Cognitive Behavior Therapy (CBT) can be understood as a type of psychosocial intervention, which is the most popular evidence based practice of addressing and managing mental health problems. CBT focuses on improving the personal coping mechanisms which helps to tackle current challenges in the modification of negative cognitive patterns (involving the beliefs, thoughts and attitudes of people), behavior of people and their emotional modulations. This process was originally designed to manage depression, however is not utilized for many other mental health problems (Farmer & Chapman, 2016).
CBT can also be understood as a type of talking therapy, which can be useful for individuals to manage their problems by changing the way a person thinks and behaves regarding the problem (Wright et al. 2017). According to NHS UK, CBT can be used not only for depression and anxiety, but also other mental health issues (nhs.uk, 2018). According to the Royal College of Psychiatrists, CBT is a way of talking about how a person thinks about himself/herself, the world and others; and how the thoughts and feelings in turn affects the actions of the person. Thus CBT is a way to change how a person thinks (cognition) and how the person behaves. These changes can be useful to make a person feel better; focusing primarily on the ‘here and now’ issues instead of the causes of the issues, and thus tries to improve the current state of mind of individuals. Apart from anxiety and depression, CBT can also be used in many other cases such as panic, phobia, stress, bulimia, obsessive compulsive disorder (OCD), post traumatic stress disorders (PTSD), bipolar disorder and psychosis. CBT can be additionally useful in anger management, low self esteem and even to manage physical health issues like pain and fatigue (Rcpsych.ac.uk, 2018).
CBT integrates principles from cognitive and behavioral psychology, and differs from psychotherapy (where meanings behaving each behavior are focused on). Instead, CBT is an action oriented and problem based approach to treat specific mental health condition that has already been diagnosed. The practice is also based on the understanding that distorted through and maladaptive behavior has a crucial part in the persistence of mental health problems and psychological disorders and that the adverse facets of these conditions can be lowered by changing how information is processed and through coping strategies (Hayes et al. 2016).
The purpose of this report is to understand the process of CBT, the mental health conditions where CBT can be utilized, analyze its strengths and weaknesses and key outcomes of the process.
CBT generally comprises of 10- 20 sessions, which can last 1 hour each and conducted one every week. The sessions can be individually delivered or in a family or small (focus) group setup. In the recent years, computer programs which are internet based and assisted by clinicians, are also used in the CBT process (Wright et al. 2017). According to the John Hopkins Psychiatry Guide, CBT can involve different types of strategies such as:
According to the John Hopkins Psychiatry Guide, CBT have shown positive outcomes for different types of mental health disorders. Among adults, different disorders which can indicate the use of CBT as a form of intervention include the following:
CBT can also be an important adjunctive treatment for bipolar disorder and schizophrenia (when used along with pharmacological intervention). Among children and adolescents, CBT was also found to be effective in the treatment of anxiety disorder, OCD, body dimorphic disorder, PTSD, depression, tic disorders, Toilette’s syndrome, eating disorder, oppositional defiant disorder, chronic pain and medical problems like chronic abdominal pain and headache (Goldstein et al., 2015; Mataix-Cols et al., 2017; Martin et al., 2015).
The focus of CBT is to bring about a change in the attitudes of people and also their behavior, by understanding the through, beliefs, attitudes and images held by individuals which are the parts of the cognitive machinery, and tries to relate these aspects to how a person behaves in order to deal with various situations. CBT also places a significant importance on Negative Thoughts and where they originate. The CBT model suggests that the meaning we give to specific events and not the events themselves are the aspects that makes us upset. That is, if we have negative thoughts about something, it can lead to improper cognition towards it and thus lead to maladaptive behavior. Also, the source of the negative though is an important consideration of the CBT process. According to Beck, out thinking patterns are developed in our childhood, and over time, it becomes automatic and relatively constant. Any dysfunctional assumption that might have been confirmed by an individual in the early childhood can lead to automatic thoughts. CBT tries to break the system of automatic thoughts, and clear out dysfunctional assumptions and helps an individual to examine the real-life experiences, trying to gain a better context to the problem, trying to analyze how other might react to the same situation. The process also considers that negative thoughts are a common phenomenon during a disturbed state of mind, and that it can bias our interpretation of reality. CBT attempts to correct these misinterpretations (Farmer & Chapman, 2016; Wright et al., 2017).
The CBT sessions with the therapist can include different activities. Given below is the work involved in a typical CBT session with a therapist:
Strengths:
Weaknesses:
De Castella (et al., 2015) pointed out that CBT can be applicable for the treatment of Social Anxiety Disorders, and suggested that changes in the beliefs of the client regarding their emotions has a crucial function in CBT for SAD. The authors conducted a randomized controlled trial where they analyzed the beliefs of the participants regarding the fixed versus variable nature of their anxiety as a key factor for CBT in SAD. According to the authors, the cognitive models of the SAD outlines several distortions in cognitive process, and dysfunctional beliefs associated with the aetiology and sustenance of the disorder. It is suggested that in a cycle of destruction, these factors can cause an emotional over response, an inability to regulate the emotions, cause avoidance behavior, all of which can further exaggerate the symptoms of anxiety. Models of anxiety disorder highlight several maladaptive processes that can foster the mentainance of the dysfunction. These processes can be divided into three types: 1) beliefs about social situations which can include unrealistic thinking and expectations, inadequate self efficacy, and dysfunctionality in beliefs regarding the probability and costs of behaving poorly 2) Belief regarding oneself which includes a negative perception of self, rumination and an increased self focus and attention 3) beliefs regarding self emotions which includes a belief that one has little control over their emotions. The Authors believe that CBT is able to address these distortions and thus are suitable therapy for treating anxiety.
Zipfel et al. (2014) in The Anorexia Nervosa Treatment for Outpatient (ANTOP) study analyzed two methods of treatment, namely CBT, focal psychodynamic therapy and optimized treatment. The authors screened 727 adults, 242 of whom underwent randomization, 80 to focal psychodynamic therapy, 80 to CBT and 82 to optimized treatment. The study lost 54 participants during follow-ups and 30% dropout by the end of 12 months. By the end of the treatment, an improvement in BMI was observed in all study groups; however, in case of the CBT group the rate of improvement in BMI was seen to be the fastest. Based on such evidences, the authors suggested that CBT can be regarded as a solid baseline treatment for adults with anorexia nervosa. The findings from the study showed that multicentre outpatient studies are possible for individuals with anorexia nervosa. The authors showed that the patients can be treated safely, and that the patients can eventually gain weight, and that a significant part of the studied population showed improvements in their eating habits, pathology and associated psychopathology, with CBT showing evidence of causing the fastest rate of recovery. This proves that CBT is an effective tool in the treatment of eating disorders such an anorexia nervosa.
Gilbody et al. (2015) studied the utility of Computerised CBT to treat depression in a primary care trial setup, as a part of a randomized controlled trial. Here the participants, all of whom were adults with depression symptoms (scores of 10 or more on the PHQ-9 questionnaire) were given a computerized CBT therapy and the usual GP care in randomized groups. Encouragement was given to the participants to complete the program using the weekly phone calls. The control group was provided the usual GP care. The primary outcome was measured using the PHQ-9 questionnaire after 4 months of treatment, and secondary outcomes identified in the study were the quality of life related to health (measured by SF-36) and psychological well being (measured using CORE-OM) at fourth, twelfth, and twenty fourth months. The study showed that Computerised CBT does not cause any significant improvement in the depressive symptoms compared to the usual GP care provided alone. The study highlights that computerized CBT might not be an entirely efficient method for treating mental health condition. The results of these trials were different from the developer led trials in the aspect that these trials were conducted entirely in the primary care center, with is the most common setup where treatment for depression can be provided. This is different from other trails where the target participants were recruited on the internet of from a secondary care setup, and thus the results of these trials can be applied to primary care setup.
Freeman et al. (2015) studied the effects of CBT for worry on persecutory delusions in patients with psychosis, in a parallel, single blind, randomized controlled trial. The authors suggested that worry can be a significant factor that contributes to the development of persecutory delusions (illogical fear of being persecuted) among patients with psychotic disorders, which led to the postulation that by reducing the worry using CBT, the delusions can be reduced or controlled. The study was conducted as four assessors blinded, two armed tests, on patients between the age of 18 and 65 years showing signs of persistent persecutory delusions, with a score of at least 3 on the Psychotic Symptoms Rating Scale (PSTRATS). The study found that reduction in long standing delusions were achieved through brief interventions which focused on the worries of the patients, and thus the findings suggests that worry can lead to paranoia, and interventions for worry can be a significant addition to the treatment for psychosis.
Conclusion:
The overview of the analysis of CBT shows that CBT has different strengths and weaknesses, which decides the conditions and situations in which it can be applied. The strengths of the process includes its efficacy in the treatment of mental health conditions such as depression and anxiety, and that it can be as effective as pharmacotherapy. The availability of sufficient details on this process allows it to be perfectly communicated and replicated in different studies and treatment approaches. The treatment helps in thru development of a therapeutic relation bet went the client and the therapist CBT puts focus on reducing the symptoms of the mental health condition and uses basic techniques like empathy to understand the thoughts of the patients. And clients have also shown preference towards CBT compared to other forms of treatment, stating that they found CBT to be more user friendly, and thus also was associated with fewer dropouts on the long term. CBT also has few weaknesses; such as CBT is based on a dysfunctional idea regarding the causal factors of cognitive dysfunction the treatment also is unable to differentiate the symptoms of a mental health condition from its causes in while focusing on specific issues. Also, the studies that found CBT’s efficacy in the treatment never really proved the validity of CBT and there is also the chance that the therapist might develop biases during the treatment while trying to identify the cognitive distortions in the client. The usage of CBT is also found to be limited in complex mental health issues like personality disorders, learning and intellectual disorders. The process also does not focus on the underlying causes of mental health conditions, which is another limitation. Moreover, some author also critiqued CBT to be very restrictive as it only considers emotions as factors that needs to be controlled and not expressed.
Studies by De Castella et al. (2015) showed that CBT can be used to treat social anxiety disorders, while Zipfel et al (2014) suggested that CBT can be an effective baseline treatment for anorexia nervosa. Studies by Gilbody et al (2015) showed that computerized CBT are not a better tool compared to treatment at GP, highlighting that they should not be depended on. Also, Freeman et al. (2015) showed that CBT can be useful to treat even psychosis, by reducing the level of worries in the patients, and thus reduce their persecutory delusions. These studies show that CBT can be an effective tool for the treatment of various types of mental health conditions.
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