skillful collaboration in which patients come to discover for themselves that there are realistic alternatives.

CBT-trained therapists work with individuals, families, and groups. The approach can be used to help anyone irrespective of ability, culture, race, gender, or sexual preference. It can be applied with or without concurrent psychopharmacological medication, depending on the severity or nature of each patient's problem.

The duration of cognitive-behavioral therapy varies, although it typically is thought of as one of the briefer psychotherapeutic treatments. Especially in research settings, duration of CBT is usually short, between 10 and 20 sessions. In routine clinical practice, duration varies depending on patient comorbidity, defined treatment goals, and the specific conditions of the health care system. For example, in Germany the mean duration of CBT in clinical (outpatient) practice is between 40 and 60 sessions; up to 80 sessions of CBT will be paid by the statutory health insurance, but the treatment must be applied for and an independent expert must check the individual indication and prognosis. The findings of the national institute of mental health study on depression are consistent with this duration of CBT, indicating that 16 to 20 sessions of cognitive-behavioral (and interpersonal therapy or pharmacotherapy of a comparable duration) are insufficient for most patients to achieve lasting remission (Shea et al., 1992).

The historical roots of behavior therapy lie in the classical learning theories derived from the work of Ivan Pavlov--respondent conditioning--and John B. Watson and B. F. Skinner--operant conditioning (Masters et al., 1987). The first generation of behavior therapy changed with the advent of cognitive methods, and cognitive therapy was developed as a movement away from the limitations of psychoanalysis and the restrictive nature of behaviorism (Dobson, 2000). Cognitive therapy, developed by Albert Ellis and Aaron T. Beck in the 1950s and 1960s, is the application of the cognitive model to a disorder with the use of different techniques to modify the dysfunctional beliefs (Beck, 1995; Beck, 2005). In combination with behavioral techniques, CBT rapidly became a favorite intervention to study in psychotherapy research in academic settings during the last 25 to 30 years (Dobson, 2000).

In the last years, new (cognitive) behavior therapies have been developed (Hayes et al., 2004). "The new behavior therapies carry forward the behavior therapy tradition, but they ( 1) abandon a sole commitment to first-order change, ( 2) adopt more contextualistic assumptions, ( 3) adopt more experiential and indirect change strategies in addition to direct strategies, and ( 4) considerably broaden the focus of change" (Hayes, 2004, p. 6). For example, faced with the challenges of patients with personality disorders, Young (1994) developed schema-focused therapy. In the schema-focused model, developmental dimensions of patients' psychopathology are emphasized, and in the schema-focused therapy, experiential and interpersonal techniques are integrated.
- Leichsenring, Falk, Hiller, Wolfgang, Weissberg, Michael & Eric Leibing; Cognitive-behavioral therapy and psychodynamic psychotherapy: techniques, efficacy, and indications; American Journal of Psychotherapy; 2006; Vol. 60; Issue 3.

Personal Reflection Exercise #3
The preceding section contained information about the history of cognitive-behavioral therapy.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 17
What style of trained questioning used in cognitive interventions gently probes for patient meanings and stimulates alternative viewpoints or ideas? Record the letter of the correct answer the Answer Booklet.

 
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