Cognitive-behavioral therapy (CBT) is an amalgam of cognitive therapy and
behavioral therapies able to help patients counter negative thoughts and
behaviors underlying various mental illnesses. Science has demonstrated that
it can pack quite a therapeutic wallop.
"There are more than 375 trials of cognitive-behavioral therapy in
the research literature," Donna Sudak, M.D., director of psychotherapy
training at Friends' Hospital in Philadelphia and a member of the APA
Committee on Psychotherapy by Psychiatrists, told Psychiatric News."
There is very robust evidence of its efficacy in depression and in
multiple anxiety disorders, particularly generalized anxiety disorder,
obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder,
and social phobia.
In addition, she noted, there are data to support its use as "an
effective adjunctive treatment for bipolar disorder and
schizophrenia—not by any means as the sole line of treatment, but in
terms of increasing medication adherence, decreasing hospital days, and
increasing patients' responses to medication. There is also good evidence of
its efficacy in bulimia and as an adjunct in the treatment of a number of
medical conditions—for example, chronic pain, chronic headache, and
irritable bowel syndrome."
In fact, of all the talk therapies, CBT is "the most widely studied
in controlled, clinical trials," added Bernard Beitman, M.D., chair of
psychiatry at the University of Missouri and a member of the APA Committee on
Psychotherapy by Psychiatrists.
Anecdotal reports from psychiatrists also underscore the value of CBT.
For example, Angela Harper, M.D., a psychiatrist in private practice in
Columbia, S.C., once had a medical student as a patient. "She had a lot
of false beliefs about her ability to do the work," Harper recalled
during an interview. "Yet with the help of a year's worth of weekly CBT,
she went from being a C+ to B student to being a B+ to A student."
H. Blair Simpson, M.D., Ph.D., an assistant professor of clinical
psychiatry at Columbia University, uses CBT to help patients with
obsessive-compulsive disorder. She has seen patients make remarkable
recoveries as a result. "It is a very moving thing when you see someone
combat their disabling anxiety and gain their life back with CBT," Blair
attested. "It can not only reduce their symptoms, but also increase
their self-esteem in the process."
And aside from the direct benefits that CBT brings patients,
psychotherapists see other advantages.
"Generally compared with longer-term psychotherapies, we see progress
pretty rapidly, which is enormously rewarding for therapists and
patients," said Judith Beck, Ph.D., director of the Beck Institute for
Cognitive Therapy and Research in Philadelphia and the daughter of Aaron Beck,
M.D., the father of CBT. "A lot of the therapy is really oriented toward
`How can I help the patient have a better week?' So we are focusing on current
problems.... We are also teaching the patients how to use the techniques, for
example, breaking down larger problems into smaller parts. These are tools
that they can use for the rest of their lives."
"The nice thing about CBT," said Harper, "is that you can
use it in a 15-minute appointment, in a 60-minute appointment, or on an
inpatient service. It has a lot of different utilities to it that other
psychotherapies don't necessarily have."
For example, she noted, "patients tend to enjoy it because it is more
interactive. They get some feedback from you as a therapist and also some
helpful suggestions on what they can do when they get home and things to
practice. And a lot of patients like homework for the simple reason that it
gives them something to work on between appointments, and they feel like they
are getting some therapeutic benefit between visits."
One of the most gratifying aspects of using CBT, Simpson pointed out, is
that it provides people "with a set of skills that they can use on their
own to master their own problems."
Yet like any psychiatric treatment, CBT has its drawbacks.
"A major challenge with CBT," Beck explained, "is that
the therapist has to learn the cognitive formulation for each of the specific
psychiatric disorders that she'll be treating and has to learn how to vary
treatment for those disorders. [For example,] treatment of panic disorder has
some similarities with treatment of depression, but it is also different in
important ways."
Simpson agreed: "This is one of the big research questions now, at
least in anxiety disorders: Is there one generic CBT that one could teach
therapists and that they could then apply to the different anxiety
disorders?"
"Some of the patients don't like to do homework," said Harper."
In order to do CBT completely correctly, you really should be using
homework in your therapy... .The other thing that may be a drawback is that
some folks who are very intelligent and have a lot of insight have difficulty
at first seeing the benefits of breaking things down to more simple ways of
looking at things."
"One of the things that is really important early on with [CBT] is to
educate the patient in this way of thinking, in this way of understanding
problems," emphasized Jesse Wright, M.D., professor and chief of adult
clinical psychiatry at the University of Louisville and a CBT proponent."
And for some patients that comes very easily,... whereas for other
people, it takes a bit of effort to educate them so that they can understand
how this therapy works."
Wright added that there are some patients who just won't cooperate with the
approach CBT requires. The therapy "is not a panacea that works for
every patient in every situation. Some people prefer other kinds of treatment.
Some people would rather just take a medication and not have psychotherapy at
all."
Even with these constraints, it looks as if CBT is not only going to
continue to flourish, but to evolve.
"One of the funny, but to me expectable, evolutions of CBT,"
Beitman observed, "is that those who practice it are starting to
recognize resistance, transference, and countertransference in what goes
on.... [In other words,] they are realizing that some of the aspects of
psychodynamic therapy have relevance for doing CBT."
"CBT techniques will be modified to make them even more effective
than they are today," said Simpson. "For example, virtual reality
CBT treatments and computer-interactive CBT treatments are being developed.
There is also interest in using medications that might enhance the effects of
CBT itself. And what I anticipate, and what I hope, is that we'll know more
and more about the brain mechanisms that underlie how CBT actually
works."
"I think that what is going to happen," Beck said, "is
that CBT is going to be applied more and more widely, for different diagnoses
and for different populations. A huge amount of research in cognitive therapy
is with medical patients who have a psychological component [to their
illness].... I think there will be more of an application of cognitive therapy
in the primary care office.... And I think it will also be used more broadly
not only in individual therapy, but also in group therapy."
Finally, as Aaron Beck, M.D., university professor of psychiatry at the
University of Pennsylvania and father of cognitive therapy, told
Psychiatric News, "I think that CBT has been refined and
perfected enough that the next stage is going to be dissemination. What I
foresee is that it will be much more widely used by psychiatrists, who will
probably integrate it into treatment of the severely mentally ill, and then by
other professional groups, including psychologists, social workers, and
nurses."
He explained that his projections "are based on observations, not
just on wish fulfillment. In Britain and the Scandinavian countries, CBT has
become the dominant form of psychotherapy and has been endorsed by the
national health services of those countries." ▪