Non-Pharmacotherapeutic Intervention: Cognitive Behavior Therapy (CBT)

Introduction to Cognitive Behavior Therapy (CBT)

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.

Process of CBT

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:

• Psycho education: Here the patients are educated on the nature of mental health issues, helping to increase understanding of its effects on cognition and behavior of people.
• Cognitive Restructuring: This is the process of identifying; challenging and eliminating maladaptive thinking process and incorporate adaptive, realistic and coping thought processes.
• Exposure to fear, and reducing avoiding behavior (since negative reinforcements can cause anxiety. This phase encourages individuals to approach or face their fears.
• Behavioral activation: this allows individuals to increase their engagement in constructive or pleasurable activities like exercising and also encourage the use of social support systems.
• Relaxation training: this helps to alleviate psychological reactivity and trigger mechanisms through relaxation routines which can include deep breathing practice, guided imagery, and muscular relaxation techniques and through sensory focus.
• Homework on out of session activities to develop mastery over the coping strategies.
• Preventing Relapse through continued practice of CBT and developing strategies for coping with future stresses and symptoms related to it.

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:

• Anxiety disorders (like agoraphobia, panic disorder, social phobia, generalized anxiety problems an specific phobias)
• Obsessive Compulsive Disorder (OCD)
• Post Traumatic Stress Disorder (PTSD)
• Depression
• Eating disorders (bulimia nervosa)
• Personality disorders (borderline personality disorder)
• Substance abuse problems
• Chronic pain and conditions like insomnia and headache

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).

Strengths and Limitations of CBT

 The CBT sessions with the therapist can include different activities. Given below is the work involved in a typical CBT session with a therapist:

• Each of the problems is first broken down into its constituent parts. Keeping a dairy or journal for this process can be very useful which will allow an individual to identify their though patterns, emotions, bodily sensations and actions, and provide scope for reflection and retrospect.
• The therapist and the patient will then analyze the thoughts together to identify whether they are unhelpful/unrealistic/negative and how they might be affecting the patient or others around them.
• The therapist then helps to work out strategies to change the negative/unhelpful/unrealistic though patterns
• After proper strategies have been identified, the therapist assists the patient to implement them. Homework’s might be given for practicing the skills.
• In each session, the progress on the previous session will be discussed, as well as how the patient performed between the sessions. The therapist can then analyze the progress of the therapy.
• Deciding upon the schedule and the strategies for the next CBT session will also be done at the end of each session.
• (Farmer & Chapman, 2016; Wright et al., 2017).

Strengths:

1. Different studies have shown that CBT is an effective treatment for mental conditions like depression and anxiety disorders, and studies suggest that CBT can be as effective as pharmacotherapy, regardless of how severe the condition is, among non-psychotic patients. Use of CBT is not contra-indicated by pharmaceutical prescription, and evidence shows that using the two treatments (pharmacotherapy and CBT) simultaneously can reinforce the effect. However, CBT therapy can be done without the need of pharmacotherapy, and hence, is not associated with any side effects, as seen with most pharmacotherapy (Wright et al., 2017).
2. Existence of detailed information allows the effective communication of the technique, as well as being standardized, replicated ad evaluated. CBT therapies are usually of shorter length and cheaper, compared to psychotherapy which can be expensive and time consuming. CBT moreover focuses on the management of symptom rather than creating an insight, which can allow quicker identification of technique to cope up with the condition. The shorter duration of CBT is also helpful for people who wants to schedule them between works, and thus does not significantly hamper the flow of their day to day life, unlike psychotherapy (Hoffmann et al., 2014).
3. In CBT it is important to develop the involvement of the client, and it is a hallmark feature of this therapy. Interpreting the cognition of the client and help to tackle them is done in CBT through an active partnership between the client and the therapist. They can also engage in a ‘Socratic Dialogue’ which can lead to the interpretation of their thinking. Hence most approaches of CBT puts vital focus in the development of a good interaction between the client and therapist, which can encourage the client to speak about their thoughts, and considers that therapeutic alliance is an important factor of cognitive techniques and helping to reach desired outcomes in client health (Pugh et al., 2015).
4. CBT approaches are more focused on the reduction of symptoms beyond the effects of the condition because of more generalized factors of therapy such as empathy and kindness. Studies show that she’s can be an effective tool for community psychiatric nurses (CPN), and that in patients suffering from severe depression, CPN’s who did not have any training in CBT failed to cause any improvement in the mental health condition of the patients (Diehle et al., 2015).
5. Interviews on clients have shown that CBT is considered to be more ‘user friendly’ by them compared to other forms of therapy (like psychotherapy or pharmacotherapy), and also has lower dropout rates than other therapies. Also, CBT focuses on the present, and not on hypothetical factors like the unconscious mind, resistance and transference non-utilization (Barlow et al., 2016).

Weaknesses:

1. Critiques have pointed out that the theory of depression by Beck, in the context of stable and dysfunctional belief is inconclusive, and has negative views regarding the causal factors of cognition. The design of CBT is also criticized as being ‘convenient and self serving’ which tries to place cognitive therapy against psychopharmacotherapies, and thus can have an antibiological and propsychological point of view (Wright et al., 2017).
2. According to some authors, CBT considers the cognitive triad (which the development of negative views about self, others and the future) and maladaptive cognition results in the maintenance of depression. However, many authors, including Beck also suggested that the cognitive problems are not really the cause of depression, but possibly its characteristic symptom (Beck et al., 2015).
3. There is also a criticism about the studies that support the efficacy of CBT to treat depression and anxiety, which suggests that the studies only points out that CBT is an efficient therapy but does not justify its validity fully. Moreover, in CBT there is the possibility of the therapist to develop a subjective bias while trying to find the bias in the thinking process of the client (such as forgetting or remembering information, first impressions, and making clinical decisions). This shows that the therapist objectivity can be jeopardized while trying to decide which through process is rational, what cognitive process needs to be changes and what are the dysfunctional beliefs and values in the client. Identification of these aspects are very important in CBT especially considering evidences that show that individuals suffering from depression can be more accurate in their perception of reality, and more realistic in its appraisal as well as of the world, themselves and others than non depressed individuals (Meichenbaum, 2017).
4. Some authors believe that CBT is effective in case of reactive depression, and not for psychotic, severe depression. Also, CBT is ineffective in cases of complex mental health conditions (Wright et al., 2017).
5. Some of the assumptions in CBT are inapplicable in cases of clients with personality disorders, learning and intellectual disorders (Wright et al., 2017).
6. There is an inadequate level of comprehension of the mechanisms that underlie mental health conditions, lacking the application of basic psychological researeech approaches and there are different terminologies used to describe similar cognitive functioning, which makes its study confusing, and lacks a theoretical unity (Farmer & Chapman, 2015).
7. CBT approaches have also been considered very restrictive, since in this therapy emotions are considered as factors which needs to be regulated instead of experiencing them, and the therapists put too much emphasis on rationalizing the though process instead of focusing on the unconsciousness part of it (Ho et al., 2015).

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.

Mental Health Conditions where CBT can be utilized

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.

Discussion on Evidence Base on CBT

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.

References:

Barlow, D. H., Allen, L. B., & Choate, M. L. (2016). Toward a Unified Treatment for Emotional Disorders–Republished Article. Behavior therapy, 47(6), 838-853.

Beck, A. T., Davis, D. D., & Freeman, A. (Eds.). (2015). Cognitive therapy of personality disorders. Guilford Publications.

De Castella, K., Goldin, P., Jazaieri, H., Heimberg, R. G., Dweck, C. S., & Gross, J. J. (2015). Emotion beliefs and cognitive behavioural therapy for social anxiety disorder. Cognitive behaviour therapy, 44(2), 128-141.

Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. (2015). Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: What works in children with posttraumatic stress symptoms? A randomized controlled trial. European child & adolescent psychiatry, 24(2), 227-236.

Farmer, R. F., & Chapman, A. L. (2016). Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action. American Psychological Association.

Farmer, R. F., & Chapman, A. L. (2016). Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action. American Psychological Association.

Farmer, R. F., & Chapman, A. L. (2016). Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action. American Psychological Association.

Freeman, D., Dunn, G., Startup, H., Pugh, K., Cordwell, J., Mander, H., … & Kingdon, D. (2015). Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis. The Lancet Psychiatry, 2(4), 305-313.

Friedberg, R. (2018). Procedures and processes in cognitive behavior therapy with children and adolescents. Pepsic.bvsalud.org. Retrieved 24 April 2018, from https://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1808-56872006000200002

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, G., Tharmanathan, P., Araya, R., … & Kessler, D. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. Bmj, 351, h5627.

Goldstein, T. R., Fersch-Podrat, R. K., Rivera, M., Axelson, D. A., Merranko, J., Yu, H., … & Birmaher, B. (2015). Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. Journal of child and adolescent psychopharmacology, 25(2), 140-149.

Hayes, S. C. (2016). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies–Republished Article. Behavior therapy, 47(6), 869-885.

Ho, F. Y. Y., Chung, K. F., Yeung, W. F., Ng, T. H., Kwan, K. S., Yung, K. P., & Cheng, S. K. (2015). Self-help cognitive-behavioral therapy for insomnia: a meta-analysis of randomized controlled trials. Sleep medicine reviews, 19, 17-28.

Hoffmann, T. C., Glasziou, P. P., Boutron, I., Milne, R., Perera, R., Moher, D., … & Lamb, S. E. (2014). Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. Bmj, 348, g1687.

Martin, P. R., Aiello, R., Gilson, K., Meadows, G., Milgrom, J., & Reece, J. (2015). Cognitive behavior therapy for comorbid migraine and/or tension-type headache and major depressive disorder: an exploratory randomized controlled trial. Behaviour research and therapy, 73, 8-18.

Mataix-Cols, D., de la Cruz, L. F., Monzani, B., Rosenfield, D., Andersson, E., Pérez-Vigil, A., … & Farrell, L. J. (2017). D-cycloserine augmentation of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders: a systematic review and meta-analysis of individual participant data. JAMA psychiatry, 74(5), 501-510.

Meichenbaum, D. (2017). Teaching thinking: A cognitive behavioral perspective. In The Evolution of Cognitive Behavior Therapy (pp. 85-104). Routledge.

nhs.uk. (2018). Cognitive behavioural therapy (CBT). nhs.uk. Retrieved 24 April 2018, from https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/

Pugh, N. E., Hadjistavropoulos, H. D., Hampton, A. J., Bowen, A., & Williams, J. (2015). Client experiences of guided internet cognitive behavior therapy for postpartum depression: A qualitative study. Archives of women’s mental health, 18(2), 209-219.

Rcpsych.ac.uk. (2018). Cognitive Behavioural Therapy (CBT). Rcpsych.ac.uk. Retrieved 24 April 2018, from https://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx

Wright, J. H., Brown, G. K., Thase, M. E., & Basco, M. R. (2017). Learning cognitive-behavior therapy: An illustrated guide. American Psychiatric Pub.

Wright, J. H., Brown, G. K., Thase, M. E., & Basco, M. R. (2017). Learning cognitive-behavior therapy: An illustrated guide. American Psychiatric Pub.

Zipfel, S., Wild, B., Groß, G., Friederich, H. C., Teufel, M., Schellberg, D., … & Burgmer, M. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. The Lancet, 383(9912), 127-137