Form of psychotherapy that aims to change cognitive distortions and self defeating behaviors

Terminology and Subtypes

Cognitive behavioral therapy (CBT) is a psychosocial intervention approach in which behavioral change is initiated by a therapist helping patients to confront and modify the irrational thoughts and beliefs that are most likely at the root of their maladaptive behaviors. Maladaptive behaviors are those that prevent an individual from adjusting appropriately to normal situations, and which are considered counterproductive or not socially acceptable (Figure 21-1).1 The primary goal of CBT is to identify these maladaptive behaviors, recognize beliefs associated with those behaviors, correct any inappropriate beliefs, and replace those beliefs with more appropriate ones that will result in greater coping skills and adaptive behaviors (Figure 21-2).

There are several approaches to CBT and various ways of incorporating CBT into the management of chronic low back pain (CLBP). CBT alone does not address all of the contributing factors to CLBP (e.g., anatomic, biologic, physiologic), and it is not intended to replace interventions aimed at correcting those factors when appropriate. The focus of CBT in the context of CLBP is mainly to address psychological comorbidities that may impede recovery. If those factors are solely responsible for CLBP, then CBT may be appropriate as the main intervention. However, patients sometimes find it difficult to perceive the utility of CBT as the sole treatment for CLBP.2 Use of the term CBT varies widely and may be used to denote self-instructions (e.g., distraction, imagery, motivational self-talk), relaxation, biofeedback, development of adaptive coping strategies (e.g., minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting (Figure 21-3).3 Patients referred for CBT may be exposed to varying selections of these strategies that are specifically tailored to their needs.

Abstract

Cognitive behavioral therapy (CBT) is increasingly being used to treat anxiety, core autism spectrum disorder (ASD) symptoms, and co-occurring emotion dysregulation associated with ASD. Because of the overlapping nature of anxiety, ASD symptoms, and other types of emotion dysregulation, these facets of mental health are each considered in this review of CBT for children with ASD. In this chapter, we review the evidence base for individually administered CBT for youth with ASD using Southam-Gerow and Prinstein’s (2014) criteria for defining efficacy. While no form of CBT for youth with ASD currently qualifies as “well-established,” CBT for anxiety, CBT for core ASD symptoms, and the Stepping Stones Positive Parenting Program qualify as “probably efficacious” treatments. One CBT protocol for treating anxiety in children and adolescents with ASD is highlighted with case examples. Limitations of extant studies and directions for future research are discussed.

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a type of psychotherapy that helps patients to dissect the relationships among their emotions, cognitions, and behaviors in order to identify and reframe irrational and self-defeating thoughts, which in turn improves their mood and alters their behaviors. CBT can be performed in groups or individually and attempts to empower individuals to control their negative cognitive and behavioral patterns.

Two randomized controlled trials (RCTs) have examined CBT in ESRD patients. Cukor et al compared patients who received 10 CBT sessions administered chair side during regular HD treatments with a wait list control group using a crossover design. CBT resulted in a significant reduction in depressive affect, increased perception of QOL, and better treatment adherence compared with control participants.

Group CBT was also used in an RCT of depressed HD patients compared with standard care. Eighty-five HD patients with a major depressive disorder were randomized. The CBT group demonstrated a more significant reduction in depressive affect at the end of treatment and at follow-up than the standard care group. CBT appears to be a promising intervention for reducing depression in HD patients.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) focuses on identifying and restructuring maladaptive thoughts and behaviors. For bereaved individuals, CBT approaches involve modification of dysfunctional thinking that prevents adaptive processing of the loss. Behavioral strategies include exposure to avoided thoughts and situations, as well as engagement in restoration-oriented, pleasurable activities.28 CBT is indicated when individuals are struggling with excessive guilt and anger that may be fueled by cognitive distortions about, for example, the relationship to the deceased or circumstances surrounding the death. CBT also may be helpful for those avoiding reminders of the loss or avoiding resuming functional activities. For individuals suffering from severe depression following bereavement, research suggests that CBT is more effective than IPT.76

Abstract

Cognitive-behavioral therapy (CBT) is mental health treatment with strong scientific evidence supporting its use with adolescents for a variety of problems. This article provides a broad overview of CBT with adolescents divided into three main sections. In the first section, the theories underlying the CBT approach are described. Specifically, behavior theory and cognitive theory are reviewed. Further, how the two theories have been integrated into what is called cognitive-behavior theory is discussed. In the second section, a description of specific interventions found in CBT and which modalities are used to deliver CBT is provided. Finally, in the third section, scientific evidence on the use of CBT for four common problem areas for adolescents is described: (a) anxiety disorders, (b) depression, (c) externalizing behavior problems, and (d) eating disorders.

Cognitive behavioral therapy (CBT)

CBT is the most widely practiced and studied psychotherapy for FM. Three of the relevant guidelines (i.e., APS, AWMF, and CPS) strongly recommend CBT for the management of FM (Burckhardt et al., 2005; Häuser et al., 2010; Fitzcharles et al., 2013). CBT can help reduce fear of pain and fear of activity (Fitzcharles et al., 2013). However, the EULAR gave a weak recommendation for the use of CBT (Macfarlane et al., 2017), possibly because the revised EULAR recommendations have a sequential workflow and adopt a gradual approach, and CBT was placed as an additional individualized treatment. Nevertheless, CBT was recommended in patients with FM with pain-related depression, those with anxiety, those tending to engage in pain catastrophizing, and those who are overly passive or active in coping with their illness (Macfarlane et al., 2017). Furthermore, CBT might be beneficial in patients with FM, because subjective pain may be exacerbated and protracted due to dysfunctional pain modulation (Sarzi-Puttini et al., 2020).

A meta-analysis of 23 RCTs indicated that 12 weeks of CBT yielded the greatest reductions in pain, negative mood, and disability compared with controls. Moreover, the improvement was sustained at long-term follow-up (median 6 months) (Bernardy et al., 2013). A CBT course for insomnia (CBT-i), designed according to the recommendations of the American Academy of Sleep Medicine (Morgenthaler et al., 2006), significantly improved subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, and sleep disturbances in patients with FM; whereas those who received sleep hygiene education alone reported only improved subjective sleep quality (Martínez et al., 2014). However, the efficacy of CBT for sleep improvements was only demonstrated for reduced awakening after sleep onset when sleep was assessed objectively using PSG in a recent RCT (Mccrae et al., 2019).

Because of the bidirectional relationship between pain and insomnia in FM, studies have examined the effects of CBT-i on chronic pain. CBT-i demonstrated higher efficacy than sleep hygiene education in improving pain catastrophizing but not in reducing pain intensity (Martínez et al., 2014). Results of another recent RCT also revealed no difference between CBT-i, CBT-pain, and a waitlist control group in terms of subjective morning and evening clinical pain intensity (Mccrae et al., 2019). Taken together, these findings suggest that CBT may improve pain-related symptoms (e.g., pain catastrophizing) but not the subjective pain intensity itself.

Notably, compared with the waitlist control group, both the CBT-i and CBT-pain groups had significantly more participants who achieved pain reductions of at least 30% immediately after treatment. However, the effect on pain reductions persisted only in the CBT-i group at the 6-month follow-up, suggesting that CBT-i may provide better long-term improvements in pain intensity than CBT-pain (Mccrae et al., 2019). Although CBT has no significant adverse effects, the acceptance of CBT is often limited when it is viewed as a psychological intervention (Clauw, 2014).

6.2.3 Treatment of Mental Health Problems

Cognitive behavioral therapy (CBT) is effective in the management and treatment of a variety of mental health problems, namely anxiety and depression. Interestingly, CBT can be delivered online, with very good results [46,47]. Plus, delivering CBT online makes it widely accessible and convenient, turning it into a cost-effective therapy that is able to benefit a greater number of patients than is possible in traditional CBT.

Online CBT can be self-guided or guided by a clinician, and it may include reminders, access to lessons and educational content [48]. Cognitive behavioral interventions can be delivered online for a variety of mental health problems and behavioral issues, with high adherence and effectiveness [46,47].

Individual therapy

CBT lends itself to manualized treatments, so there has been an abundance of experimental data. Extensive evidence supports the use of CBT in axis I disorders.

In depression, CBT has been shown to be effective in nonpsychotic, unipolar depression and in decreasing rates of relapse. These findings are particularly robust in mild to moderate major depression. It has also demonstrated some benefit in patients with a poor response to medication intervention. Some studies have indicated that the combination of CBT and medications may provide a benefit surpassing that of CBT or medications alone, especially when the rates of relapse are examined. A limited number of studies, including both psychotic and nonpsychotic depressed patients, showed considerable benefit from the addition of CBT to medications.

Studies have shown CBT to be effective for panic and anxiety symptoms, indicating that it may be more effective than medications in some instances. In studies of panic disorder, CBT has proven to be more effective than both placebo and medication in terms of symptom reduction as well as tolerability. The use of behavioral therapy in obsessive–compulsive disorder (OCD) has been widely accepted in the form of exposure and ritual prevention (ERP), and has shown significant benefit both for symptom relief and for relapse prevention, even in comparison to medication treatment. Evidence also exists for its use in social phobia. A recent meta-analysis of CBT for generalized anxiety disorder shows this treatment to be highly effective and better tolerated than medications.

CBT has also been effective in the treatment of another anxiety disorder, PTSD. One meta-analysis of CBT found that a brief course produced substantial improvement, with a 56% recovery rate for those entering the studies. Moreover, 67% of those completing the protocol no longer met the criteria for PTSD.

Multiple studies have shown significant benefits from CBT in acute and chronic schizophrenia. These improvements were noted in overall symptomatology as well as in positive and negative symptoms. On follow-up, these gains were sustained across studies. Investigators have noted that the use of CBT may also be able to decrease the likelihood of schizophrenia progressing in patients with prodromal symptoms.

A growing area of research in the use of CBT is in the treatment of personality disorders. As previously noted, CBT appears to be efficacious with cluster C patients. One particular outgrowth of CBT has been DBT, originally designed for borderline personality disorder. This approach, consisting of one weekly individual session and one skills group per week, has been shown to decrease suicidal behaviors, self-harm, substance abuse, and binge eating. Moreover, greater numbers of patients tend to remain in treatment, and those that do require less inpatient treatment. Studies have also shown promising benefits for borderline patients with comorbid substance abuse.

A smaller body of research suggests that CBT is useful for other conditions as well. CBT has significant evidence supporting it as perhaps the most effective treatment for bulimia nervosa. Finally, CBT has shown benefits for alcohol and cocaine abuse.

Although CBT has proven its utility as a primary treatment, researchers have also examined its use in promoting treatment compliance. Patients suffering from bipolar disorder have greater medication compliance and decreased relapses/hospitalizations when a short course of CBT is added to their medications. CBT also increases adherence to medication when used in patients with schizophrenia.

Cognitive behavioral therapy

Cognitive behavioral therapy is typically used in outpatient settings and can be administered in either individual or group formats. The underlying principles of CBT emerged from behaviorism and social learning theories. Substance use is seen as a learned behavior that is influenced by cognitive processes and the environmental contexts in which it occurs. CBT creates behavioral change by teaching new skills for modifying cognitions, emotional responses, and interpersonal dynamics to help youths problem solve without reverting to drugs, cope with intense emotions, communicate more effectively, refuse opportunities to use drugs, and manage drug-related thoughts and cravings (Myers & Brown, 1990). The goal is to diminish interpersonal and intrapersonal determinants that contribute to drug involvement and promote factors that protect against relapse (Kaminer, Burleson, & Goldberger, 2002). Therapists help youths identify contextual factors (e.g., situations, triggers, the influence of drug-using peers) and alternatives to substance use. They also teach problem-solving skills and positive coping strategies through the use of modeling, behavioral rehearsal, feedback, and homework assignments.

There is some variability across CBT interventions. CBT has been used alone (e.g., Kaminer et al., 2002) and in combination with other interventions (e.g., Dennis et al., 2004; Latimer, Winters, D’Zurilla, & Nichols, 2003), as well as in group (e.g., Kaminer et al., 2002) and individual (e.g., Waldron et al., 2005) modalities. Waldron and Turner (2008) subdivided CBT by modality for their meta-analysis. They found more variability in the content of interventions among individual CBTs than group interventions. Of the seven studies that examined individual CBT, four tested CBT in combination with other interventions. However, group versions of CBT, especially those with 12 or more sessions, generally used therapy manuals that were very similar. CBT in both modalities was associated with reductions in substance use at discharge from treatment and post-treatment follow-up assessments. Effect sizes varied across studies, and outcome studies of individual CBT tended to produce smaller effect sizes than for group CBT.

Efficacy of CBT

CBT has played a very important role in establishing the evidence-based approach within psychotherapy, by using meticulous scientific methods to explore the validity of theory and therapy. Initially a treatment for depression, CBT has become a treatment approach to very many different psychiatric disorders. With time, many studies have evaluated the efficacy of CBT, so meta-studies are rather common. One such study undertaken in 2006 by Butler and colleagues summarized 16 methodologically rigorous meta-analyses. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with and without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Moderate effect sizes were found for marital distress, anger, childhood somatic disorder, and chronic pain. CBT and behavioral therapy was equally effective for adult depression and obsessive–compulsive disorder. For bulimia nervosa and schizophrenia, there were found large uncontrolled effect sizes. Another meta-analysis of 108 treatment trials across anxiety disorders in 2007 by Norton and colleagues found that treatment was superior to no treatment and expectancy control treatments.

In summary, there are many randomized controlled treatment trials for CBT with large numbers of participants that collectively support the efficacy of CBT across a wide variety of diagnoses. Collectively, these studies suggest that CBT could be considered the treatment of choice for anxiety and depressive disorders. Despite extensive evidence, the scientific and hypotheses-driven approach of CBT has resulted in the development of newer cognitive treatment approaches, which we describe next.