Understanding Cognitive-Behavioral Therapy?
Cognitive-Behavioral Therapy (or Cognitive-Behavior Therapy, hereafter CBT) has been noted as the most common evidence-based therapy approach used in the United States. That said, the most common “therapy” approach used here remains generic talk therapy with more or less psychodynamic characteristics. Given the absolute limited level of outcome-based evidence for effectiveness of generic “talk therapy,” it amazes me how many licensed therapists still use it. Perhaps there is a reciprocal – perhaps unconscious – emotional/attachment need satisfaction process between client and therapist. Most clients like this “talk therapy,” and they will continue to show up mainly because of the positive, accepting nature of the 
therapeutic relationship. In some cases, the clinical alliance and therapeutic relationship may be qualitatively superior than in other therapies. However, in cases of severe co-occurring disorders (those that tend to make mental health-behavioral health treatment the most costly of all), the alliance is essential for progress but the relationship alone does NOT cure. It is interesting that systems paying for professional therapy services still fund this generic form of therapy. Back to CBT.
A general way to understand CBT is to note it is present minded (a mindfulness characteristic), with ample skills learning AND PRACTICE in sessions, as well as in homework. To get clients to pay attention to homework practices, best to begin them in the session. CBT is time-limited, solutions-oriented, and aimed at problem improvement/resolution and recovery processes. The behavioral components, those that are required to distinguish CBT from cognitive therapy, include behaviorally-oriented action learning. Learning to do better, to live better, by DOING. CBT is collaborative, requires a good clinical alliance, includes ample psychoeducation, and importantly is skilled-based. It is by way of both insight and new cognitive-behavioral skills to cope better with life’s challenges/stressors that makes CBT so effective. It must be done correctly, however, to be effective. Although effective CBT requires effective assessment of past causes and conditions, it remains present-to-future oriented in its intention and direction. Some uninformed therapists may think they are doing CBT, but without the behavioral components they are simply doing cognitive therapy. Whereas CBT includes processes and skills from both cognitive and behavioral therapies, the earliest version was A. Ellis’ Rational-Emotive Behavior Therapy. More on the cognitive components to follow below.
The process of CBT includes interactive, systemic cycles of repeated thoughts and behaviors. The A-B-C model (quite behavioral) is often used. In this process model, events lead to thoughts/beliefs, which have emotional consequences. The emotional consequences (good vs bad), lead to behavioral activations (some impulsive). The thoughts and their related behaviors produce consequences. CBT is a highly structured therapy, and one that includes verbal reviews of progress (from treatment), check-ins, clarification of the session plan, etc. Cognitive components of CBT include identification of idiosyncratic automatic negative thoughts (I call them “Red Ants’) and their correction via disputation techniques. Do not use the term 
irrational; it is outdated and insulting to clients. How would you feel if a person told you “your thoughts are irrational?” Clients are helped to recognize advantages and disadvantages of their self-defeating thought patterns (more meta-cognition than single thoughts) by examination of consequences for having such thoughts – often depression, anxiety, helplessness, hopelessness, and loss of motivation. Reattribution of responsibility for outcomes is also important, as is the reframing process often used to establish reattributions. A more balanced locus of control may be a goal. Thought records are used. However, to do a better job using both cognitive and behavioral aspects, I suggest using an Experience Record that includes events, thoughts, emotions, sensations, behaviors (especially self-medication), consequences of behaviors and an evaluation of the helpfulness of the consequences. Using the cost-benefits analysis grid may also be helpful. This approach includes a quadrant regarding actual good consequences about keeping the thoughts/behaviors; actual negative consequences about maintaining the thoughts and behaviors; expected good consequences about changing the thoughts and behaviors; and, expected barriers/roadblocks about making such changes. CBT can include a harm reduction process in slowly improving thoughts and behaviors, especially in related substance misuse or self-harm aspects of problem solving. I suggest the most important parts of CBT are a solid therapeutic relationship, use of both cognitive and behavioral skills for modifying unhelpful thoughts and behaviors, and built-in behavioral reinforcement for any changes made by the client. Now we go into the behavioral components of CBT.
Common behavioral components of CBT include the use of learning theory, reinforcement, and conditioning. These clinical skills are not easy to use. As clients learn to use new behavioral coping skills they actively monitor and track their situations, their thoughts, and especially their behaviors. It is common to use an 
activity schedule to help clients engage more fully with helpful behaviors that may slowly come to replace older unhelpful (rewarding) behaviors. Clients learn how to recognize and monitor both external conditions and internal states of being in response to the external conditions. Of course, there are also internal conditions that may be monitored as well: depression, anxiety, fear, dread, sensation-emotion links, etc. Relaxation and mindfulness training (MBSR or ACT may be best) are used to help client cope better with
real and imagined (in session) challenging causes and conditions. Such stress reduction and equanimity skills are taught and practiced in sessions. Sometimes a behavioral hierarchy may be used (task analysis, exposure hierarchy, etc.). In this highly organized setting, clients practice related relaxation/mindfulness coping skills as they slowly make progress up the hierarchy; the process is matching effective coping skills with imagined or real life challenges along the way. It is common to use SUDs measures: from zero to 100 how much discomfort exists right now? Since SUDs scores tend to be used with negative situations, I have developed a SUPs scale. In SUPs: from zero to 100 how pleasant is this situation right now?In such learning, clients come to recognize how conscious and unconscious cues and stimuli may trigger internal negative states; such states have in the past caused maladaptive responses, thus making bad situations worse. A very powerful intervention is to enhance self-efficacy. As clients become more skilled and competent to deal effectively with life problems and challenges, they develop an inner sense of “can-do-it-ness.” This change has dramatic impact on both self-esteem and courage to carry on. In more advanced practice of CBT, many mindfulness-based interventions may be added. I refer to this as CBT-M. For effectiveness all mindfulness skills must be practiced, personally, by the therapist. Both cognitive an behavioral aspects of CBT are used in relapse prevention practices, where new insights (cognitive) may lead to new skill applications (behavioral). CBT, when effectively delivered and experienced, can produce highly positive changes in long-term problematic cycles of thinking and behaving.
For more information refer to Meichenbaum, D. (1977). Cognitive-Behavioral Modification: An Integrative Approach. New York: Plenum Press. Beck, A.T., Rush, A. J., Shaw, B. F. and Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Wilson, G. T. and Franks, C. M. (Eds.) (1982). Contemporary Behavior Therapy: Conceptual and Empirical Foundations. New York: Guilford Press. Persons, J. B., Davidson, J, and Tomkins, M. A. (2001). Essential Components of Cognitive-Behavior Therapy for Depression. Washington, DC: American Psychological Association. Padesky, C. A. and Greenberger, D. (1995). Clinician’s Guide to Mind Over Mood. New York: Guilford Press. Bandura, A. (1997). Self-Efficacy: The Exercise of Control. New York: W. H. Freeman. Germer, C. K., Siegel, R. D. and Fulton, P. R. (2005). Mindfulness and Psychotherapy. New York: Guilford Press. Freeman, C. and Power, M. (2007). Handbook of Evidence-Based Psychotherapies: A Guide for Research and Practice. Hoboken, NJ: J. Wiley. I have noted some classics because their details are far more specific and explicit than some more current publications.
Anthony R. Quintiliani, PhD., LADC
From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont
Author of Mindful Happiness
especially trauma and substance misuse, initiating, developing, and sustaining a hopeful future-view is highly important in client motivation and faith in beneficial change. In the client’s personal world of hopelessness (possibly helplessness), pain and suffering, a common expectation is that this “hell realm” will not end. Therefore, to enhance hope in the intersubjective space of psychotherapy, therapists need to implement certain on-going hope-based strategic interventions. Here is a list to consider. Do you routinely do these things in your sessions?
requires an exceptional therapeutic alliance (psychodynamic therapy), modifications in automatic negative thoughts (cognitive therapy), changes in unhelpful behaviors, like self-medication of pain (behavior therapy, and combinations like very well executed cognitive-behavioral therapy), commonly long-term healing outcomes have been somewhat disappointing. Perhaps an experienced and skilled therapist able to develop a high quality psychodynamic clinical alliance as well as highly effective cognitive-behavioral interventions may achieve admirable outcomes; however, that specific combination of skills is not common. I am suggesting that a high quality helping alliance and successful interventions in thinking and behavior problems may be helpful for people suffering from serious trauma. However, most of these approaches (other than informed and skilled DBT) miss the mark when it comes to integrated positive impact on the mind-body system. Even in DBT (and CBT), it is common for it to be used as a form of cognitive therapy – leaving the important behavioral and body-based areas out all together. To take a new look at the traumatized mind-body, witness current successes in trauma-informed yoga and meditation for PTSD. Recent meta-analytical reviews have noted that meditation (and yoga to a lesser degree) do improve depression, anxiety, physical pain (emotional pain?), and emotion regulation. Therefore, such body-based approaches improve three (depression, anxiety, self-medication) of the common clinical conditions associated with serious trauma.
mindfulness-based interventions in trauma, the best therapists are also practitioners in these practices. Limbic and prefrontal interventions, NOT psychodynamic and cognitive interventions, may be highly helpful in effective trauma-informed psychotherapy.
