Application of experimentally derived principles of learning to the treatment of psychological disorders and the control of behaviour. The concept, which has its roots in the work of Edward L. Thorndike, was popularized in the U.S. by theorists of behaviourism, including B.F. Skinner. Behaviour-therapy techniques are based on the principle of operant conditioning, in which desired behaviours are rewarded. There is little or no concern for conscious experience or unconscious processes. Such techniques have been applied with some success to disturbances such as enuresis, tics, phobias, stuttering, obsessive-compulsive disorder, and various neuroses. Behaviour modification more generally refers to the application of reinforcement techniques for shaping individual behaviour toward some desired end or for controlling behaviour in classrooms or institutional situations. Seealso psychotherapy.
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Cognitive Behavioral Therapy (CBT) is an umbrella-term for psychotherapeutic systems that deal with cognitions, interpretations, beliefs and responses, with the aim of influencing problematic emotions and behaviors. CBT can be seen as an general term for many different therapies that share some common elements and theoretical underpinnings.
CBT is widely accepted as an evidence- and empiricism-based, cost-effective psychotherapy for many disorders and psychological problems. It is often 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. One of the objectives of CBT typically is to identify and monitor thoughts, assumptions, beliefs and behaviors that are related and accompanied to debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace or transcend them with more realistic and useful ones. CBT that was primarily developed out of Behavior Modification, Cognitive Therapy and Rational Emotive Behavior Therapy and has become widely used to treat various kinds of psychopathology, including mood disorders and anxiety disorders and has many clinical and non-clinical applications.
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). 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.
Other types of Cognitive Behavioral Therapy include Dialectical Behavior Therapy, Acceptance and Commitment Therapy, Self-Instructional Training, Schema-Focused Therapy and many others. Cognitive Behavioral Group Therapy (CBGT) is also a similar approach in treating clinical conditions, based on the protocol by Richard Heimberg.
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 this theory, 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.
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; Beck theorized that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as “I never do a good job,” and "things will never get better." 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.
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.
In 1989, this theory was challenged by Hopelessness Theory. 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.
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. 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.
The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may 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, mindfulness and distraction techniques are also commonly included. Cognitive behavioral therapy is often used in conjunction with mood stabilizing medications to treat conditions like 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 generally 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 and adaptive one.
For example, Gina is upset because she fails an important math test. The activating event, A then is that she failed her test and infers that she will not be able to get her degree. The evaluative belief, B about A, is that she believes in her heart and head that she absolutely always must have good grades and succeed or else it is the end of the world. The Consequence, C, is that Gina tends to feel depressed, thinking it may be no use to continue school.
In the example above, a therapist may help Gina realize that it is self-defeating and does not make sense to believe, and there is no evidence for believing, that she absolutely always must pass her tests and succeed, and that failure to do so is an absolute horror; although she normally may want and strongly prefer to pass her tests and succeed, she has alternatives, that not doing it would not be the end of the world. If she realizes that not passing her tests or having trouble getting her degree is highly unfortunate and sad, but not awful and horrible, she will tend to feel sad or frustrated, but not depressed and helpless. The sadness and frustration are then healthy negative emotions because they are more likely to make her study more effectively or deal with her problems as a response.
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 antidepressant medication. A new UK government initiative for tackling Mental Health issues has recently been launched by the Care Services Improvement Partnership. This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE 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 met. Some areas have developed, or are trialing, other CCBT products notably Outreach-online developed in-house by the NHS and currently being trialed in North Wales (UK).
In the United States, Chicago-based Prevail Health Solutions is leading the development of computerized Cognitive-Behavioral Therapy. Their products are not yet offered to the general population, but currently they are engaged in ongoing efforts to determine efficacy in the treatment of several mental health disorders.
There are also Interactive computerized interventions available that provide measurable outcomes. For example, The Challenge Software Program is an interactive online program designed to help children struggling with Self-regulation and Social Skills. The program is based on Fundamental Cognitive-Behavioral principles and teaches children how to challenge unhealthy thinking patterns.
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.
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, which states: 1000 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.
Hypnotic drugs are of poor value for the management of chronic insomnia. It is widely accepted that hypnotic drug usage beyond 4 weeks is undesirable for all age groups of patients. Many continuous sedative hypnotic users exhibit disturbed sleep as a consequence of tolerance but experience worsening rebound or withdrawal insomnia when the dose is reduced too quickly, which compounds the problem of chronic hypnotic drug use. No formal withdrawal programs for benzodiazepines exist with local providers in the United Kingdom.
CBT has been found to be more effective for the long-term management of insomnia than sedative hypnotic drugs. A meta-analysis of published data on psychological treatments for insomnia shows a success rate between 70 and 80%. A large-scale trial utilising cognitive behavioural therapy in chronic users of sedative hypnotics including nitrazepam, temazepam and zopiclone found CBT to be a more effective long-term treatment for chronic insomnia. Persisting improvements in sleep quality, sleep latency, and increased total sleep, as well as improvements in sleep efficiency and significant improvements in vitality and physical and mental health at 3-, 6- and 12-month follow-ups were found in those receiving cognitive behavioural therapy.
A marked reduction in total sedative hypnotic drug use was found in those receiving CBT, with 33% reporting no hypnotic drug use. Age has been found not to be a barrier to successful outcome of CBT.
It was concluded that CBT for the management of chronic insomnia is a flexible, practical, and cost-effective treatment for the treatment of insomnia and that CBT leads to a reduction of benzodiazepine drug intake in a significant number of patients.