Cognitive Behavioral Therapy

The historical foundations of behavioral therapy (BT) and cognitive behavioral therapy (CBT) date back thousands of years to ancient philosophers who advocated the use of consequences to change behavior and the role of perception in mood. The modern history of CBT began with early learning theorists such as John B. Watson, the founder of behaviorism, who recommended focusing only on observable behaviors that can be reliably measured. Ivan Pavlov and B. F. Skinner laid the groundwork for classical and operant learning theories, which provide a framework for understanding the development and maintenance of emotions and behavior.

The 1950s marked the beginning of the modern era of contemporary CBT with the advent of behavioral treatments for the problematic anxiety reactions (e.g., systematic desensitization by Joseph Wolpe) seen in many of the returning World War II veterans. These early contemporary CBT theorists focused on the assessment of observable behavior and treatment changes to demonstrate the efficacy of the treatment plan. During the 1960s, Albert Bandura's social learning theory introduced the notion that we can learn through modeling; this required a role for cognition in learning and paved the way for CBT. At first, BT and CBT were met with skepticism by the clinical psychology field. Both theories proposed that current environmental and cognitive appraisals could be addressed in the here and now to produce lasting therapeutic change. These ideas were fought with vigor, and theories of symptom substitution–the notion that treatment without uncovering the intrapsychic source of symptoms could lead to the development of other symptoms– were presented but never empirically supported. Today, BT and CBT have been firmly established as mainstream treatments.

Cognitive behavioral therapy assumes that problems of thoughts, emotions, and behavior are developed, maintained, and changed through the process of learning (e.g., reinforcement, associative learning, modeling) unrealistic beliefs and expectations. It is based on the scientific method in that it involves a systematic assessment of problem thoughts, emotions, and behaviors and leads to specific interventions that are designed to target these problem areas, as well as the assessment and evaluation of treatment outcome. Behavioral assessment is characterized by multimodal (cognitions, emotions, physiology, and behaviors) and multimethod (interview, self- and other report, self-monitoring, observation of behavior) strategies. These procedures are designed to create measurable treatment goals that encapsulate the client's presenting problems and inform the treatment plan.

Cognitive behavioral therapy is a here-and-now treatment in that client problems are conceptualized on the basis of current maintaining factors (e.g., current environmental antecedents and reinforcement). The present focus of CBT is predicated on the notion that the factors and precipitants associated with the onset of symptoms are not necessarily responsible for the maintenance of these symptoms. For example, a 33-year-old client with a 10-year history of panic symptoms and behavioral avoidance that developed upon graduating college may respond better to the treatment of current unrealistic thought patterns and avoidance than to interventions focused on uncovering a presumed precipitating conflict.

Cognitive behavioral therapy takes an active approach in which the maintaining antecedents and consequences of behavior are treated through a collaborative therapy relationship. Clients actively engage in exercises jointly designed to learn new adaptive behavior (skill-building interventions) and develop alternative interpretations of life events (cognitive restructuring). In cognitive restructuring, clients learn that “thoughts are not facts.” Collaborative analyses of specific problematic situations and their associated thoughts, emotions, and behaviors are often written on a thought record. The thought record is used to demonstrate how our thoughts lead to problematic emotional and behavioral responses and to develop evidence-based alternative interpretations and coping strategies. For example, an individual who expects that a request for a date will be met with a response of horror may be encouraged to engage in a behavioral experiment that is designed to collect information on whether that prediction is evidence based. It is important for the CBT therapist to remind the client that the experiment is designed to gather [Page 105]evidence about a belief (within the client's control), not to obtain a date (outside the client's control). Clients are encouraged to examine the evidence for negative or “hot” cognitions by retrospectively listing evidence for and against a particular belief.

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