Within the field of psychology, there are numerous schools of thought that attempt to explain and understand the complex mechanisms that take place within the human mind. From exploring childhood events and dream analysis, to specialized flooding techniques and examining how individuals within a family operate, there are a variety of different theories and approaches that assist mental health professionals in helping clients to overcome the challenges that occur in one’s life. However, not all theories view the human condition the same, and as such, the various theories, each have unique approaches and interpretations of life’s events, which influence the technique used to bring about change in the life of the client. Understanding a theory or approach is essential in order to implement it correctly, as an incorrectly utilized approach can lead to more harm than good, which would be unethical and potentially dangerous.
What is Cognitive Behavior Therapy?
Cognitive behavioral therapy is a mix of two psychological theories: behavior therapy and cognitive therapy. Behavioral therapy was introduced in the 1950s as an alternative to the psychoanalytic perspective that dominated the field of psychology at that time. Behavior therapy, developed by Joseph Wolpe, Arnold Lazarus, and Hans Eysenck among others, was first utilized to understand and treat phobias (Corey, 1986) and uses a scientific approach to understand a behavior, often utilizing experimental methods. According to behavioral therapy, the goal of treatment or counseling is to create new conditions for learning, which can lead to a ceasing of the problem behavior (Corey, 1986).
The other part of cognitive behavioral therapy is the cognitive side that behavioral therapy often does not address in a counseling setting. Introduced by Aaron Beck around the same time as behavioral therapy, and is considered as one of the biggest success stories within the field of contemporary psychology (Hofmann, Asmundson, & Beck, 2013). Emotional disorders such as anxiety and depression are considered to be due to negative emotional responses and an altered perception of reality, with change occurring through the development of more accurate views of events and situations (Hofmann, Asmundson, & Beck, 2013). The melding of behavioral therapy and cognitive therapy results in a useful approach to understanding and assisting clients as they navigate through life.
Cognitive behavioral therapy is a diverse umbrella term that encompasses several approaches, including rational emotive behavior therapy (REBT), rational emotive therapy (RET), schema focused therapy, dialectical behavior therapy (DBT), as well as cognitive and behavioral therapies. While there may be a variety of theories that fall under the term CBT, they all focus on the role thoughts (cognitions) have on behaviors, feelings, and perception of reality. The concept that one’s thoughts influence behaviors rather than external stimuli, such as people and situations is considered a hallmark of CBT, with change occurring when the thoughts or cognitions change, even when the situation or environment remains the same (Baardseth et al., 2013).
There are three general assumptions within the CBT approach:
- The cognitive approach believes that abnormality stems from faulty cognitions about others, our world and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately).
- These cognitions cause distortions in the way we see things; Ellis suggested it is through irrational thinking, while Beck proposed the cognitive triad.
- We interact with the world through our mental representation of it. If our mental representations are inaccurate or our ways of reasoning are inadequate, then our emotions and behavior may become disordered (McLeod, 2008).
The cognitive triad, which was suggested by Beck emphasizes the recognition of negative thoughts as a critical aspect of changing behavior. Beck believed that the client’s reaction to an event or situation may contribute to the negative thoughts that the client believes, which in turn, may lead to automatic thoughts that are negative. Such a negative view may also taint the way the client views his or her surroundings or experiences. When the automatic thoughts are negative, there is a higher likelihood of anxiety or depression being present; the negative thoughts can and will persist despite evidence to the contrary. According to CBT, the way to break the negative cycle of automatic thoughts, it is imperative to make changes to the three legs of the cognitive triad: feelings, thoughts, and behaviors. The cognitive triad consists of negative views about the world (“Everybody hates me because I am worthless”), negative views about the future (“I’ll never be good at anything because everyone hates me”), and negative views about oneself (“I am worthless”). Through creating a change in at least one belief or cognition that is held by the client, change can occur (Beck, 1967).
The ability for thoughts or cognitions to influence the perception of the reality one experiences is at the core of CBT and through changing the cognitions. In order to change the negative, destructive, and unhealthy thought patterns, therapists work with clients to identify the beliefs that influence the cognitions. Through learning how thoughts, beliefs, and behaviors contribute to the formation and maintenance of maladaptive thought patterns and behaviors, change is possible. However, in order for CBT to be successful, the client needs to be able to examine and understand their own thought process, which can be challenging for some individuals.
Just as there are a variety of therapies that fall under the category of CBT, there are also a number of different types of CBT, all of which focus on either restructuring of cognitions, behavior modification, and/or the development of alternative coping skills. There are two main components of CBT that are deemed to be critical, regardless of which application method is selected: functional analysis and skills training (SAMHSA, n.d.). Functional analysis allows counselors and therapists to work with the client to assess events and situations in the life of the client that is likely to cause distress or areas in which the client has difficulty employing positive and healthy coping strategies. In order to paint a clear picture and increase the clarity of the situation, clients are asked a series of questions about his or her behavior prior to the distress, the feelings present during the event, as well as what coping skills were utilized and any negative consequences that occurred due to the coping method selected.
Once the client recognizes the behavior and unhealthy coping skills he or she has used as a crutch in previous situations, the client can start to learn new skills through skills training. In the CBT approach, clients unlearn old habits that were counterproductive, replacing them instead with healthier coping skills. By acquiring new coping skills that are broad in nature, the client will be able to address a broad spectrum of distress-causing experiences and have the use of both behavioral and cognitive coping methods to deal with the problems, rather than relying on maladaptive coping mechanisms (Kadden et al., 2003). In retraining habits and acquiring new skills, clients learn to make accurate evaluations of events, thus making “healthy thinking” an automatic response.
According to the United Kingdom’s National Health Service (2012), the theories that fall under the CBT umbrella differ from the wide variety of theories and approaches mental health professionals have to choose among. Compared to other forms of psychotherapies, CBT is considered to be more pragmatic, is highly structured, focuses on the current problem, and is collaborative in nature. CBT is considered to be pragmatic since the approach aims to identify specific problems and devise solutions to them; the structured nature of CBT is found in the nature of the discussion between the client and therapist or counselor since the session is focused on specific problems and the goals the client wants to achieve; focusing on the current problem rather than past issues can help the client to stay “in the moment,” rather than dwelling on past issues or problems; and the relationship between the client and counselor or therapist is collaborative since the client is an active participant in finding solutions to the current issues being experienced by the client (NHS, 2012).
Strengths and Weaknesses of CBT
Since clients are individual and bring with them unique experiences, mental health professionals need to keep in mind the characteristics of the client when considering which therapeutic approach is the most appropriate to utilize in order to assist the client. Cognitive behavioral therapy can be successful for a variety of mental health problems, but only if it is applied correctly in a session with a client who is capable of carrying out the often complex requirements that accompany CBT.
Strengths of CBT
The strengths of CBT are plentiful, as the approach involves focusing on the current problems and learning how to address the issues as they arise with the skills acquired through the counseling sessions. The instructive nature of CBT allows clients to learn how to counsel themselves, which can help not only in the current issues faced by the client, but the skills can also be utilized in the future to better prepare the client to take on life’s challenges. Through teaching rational self-counseling skills, CBT assists clients to build confidence in themselves that they will continue to successfully overcome stressors and issues that may occur in their lives.
The short duration of CBT in comparison to other forms of psychotherapies is also viewed as an advantage, as most clients require an average of 16 sessions, versus years of counseling as required by theories such as psychoanalysis (Pucci, 2010). The short duration can also be viewed as an advantage in regards to the cost of services, not only in the shorter duration of services required, but it can be a highly cost-effective way to reduce school or employment absences that occur as a result of mental health problems (Smith, 2006). Depression alone has been estimated to cost employers up to $44 billion in lost revenue due to lost workdays (CDC, 2013), which can be reduced greatly through the short-term nature of CBT. The emphasis on getting better, rather than feeling better through the acquisition of healthy coping skills and correcting inaccurate assessments and assumptions of situations, long-term effects can result due to the solving of the problem through cognitive restructuring, which allows the client to accurately appraise the issue at hand. The structured aspect of CBT also contributes to the streamlined approach, which reduces the likelihood that counseling sessions get off topic.
The various approaches that comprise CBT, while varied in approach are also very applicable to a multicultural environment, as CBT is rooted in what are considered to be universal laws of human behavior which assist to predict the tendencies of thoughts, feelings, and actions (Hergenhahn & Henley, 2014). While the interpretation and assessment of challenges and mental illnesses may differ depending on cultural values, the ability to address the cognitive factors that contribute to emotional distress allow for CBT to be used in a variety of settings within a multicultural environment, and has been shown to be effective when working with American Indians, Alaska Native clients, Latinos and Latinas, African Americans, and Lesbian, Gay, and Bisexual clients, as well as clients who come from a variety of religious perspectives (Iwamasa, Pai, & Sorocco, 2006).
The ability for CBT to be tailored for each individual client allows for counselors and mental health professionals to assist a variety of client concerns; ranging from depression and anxiety, to sexual disorders and addiction, through changing the maladaptive assumptions and thoughts, change is possible. Some of the greatest success in a therapeutic environment has been seen in clients being treated for depression, with great benefit also reported for clients seeking treatment for a variety of anxiety-related symptoms (Beck, Epstein, & Harrison, 1983).
Another advantage of CBT is that is has been thoroughly researched, is an evidence-based approach, which includes clearly defined goals and techniques, implementing the scientific method. Research into treatment options for depression and anxiety has identified CBT as a valuable and effective intervention, with a reduction in symptoms when used as either the primary treatment or as an adjunct to medication treatment (Whitfield & Williams, 2003). While other forms of therapy have been known to be effective yet not be supported by thorough research or backed by scientific data, the support from the research community in regards to the application and outcome of CBT lends credence and credibility to the theory within the field of mental health.
Weaknesses of CBT
While the aforementioned strengths associated with the use of CBT as a therapeutic intervention, it may not be suitable for all clients in all situations. Some of the following weaknesses are due to certain character traits of the client, while others may stem from the preconceived notions and expectations the client has of the counseling session. While the weaknesses of CBT do not necessarily mean that the approach would not be of benefit to the client, a different therapeutic theory may be more effective and appropriate as deemed by the counselor or mental health professional upon assessing the unique client characteristics.
Some clients enter into therapy or counseling with a desire to talk about emotions or childhood experiences as they may deem them to be contributing to their current level of distress; however, the methods used within the CBT approach focuses on cognitions and how they influence perception and behavior, rather than focusing on emotions or events of the client’s past. As such, the client may not be able to commit to the effort required to bring about change. Additionally, the focus on changing cognitions and increasing positive thinking practices may appear to be superficial to some clients who desire a more direct method of therapy or one that attempts to dig deeper into the past of the client to bring about change, such as the methods that are utilized in psychoanalysis or other theories which take such things into account. The client also has to be in counseling voluntarily and motivated to achieve results in order for CBT to be successful. Research into the application of CBT in the field of addiction treatment has revealed that CBT is not an effective approach when the client is ambivalent about being in treatment or if treatment is a mandatory requirement to avoid prison or other punishment (Hofman, Asnaani, Vonk, Sawyer, & Fang, 2012).
Another possible weakness when it comes to CBT has to do with the client’s ability to engage fully and comprehend the often complex methods that are used with the theory. For example, if a client has severe mental retardation, learning disabilities, or developmental delay, he or she may not be able to grasp the complex nature of CBT, which requires the client to be aware of one’s cognitions or thoughts in order to change the outcome of future behavior or assess situations or events in a more accurate way. However, recent research suggests that clients with mild to moderate intellectual disabilities may benefit from some aspects of CBT as some are able to establish the link between cognitions or thoughts and feelings or behavior (Hassiotis et al., 2011). The mental health professional would need to take into consideration the client characteristics and assess for the ability for the client to make the connection that is the underpinning of CBT.
Some clients may not prefer the format of CBT, as they may not be committed to changing their cognitions. While clients may recognize that some of their thoughts may not be rational nor healthy, stopping the behavior or thoughts is not always easy. A willingness to change thoughts and cognitions needs to be present in order for change to occur in the beliefs held and behaviors engaged in by the client. Some of the push-back from the client in regards to addressing some beliefs may be due to the possibility of an increase in anxiety experienced by the client due to the need to confront the topics and situations that are known to cause anxiety within the client.
Relevance to Contemporary Psychology Practice
The application and effectiveness of CBT has been praised by a number of governmental entities, including the British government, which in 2005 identified CBT as the preferred method for patients, especially for clients with depressive and anxiety disorders. As of 2011, over 3,400 new mental health professionals have been trained in the UK alone, with another 53,000 entering into CBT training during the 2011/12 academic year (Wright, 2014). Research has suggested that components of CBT have been shown to be very effective for a variety of mental health issues, many of which commonly occur within contemporary counseling services.
Some of the common emotional disorders treated with the use of CBT include mild depression, social anxiety, gnawing regrets, and the feeling of being overwhelmed by excessive demands, with each being explained in a unique manner according to CBT terminology. However, while the definitions and explanations may differ among the disorders, the underlying thread of CBT, namely the assumptions or faulty cognitions is present in both the description and treatment plans.
According to CBT, mild depression occurs when a client underestimates his or her power of acting or overestimates the “fatedness” of the world. Such a mismatch between reality and perception is also referred to as an assumption; the second assumption that contributes to mild depression occurs when a client confuses a misfortune in his or her life with a horrible, life-altering event which he or she is not able to cope with nor overcome. Additionally, irrational beliefs may work as a trigger or flawed lens in which the client observes his or her world and environment, leading to a feeling of sadness or depression. Social anxiety is explained as an overvaluing of the opinions of others, which is out of the control of the client. Placing such a high value on the judgements of others can leave individuals with a feeling of ineptitude or unworthiness, depending on the client’s perception of how others view the client, which may not be an accurate view of either the client or the perceptions of the client held by others. A preoccupation with the events of the past is how CBT explains the experience of gnawing regrets. In order for the client to experience relief from his or her regrets, it is essential to learn that there is nothing that can be done or changed, as the past is the past and has already happened. The only aspect of the past that the client can change is his or her attitude held about the past.
Conclusion
The evolution of CBT, from the early days of cognitive therapy and behavioral therapy, to the current version that has been adopted by various governmental agencies worldwide, the benefits of CBT are well known throughout the mental health care community. While there are currently a variety of psychotherapies to choose among, it appears that CBT is useful in a vast array of emotional and psychological illnesses. The ability to change one’s life by augmenting the perception of reality is the hallmark of CBT, but it is important for mental health professionals to realize that while the techniques used within CBT, not all clients are able to benefit due to unique client characteristics such as motivation for change and cognitive abilities. Despite the weaknesses that have been addressed in this paper, the strengths and ability for CBT to be tailored and customized for each client, the approach and techniques that fall under the umbrella of CBT are a priceless addition to the field of psychology.
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