Johns Hopkins Psychiatry Guide

Cognitive Behavioral Therapy (CBT)

Kelly Drake, Ph.D., Courtney P. Keeton, Ph.D., Golda S. Ginsburg, Ph.D.

DESCRIPTION

  • Cognitive behavioral therapy (CBT) is an empirically-supported approach to psychotherapy characterized by teaching the patient a set of coping skills.
    • The skills are intended to modify maladaptive cognitions, behaviors, and physiological responses that maintain and/or exacerbate psychopathology.
  • The approach is present–focused and problem-specific.
    • CBT sessions are structured and goal-oriented.
    • The course is time-limited (typically one hour session per week for 10-20 weeks) and the CBT therapist is directive and action-oriented.

MECHANISM

The mechanisms of action are unclear but researchers have explored:

  • Cognitive mechanisms: Increase in adaptive cognitions may occur through restructuring of maladaptive thought patterns, correction of misinterpretations, changes in attentional focus, and development of adaptive coping thoughts.
  • Behavioral mechanisms: Increase of adaptive behavioral responses may occur through habituation, extinction of maladaptive responses, behavioral activation, associative learning, and reinforcement of adaptive responding.
  • Physiological mechanisms: Normalization of physiological arousal may occur through habituation, incompatible response training, and changes in autonomic nervous system activity.

INDICATIONS

CONTRAINDICATIONS

  • For patients with significant illness, such as a severe mood disorder for example, providers may need to initiate a trial of medications prior to starting CBT in order to facilitate session attendance and adherence.
  • Individuals with very limited intellectual functioning may not fully benefit from CBT.
  • CBT strategies should be modified/adapted for use with special groups (e.g., older adults, young children) to ensure it is delivered in a developmentally appropriate and culturally competent manner.
  • CBT therapists should routinely monitor the need for alternative treatments for comorbid conditions (e.g., in patients who are suicidal).

TECHNIQUE

  • CBT typically consists of 10-20 sessions, lasting approximately one hour, once per week, that are delivered individually, with a family, or in small groups. Innovative methods involving Internet-based and clinician-assisted computer programs have begun to emerge in recent years.
  • CBT includes a variety of therapeutic strategies, including:
    • Psychoeducation: Providing information to help the patient understand the nature of mental illness
    • Cognitive restructuring: Identifying, challenging, and replacing maladaptive thoughts with adaptive, realistic, coping thoughts
    • Exposure: Reducing avoidance (which maintains anxiety states via negative reinforcement) and increasing approach behavior (e.g., facing fears rather than avoiding them)
    • Behavioral activation: Increasing engagement in pleasurable or useful activities (e.g., exercise), and utilizing social support
    • Relaxation training: Reducing physiological reactivity by learning and practicing relaxation exercises including deep diaphragmatic breathing, guided imagery, progressive muscle relaxation, and present sensory focus
    • Homework: Conducting out-of-session practice to facilitate the acquisition and mastery of coping skills
    • Relapse prevention: Normalizing “slips” and preventing future episodes by continuing to practice CBT skills and develop proactive plans for coping with future stressors and/or symptoms

EFFICACY

  • A recent review of 269 meta-analyses found strong evidence to support the use of CBT to treat anxiety disorders, somatoform disorders, eating disorders, anger problems, and general stress [3].
  • The evidence supporting CBT for anxiety disorders is consistently strong [1] [2] [3] [4].
  • CBT for depression is more effective than treatment as usual and waitlist control conditions, but there is insufficient evidence to suggest that it is more effective than other active treatments [3] [5].

SPECIAL POPULATIONS

  • Children: evidence supporting the efficacy of CBT in young children is promising but limited.
  • Autism spectrum: CBT appears to be effective in children and adolescents with high-functioning autism spectrum disorders.
  • Older adults: CBT is more effective than treatment as usual and wait list control treatments in reducing symptoms of depression in older adults but is equally effective compared to other active psychological treatments [5].

ADVERSE REACTIONS

  • There are no known significant long-term side effects.

COMMENTS

  • CBT is the most widely studied psychotherapeutic approach.
  • A wealth of evidence supports its use with a variety of psychiatric symptoms and illnesses. Moreover, positive findings have been reported with patients across the lifespan. More rigorous evidence is needed to evaluate CBT in comparison with other active treatments before conclusions can be drawn regarding its superiority to other treatments. Notwithstanding, given the existing evidence and time-limited nature of CBT, the intervention may be a useful and cost-effective first-line of treatment for many patients.

References

  1. Butler AC et al: The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 26:17, 2006  [PMID:16199119]
  2. Chambless DL, Ollendick TH: Empirically supported psychological interventions: controversies and evidence. Annu Rev Psychol 52:685, 2001  [PMID:11148322]
  3. Gould RL, Coulson MC, Howard RJ: Cognitive behavioral therapy for depression in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc 60:1817, 2012  [PMID:23003115]
  4. Hofmann SG et al: The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res 36:427, 2012  [PMID:23459093]
  5. James AC et al: Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 6:, 2013  [PMID:23733328]
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Last updated: November 21, 2014