What is Rational Emotive Behaviour Therapy?

Introduction

Rational emotive behaviour therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioural problems and disturbances and to help people to lead happier and more fulfilling lives.

REBT posits that people have erroneous beliefs about situations they are involved in, and that these beliefs cause disturbance, but can be disputed with and changed.

Brief History

Rational emotive behaviour therapy (REBT) was created and developed by the American psychotherapist and psychologist Albert Ellis, who was inspired by many of the teachings of Asian, Greek, Roman and modern philosophers. REBT is the first form of cognitive behavioural therapy (CBT) and was first expounded by Ellis in the mid-1950s; development continued until his death in 2007. Ellis became synonymous with the highly influential therapy. Psychology Today noted, “No individual—not even Freud himself—has had a greater impact on modern psychotherapy.”

REBT is both a psychotherapeutic system of theory and practices and a school of thought established by Ellis. He first presented his ideas at a conference of the American Psychological Association in 1956 then published a seminal article in 1957 entitled “Rational psychotherapy and individual psychology”, in which he set the foundation for what he was calling rational therapy (RT) and carefully responded to questions from Rudolf Dreikurs and others about the similarities and differences with Alfred Adler’s Individual psychology. This was around a decade before psychiatrist Aaron Beck first set forth his “cognitive therapy”, after Ellis had contacted him in the mid 1960s. Ellis’ own approach was renamed Rational Emotive Therapy in 1959, then the current term in 1992.

Precursors of certain fundamental aspects of rational emotive behaviour therapy have been identified in ancient philosophical traditions, particularly to Stoicists Marcus Aurelius, Epictetus, Zeno of Citium, Chrysippus, Panaetius of Rhodes, Cicero, and Seneca, and early Asian philosophers Confucius and Gautama Buddha. In his first major book on rational therapy, Ellis wrote that the central principle of his approach, that people are rarely emotionally affected by external events but rather by their thinking about such events, “was originally discovered and stated by the ancient Stoic philosophers”. Ellis illustrates this with a quote from the Enchiridion of Epictetus: “Men are disturbed not by things, but by the views which they take of them.” Ellis noted that Shakespeare expressed a similar thought in Hamlet: “There’s nothing good or bad but thinking makes it so.” Ellis also acknowledges early 20th century therapists, particularly Paul Charles Dubois, though he only read his work several years after developing his therapy.

Theoretical Assumptions

The REBT framework posits that humans have both innate rational (meaning self-helping, socially helping, and constructive) and irrational (meaning self-defeating, socially defeating, and unhelpful) tendencies and leanings. REBT claims that people to a large degree consciously and unconsciously construct emotional difficulties such as self-blame, self-pity, clinical anger, hurt, guilt, shame, depression and anxiety, and behaviours and behaviour tendencies like procrastination, compulsiveness, avoidance, addiction and withdrawal by the means of their irrational and self-defeating thinking, emoting and behaving.

REBT is then applied as an educational process in which the therapist often active-directively teaches the client how to identify irrational and self-defeating beliefs and philosophies which in nature are rigid, extreme, unrealistic, illogical and absolutist, and then to forcefully and actively question and dispute them and replace them with more rational and self-helping ones. By using different cognitive, emotive and behavioural methods and activities, the client, together with help from the therapist and in homework exercises, can gain a more rational, self-helping and constructive rational way of thinking, emoting and behaving.

One of the main objectives in REBT is to show the client that whenever unpleasant and unfortunate activating events occur in people’s lives, they have a choice between making themselves feel healthily or, self-helpingly, sorry, disappointed, frustrated, and annoyed or making themselves feel unhealthily and self-defeatingly horrified, terrified, panicked, depressed, self-hating and self-pitying. By attaining and ingraining a more rational and self-constructive philosophy of themselves, others and the world, people often are more likely to behave and emote in more life-serving and adaptive ways.

Beliefs about Circumstances, and Disputing the Beliefs

A fundamental premise of REBT is humans do not get emotionally disturbed by unfortunate circumstances, but by how they construct their views of these circumstances through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others. This concept has been attributed as far back as the Roman philosopher Epictetus, who is often cited as utilising similar ideas in antiquity.

In REBT, clients usually learn and begin to apply this premise by learning the A-B-C-D-E-F model of psychological disturbance and change. The following letters represent the following meanings in this model:

  • A – The adversity.
  • B – The developed belief in the person of the Adversity.
  • C – The consequences of that person’s Beliefs i.e., B.
  • D – The person’s disputes of A, B, and C. In latter thought.
  • E – The effective new philosophy or belief that develops in that person through the occurrence of D in their minds of A and B.
  • F – The developed feelings of one’s self either at point and after point C or at point after point E.

The A-B-C model states that it is not an A, adversity (or activating event) that cause disturbed and dysfunctional emotional and behavioural Cs, consequences, but also what people B, irrationally believe about the A, adversity. A, adversity can be an external situation, or a thought, a feeling or other kind of internal event, and it can refer to an event in the past, present, or future.

The Bs, irrational beliefs that are most important in the A-B-C model are explicit and implicit philosophical meanings and assumptions about events, personal desires, and preferences. The Bs, beliefs that are most significant are highly evaluative and consist of interrelated and integrated cognitive, emotional and behavioural aspects and dimensions. According to REBT, if a person’s evaluative B, belief about the A, activating event is rigid, absolutistic, fictional and dysfunctional, the C, the emotional and behavioural consequence, is likely to be self-defeating and destructive. Alternatively, if a person’s belief is preferential, flexible and constructive, the C, the emotional and behavioural consequence is likely to be self-helping and constructive.

Through REBT, by understanding the role of their mediating, evaluative and philosophically based illogical, unrealistic and self-defeating meanings, interpretations and assumptions in disturbance, individuals can learn to identify them, then go to D, disputing and questioning the evidence for them. At E, effective new philosophy, they can recognise and reinforce the notion no evidence exists for any psychopathological must, ought or should and distinguish them from healthy constructs, and subscribe to more constructive and self-helping philosophies. This new reasonable perspective leads to F, new feelings and behaviours appropriate to the A they are addressing in the exercise.

Psychological Dysfunction

One of the main pillars of REBT is that irrational and dysfunctional ways and patterns of thinking, feeling, and behaving are contributing to human disturbance and emotional and behavioural self-defeatism and social defeatism. REBT generally teaches that when people turn flexible preferences, desires and wishes into grandiose, absolutistic and fatalistic dictates, this tends to contribute to disturbance and upset. These dysfunctional patterns are examples of cognitive distortions.

Core Beliefs that Disturb Humans

Albert Ellis has suggested three core beliefs or philosophies that humans tend to disturb themselves through:

“I absolutely MUST, under practically all conditions and at all times, perform well (or outstandingly well) and win the approval (or complete love) of significant others. If I fail in these important—and sacred—respects, that is awful and I am a bad, incompetent, unworthy person, who will probably always fail and deserves to suffer.”“Other people with whom I relate or associate, absolutely MUST, under practically all conditions and at all times, treat me nicely, considerately and fairly. Otherwise, it is terrible and they are rotten, bad, unworthy people who will always treat me badly and do not deserve a good life and should be severely punished for acting so abominably to me.”“The conditions under which I live absolutely MUST, at practically all times, be favorable, safe, hassle-free, and quickly and easily enjoyable, and if they are not that way it’s awful and horrible and I can’t bear it. I can’t ever enjoy myself at all. My life is impossible and hardly worth living.”
Holding this belief when faced with adversity tends to contribute to feelings of anxiety, panic, depression, despair, and worthlessness.Holding this belief when faced with adversity tends to contribute to feelings of anger, rage, fury, and vindictiveness.Holding this belief when faced with adversity tends to contribute to frustration and discomfort, intolerance, self-pity, anger, depression, and to behaviours such as procrastination, avoidance, addictive behaviours and inaction.

Rigid Demands that Humans Make

REBT commonly posits that at the core of irrational beliefs there often are explicit or implicit rigid demands and commands, and that extreme derivatives like awfulising, low frustration tolerance, people deprecation and over-generalisations are accompanied by these. According to REBT the core dysfunctional philosophies in a person’s evaluative emotional and behavioural belief system, are also very likely to contribute to unrealistic, arbitrary and crooked inferences and distortions in thinking. REBT therefore first teaches that when people in an insensible and devout way overuse absolutistic, dogmatic and rigid “shoulds”, “musts”, and “oughts”, they tend to disturb and upset themselves.

Over-Generalisation

Further, REBT generally posits that disturbed evaluations to a large degree occur through over-generalisation, wherein people exaggerate and globalise events or traits, usually unwanted events or traits or behaviour, out of context, while almost always ignoring the positive events or traits or behaviours. For example, awfulising is partly mental magnification of the importance of an unwanted situation to a catastrophe or horror, elevating the rating of something from bad to worse than it should be, to beyond totally bad, worse than bad to the intolerable and to a “holocaust”. The same exaggeration and overgeneralising occurs with human rating, wherein humans come to be arbitrarily and axiomatically defined by their perceived flaws or misdeeds. Frustration intolerance then occurs when a person perceives something to be too difficult, painful or tedious, and by doing so exaggerates these qualities beyond one’s ability to cope with them.

Secondary Disturbances

Essential to REBT theory is also the concept of secondary disturbances which people sometimes construct on top of their primary disturbance. As Ellis emphasizes:

“Because of their self-consciousness and their ability to think about their thinking, they can very easily disturb themselves about their disturbances and can also disturb themselves about their ineffective attempts to overcome their emotional disturbances.”

Origins of Dysfunction

Regarding cognitive-affective-behavioral processes in mental functioning and dysfunctioning, originator Albert Ellis explains:

“REBT assumes that human thinking, emotion, and action are not really separate or disparate processes, but that they all significantly overlap and are rarely experienced in a pure state. Much of what we call emotion is nothing more nor less than a certain kind—a biased, prejudiced, or strongly evaluative kind—of thought. But emotions and behaviors significantly influence and affect thinking, just as thinking influences emotions and behaviors. Evaluating is a fundamental characteristic of human organisms and seems to work in a kind of closed circuit with a feedback mechanism: First, perception biases response, and then response tends to bias subsequent perception. Also, prior perceptions appear to bias subsequent perceptions, and prior responses appear to bias subsequent responses. What we call feelings almost always have a pronounced evaluating or appraisal element.”

REBT then generally proposes that many of these self-defeating cognitive, emotive and behavioural tendencies are both innately biological and indoctrinated early in and during life, and further grow stronger as a person continually revisits, clings and acts on them. Ellis alludes to similarities between REBT and the general semantics when explaining the role of irrational beliefs in self-defeating tendencies, citing Alfred Korzybski as a significant modern influence on this thinking.

REBT differs from other clinical approaches like psychoanalysis in that it places little emphasis on exploring the past, but instead focuses on changing the current evaluations and philosophical thinking-emoting and behaving in relation to themselves, others and the conditions under which people live.

Irrational Beliefs

REBT proposes four core irrational beliefs;

  1. Demands: The tendency to demand success, fair treatment, and respect (e.g. I must be treated fairly).
  2. Awfulizing: The tendency to consider adverse events as awful or terrible (e.g. It is awful when I am disrespected).
  3. Low Frustration Tolerance (LFT): The belief that one could not stand or tolerate adversity (e.g. I cannot stand being treated unfairly).
  4. Depreciation: The belief that one event reflects the person as a whole (e.g. When I fail it shows that I am a complete failure).

Other Insights

Other insights of REBT (some referring to the ABCDEF model above) are:

  • Insight 1:
    • People seeing and accepting the reality that their emotional disturbances at point C are only partially caused by the activating events or adversities at point A that precede C.
    • Although A contributes to C, and although disturbed Cs (such as feelings of panic and depression) are much more likely to follow strong negative As (such as being assaulted or raped), than they are to follow weak.
    • As (such as being disliked by a stranger), the main or more direct cores of extreme and dysfunctional emotional disturbances (Cs) are people’s irrational beliefs – the “absolutistic” (inflexible) “musts” and their accompanying inferences and attributions that people strongly believe about the activating event.
  • Insight 2:
    • No matter how, when, and why people acquire self-defeating or irrational beliefs (i.e. beliefs that are the main cause of their dysfunctional emotional-behavioural consequences), if they are disturbed in the present, they tend to keep holding these irrational beliefs and continue upsetting themselves with these thoughts.
    • They do so not because they held them in the past, but because they still actively hold them in the present (often unconsciously), while continuing to reaffirm their beliefs and act as if they are still valid.
    • In their minds and hearts, the troubled people still follow the core “musturbatory” philosophies they adopted or invented long ago, or ones they recently accepted or constructed.
  • Insight 3:
    • No matter how well they have gained insights 1 and 2, insight alone rarely enables people to undo their emotional disturbances.
    • They may feel better when they know, or think they know, how they became disturbed, because insights can feel useful and curative.
    • But it is unlikely that people will actually get better and stay better unless they have and apply insight 3, which is that there is usually no way to get better and stay better except by continual work and practice in looking for and finding one’s core irrational beliefs; actively, energetically, and scientifically disputing them; replacing one’s absolute “musts” (rigid requirements about how things should be) with more flexible preferences; changing one’s unhealthy feelings to healthy, self-helping emotions; and firmly acting against one’s dysfunctional fears and compulsions.
    • Only by a combined cognitive, emotive, and behavioural, as well as a quite persistent and forceful attack on one’s serious emotional problems, is one likely to significantly ameliorate or remove them, and keep them removed.

Intervention

As explained, REBT is a therapeutic system of both theory and practice; generally one of the goals of REBT is to help clients see the ways in which they have learned how they often needlessly upset themselves, teach them how to “un-upset” themselves and then how to empower themselves to lead happier and more fulfilling lives. The emphasis in therapy is generally to establish a successful collaborative therapeutic working alliance based on the REBT educational model. Although REBT teaches that the therapist or counsellor is better served by demonstrating unconditional other-acceptance or unconditional positive regard, the therapist is not necessarily always encouraged to build a warm and caring relationship with the client. The tasks of the therapist or counsellor include understanding the client’s concerns from his point of reference and work as a facilitator, teacher and encourager.

In traditional REBT, the client together with the therapist, in a structured active-directive manner, often work through a set of target problems and establish a set of therapeutic goals. In these target problems, situational dysfunctional emotions, behaviours and beliefs are assessed in regards to the client’s values and goals. After working through these problems, the client learns to generalise insights to other relevant situations. In many cases after going through a client’s different target problems, the therapist is interested in examining possible core beliefs and more deep rooted philosophical evaluations and schemas that might account for a wider array of problematic emotions and behaviours. Although REBT much of the time is used as a brief therapy, in deeper and more complex problems, longer therapy is promoted.

In therapy, the first step often is that the client acknowledges the problems, accepts emotional responsibility for these and has willingness and determination to change. This normally requires a considerable amount of insight, but as originator Albert Ellis explains:

“Humans, unlike just about all the other animals on earth, create fairly sophisticated languages which not only enable them to think about their feeling, their actions, and the results they get from doing and not doing certain things, but they also are able to think about their thinking and even think about thinking about their thinking.”

Through the therapeutic process, REBT employs a wide array of forceful and active, meaning multimodal and disputing, methodologies. Central through these methods and techniques is the intent to help the client challenge, dispute and question their destructive and self-defeating cognitions, emotions and behaviours. The methods and techniques incorporate cognitive-philosophic, emotive-evocative-dramatic, and behavioural methods for disputation of the client’s irrational and self-defeating constructs and helps the client come up with more rational and self-constructive ones. REBT seeks to acknowledge that understanding and insight are not enough; in order for clients to significantly change, they need to pinpoint their irrational and self-defeating constructs and work forcefully and actively at changing them to more functional and self-helping ones.

REBT posits that the client must work hard to get better, and in therapy this normally includes a wide array of homework exercises in day-to-day life assigned by the therapist. The assignments may for example include desensitisation tasks, i.e. by having the client confront the very thing he or she is afraid of. By doing so, the client is actively acting against the belief that often is contributing significantly to the disturbance.

Another factor contributing to the brevity of REBT is that the therapist seeks to empower the client to help himself through future adversities. REBT only promotes temporary solutions if more fundamental solutions are not found. An ideal successful collaboration between the REBT therapist and a client results in changes to the client’s philosophical way of evaluating himself or herself, others, and his or her life, which will likely yield effective results. The client then moves toward unconditional self-acceptance, other-acceptance and life-acceptance while striving to live a more self-fulfilling and happier life.

Applications and Interfaces

Applications and interfaces of REBT are used with a broad range of clinical problems in traditional psychotherapeutic settings such as individual-, group- and family therapy. It is used as a general treatment for a vast number of different conditions and psychological problems normally associated with psychotherapy.

In addition, REBT is used with non-clinical problems and problems of living through counselling, consultation and coaching settings dealing with problems including relationships, social skills, career changes, stress management, assertiveness training, grief, problems with aging, money, weight control etc. More recently, the reported use of REBT in sport and exercise settings has grown, with the efficacy of REBT demonstrated across a range of sports.

REBT also has many interfaces and applications through self-help resources, phone and internet counselling, workshops & seminars, workplace and educational programmes, etc. This includes Rational Emotive Education (REE) where REBT is applied in education settings, Rational Effectiveness Training in business and work-settings and SMART Recovery (Self Management And Recovery Training) in supporting those in addiction recovery, in addition to a wide variety of specialised treatment strategies and applications.

Efficacy

REBT and CBT in general have a substantial and strong research base to verify and support both their psychotherapeutic efficiency and their theoretical underpinnings. Meta-analyses of outcome-based studies reveal REBT to be effective for treating various psychopathologies, conditions and problems. Recently, REBT randomised clinical trials have offered a positive view on the efficacy of REBT.

In general REBT is arguably one of the most investigated theories in the field of psychotherapy and a large amount of clinical experience and a substantial body of modern psychological research have validated and substantiated many of REBTs theoretical assumptions on personality and psychotherapy.

REBT may be effective in improving sports performance and mental health.

Limitations and Critique

The clinical research on REBT has been criticised both from within and by others. For instance, originator Albert Ellis has on occasions emphasized the difficulty and complexity of measuring psychotherapeutic effectiveness, because many studies only tend to measure whether clients merely feel better after therapy instead of them getting better and staying better. Ellis has also criticised studies for having limited focus primarily to cognitive restructuring aspects, as opposed to the combination of cognitive, emotive and behavioural aspects of REBT. As REBT has been subject to criticisms during its existence, especially in its early years, REBT theorists have a long history of publishing and addressing those concerns. It has also been argued by Ellis and by other clinicians that REBT theory on numerous occasions has been misunderstood and misconstrued both in research and in general.

Some have criticised REBT for being harsh, formulaic and failing to address deep underlying problems. REBT theorists have argued in reply that a careful study of REBT shows that it is both philosophically deep, humanistic and individualised collaboratively working on the basis of the client’s point of reference. They have further argued that REBT utilises an integrated and interrelated methodology of cognitive, emotive-experiential and behavioural interventions. Others have questioned REBTs view of rationality, both radical constructivists who have claimed that reason and logic are subjective properties and those who believe that reason can be objectively determined. REBT theorists have argued in reply that REBT raises objections to clients’ irrational choices and conclusions as a working hypothesis and through collaborative efforts demonstrate the irrationality on practical, functional and social consensual grounds. In 1998 when asked what the main criticism on REBT was, Albert Ellis replied that it was the claim that it was too rational and not dealing sufficiently enough with emotions. He repudiated the claim by saying that REBT on the contrary emphasizes that thinking, feeling, and behaving are interrelated and integrated, and that it includes a vast amount of both emotional and behavioural methods in addition to cognitive ones.

Ellis has himself in very direct terms criticised opposing approaches such as psychoanalysis, transpersonal psychology and abreactive psychotherapies in addition to on several occasions questioning some of the doctrines in certain religious systems, spiritualism and mysticism. Many, including REBT practitioners, have warned against dogmatising and sanctifying REBT as a supposedly perfect psychological panacea. Prominent REBTers have promoted the importance of high quality and programmatic research, including originator Ellis, a self-proclaimed “passionate sceptic”. He has on many occasions been open to challenges and acknowledged errors and inefficiencies in his approach and concurrently revised his theories and practices. In general, with regard to cognitive-behavioural psychotherapies’ interventions, others have pointed out that as about 30-40% of people are still unresponsive to interventions, that REBT could be a platform of reinvigorating empirical studies on the effectiveness of the cognitive-behavioural models of psychopathology and human functioning.

REBT has been developed, revised and augmented through the years as understanding and knowledge of psychology and psychotherapy have progressed. This includes its theoretical concepts, practices and methodology. The teaching of scientific thinking, reasonableness and un-dogmatism has been inherent in REBT as an approach, and these ways of thinking are an inextricable part of REBT’s empirical and sceptical nature.

I hope I am also not a devout REBTer, since I do not think it is an unmitigated cure for everyone and do accept its distinct limitations. (Albert Ellis).

Mental Wellness

As would be expected, REBT argues that mental wellness and mental health to a large degree results from an adequate amount of self-helping, flexible, logico-empirical ways of thinking, emoting and behaving. When a perceived undesired and stressful activating event occurs, and the individual is interpreting, evaluating and reacting to the situation rationally and self-helpingly, then the resulting consequence is, according to REBT, likely to be more healthy, constructive and functional. This does not by any means mean that a relatively un-disturbed person never experiences negative feelings, but REBT does hope to keep debilitating and un-healthy emotions and subsequent self-defeating behaviour to a minimum. To do this, REBT generally promotes a flexible, un-dogmatic, self-helping and efficient belief system and constructive life philosophy about adversities and human desires and preferences.

REBT clearly acknowledges that people, in addition to disturbing themselves, also are innately constructivists. Because they largely upset themselves with their beliefs, emotions and behaviours, they can be helped to, in a multimodal manner, dispute and question these and develop a more workable, more self-helping set of constructs.

REBT generally teaches and promotes:

  • That the concepts and philosophies of life of unconditional self-acceptance, other-acceptance, and life-acceptance are effective philosophies of life in achieving mental wellness and mental health.
  • That human beings are inherently fallible and imperfect and that they are better served by accepting their and other human beings’ totality and humanity, while at the same time they may not like some of their behaviours and characteristics.
    • That they are better off not measuring their entire self or their “being” and give up the narrow, grandiose and ultimately destructive notion to give themselves any global rating or report card.
    • This is partly because all humans are continually evolving and are far too complex to accurately rate; all humans do both self-defeating/socially defeating and self-helping / socially helping deeds, and have both beneficial and un-beneficial attributes and traits at certain times and in certain conditions.
    • REBT holds that ideas and feelings about self-worth are largely definitional and are not empirically confirmable or falsifiable.
  • That people had better accept life with its hassles and difficulties not always in accordance with their wants, while trying to change what they can change and live as elegantly as possible with what they cannot change.

What is Cognitive Behavioural Therapy?

Introduction

Cognitive behavioural therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing unhelpful cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviours, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behaviour psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

CBT is based on the combination of the basic principles from behavioural and cognitive psychology. It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviours and then formulates a diagnosis. Instead, CBT is a “problem-focused” and “action-oriented” form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist’s role is to assist the client in finding and practicing effective strategies to address the identified goals and decrease symptoms of the disorder. CBT is based on the belief that thought distortions and maladaptive behaviours play a role in the development and maintenance of psychological disorders, and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.

When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression, anxiety, post traumatic stress disorder (PTSD), tics, substance abuse, eating disorders and borderline personality disorder. Some research suggests that CBT is most effective when combined with medication for treating mental disorders such as major depressive disorder. In addition, CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice. Psychiatry residents in the United States are mandated to receive training in psychodynamic, cognitive-behavioural, and supportive psychotherapy.

Brief History

Philosophical Roots

Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioural therapists identify cognitive distortions that contribute to depression and anxiety. For example, Aaron T. Beck’s original treatment manual for depression states, “The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers”. Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis. A key philosophical figure who also influenced the development of CBT was John Stuart Mill.

Behaviour Therapy Roots

The modern roots of CBT can be traced to the development of behaviour therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Groundbreaking work of behaviourism began with John B. Watson and Rosalie Rayner’s studies of conditioning in 1920. Behaviourally-centred therapeutic approaches appeared as early as 1924 with Mary Cover Jones’ work dedicated to the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe’s behavioural therapy in the 1950s. It was the work of Wolpe and Watson, which was based on Ivan Pavlov’s work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioural therapy techniques based on classical conditioning.

During the 1950s and 1960s, behavioural therapy became widely utilised by researchers in the United States, the United Kingdom, and South Africa, who were inspired by the behaviourist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull. In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitisation, applied behavioural research to the treatment of neurotic disorders. Wolpe’s therapeutic efforts were precursors to today’s fear reduction techniques. British psychologist Hans Eysenck presented behaviour therapy as a constructive alternative.

At the same time as Eysenck’s work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning. Skinner’s work was referred to as radical behaviourism and avoided anything related to cognition. However, Julian Rotter, in 1954, and Albert Bandura, in 1969, contributed behaviour therapy with their respective work on social learning theory, by demonstrating the effects of cognition on learning and behaviour modification. The work of the Australian Claire Weekes dealing with anxiety disorders in the 1960s was also seen as a prototype of behaviour therapy.

The emphasis on behavioural factors constituted the “first wave” of CBT.

Cognitive Therapy Roots

One of the first therapists to address cognition in psychotherapy was Alfred Adler with his notion of basic mistakes and how they contributed to creation of unhealthy or useless behavioural and life goals. Adler’s work influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy, known today as rational emotive behaviour therapy (REBT). Ellis also credits Abraham Low as a founder of cognitive behavioural therapy.

Around the same time that rational emotive therapy, as it was known then, was being developed, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorised, and that certain types of thinking may be the culprits of emotional distress. It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts “automatic thoughts”. Beck has been referred to as “the father of cognitive behavioural therapy.”

It was these two therapies, rational emotive therapy and cognitive therapy, that started the “second wave” of CBT, which was the emphasis on cognitive factors.

Behaviour and Cognitive Therapies Merge – “Third Wave” CBT

Although the early behavioural approaches were successful in many of the neurotic disorders, they had little success in treating depression. Behaviourism was also losing in popularity due to the so-called “cognitive revolution”. The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behaviour therapists, despite the earlier behaviourist rejection of “mentalistic” concepts like thoughts and cognitions. Both of these systems included behavioural elements and interventions and primarily concentrated on problems in the present.

In initial studies, cognitive therapy was often contrasted with behavioural treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioural techniques were merged into cognitive behavioural therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US.

Over time, cognitive behaviour therapy came to be known not only as a therapy, but as an umbrella term for all cognitive-based psychotherapies. These therapies include, but are not limited to, rational emotive therapy (RET), cognitive therapy, acceptance and commitment therapy, dialectical behaviour therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy. All of these therapies are a blending of cognitive- and behaviour-based elements.

This blending of theoretical and technical foundations from both behaviour and cognitive therapies constituted the “third wave” of CBT. The most prominent therapies of this third wave are dialectical behaviour therapy and acceptance and commitment therapy.

Despite increasing popularity of “third-wave” treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with “non-third wave” CBT for the treatment of depression.

Description

Mainstream cognitive behavioural therapy assumes that changing maladaptive thinking leads to change in behaviour and affect, but recent variants emphasize changes in one’s relationship to maladaptive thinking rather than changes in thinking itself. The goal of cognitive behavioural therapy is not to diagnose a person with a particular disease, but to look at the person as a whole and decide what can be altered.

Cognitive Distortions

Therapists or computer-based programmes use CBT techniques to help people challenge their patterns and beliefs and replace errors in thinking, known as cognitive distortions, such as “overgeneralising, magnifying negatives, minimising positives and catastrophising” with “more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behaviour”. Cognitive distortions can be either a pseudo-discrimination belief or an over-generalisation of something. CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward cognitive distortions so as to diminish their impact.

Skills

Mainstream CBT helps individuals replace “maladaptive… coping skills, cognitions, emotions and behaviours with more adaptive ones”, by challenging an individual’s way of thinking and the way that they react to certain habits or behaviours, but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioural elements such as exposure and skills training.

Phases in Therapy

CBT can be seen as having six phases:

  1. Assessment or psychological assessment;
  2. Reconceptualisation;
  3. Skills acquisition;
  4. Skills consolidation and application training;
  5. Generalisation and maintenance;
  6. Post-treatment assessment follow-up.

These steps are based on a system created by Kanfer and Saslow. After identifying the behaviours that need changing, whether they be in excess or deficit, and treatment has occurred, the psychologist must identify whether or not the intervention succeeded. For example, “If the goal was to decrease the behaviour, then there should be a decrease relative to the baseline. If the critical behaviour remains at or above the baseline, then the intervention has failed.”

The steps in the assessment phase include:

  • Step 1: Identify critical behaviours.
  • Step 2: Determine whether critical behaviours are excesses or deficits.
  • Step 3: Evaluate critical behaviours for frequency, duration, or intensity (obtain a baseline).
  • Step 4: If excess, attempt to decrease frequency, duration, or intensity of behaviours; if deficits, attempt to increase behaviours.

The re-conceptualisation phase makes up much of the “cognitive” portion of CBT. A summary of modern CBT approaches is given by Hofmann.

Delivery Protocols

There are different protocols for delivering cognitive behavioural therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimising negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”. Treatment is sometimes manualised, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviourally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Related Techniques

CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, metacognitive therapy, metacognitive training, relaxation training, dialectical behaviour therapy, and acceptance and commitment therapy. Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.

Medical Application

In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders, body dysmorphic disorder, depression, eating disorders, chronic low back pain, personality disorders, psychosis, schizophrenia, substance use disorders, in the adjustment, depression, and anxiety associated with fibromyalgia, and with post-spinal cord injuries.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive compulsive disorder (OCD), and posttraumatic stress disorder, as well as tic disorders, trichotillomania, and other repetitive behaviour disorders. CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youths who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. CBT has also been shown to be effective for post traumatic stress disorder in very young children (3 to 6 years of age). Reviews found “low quality” evidence that CBT may be more effective than other psychotherapies in reducing symptoms of posttraumatic stress disorder in children and adolescents. CBT has also been applied to a variety of childhood disorders, including depressive disorders and various anxiety disorders.

CBT combined with hypnosis and distraction reduces self-reported pain in children.

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviours in the youths under their care,[79] nor was it helpful in treating people who abuse their intimate partners.

According to a 2004 review by INSERM of three methods, cognitive behavioural therapy was either “proven” or “presumed” to be an effective therapy on several specific mental disorders. According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.

Computerized CBT (CCBT) has been proven to be effective by randomised controlled and other trials in treating depression and anxiety disorders, including children, as well as insomnia. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety and insomnia.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners. However, evidence supports the effectiveness of CBT for anxiety and depression. Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT). ACT uses mindfulness and acceptance interventions and has been found to have a greater longevity in therapeutic outcomes. In a study with anxiety, CBT and ACT improved similarly across all outcomes from pre-to post-treatment. However, during a 12-month follow-up, ACT proved to be more effective, showing that it is a highly viable lasting treatment model for anxiety disorders.

Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioural problems. A systematic review of CBT in depression and anxiety disorders concluded that “CBT delivered in primary care, especially including computer- or Internet-based self-help programmes, is potentially more effective than usual care and could be delivered effectively by primary care therapists.”

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD); hypochondriasis; coping with the impact of multiple sclerosis; sleep disturbances related to aging; dysmenorrhea; and bipolar disorder, but more study is needed and results should be interpreted with caution. CBT can have a therapeutic effects on easing symptoms of anxiety and depression in people with Alzheimer’s disease. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter, but not in reducing stuttering frequency.

In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management.

There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. CBT has been shown to be moderately effective for treating chronic fatigue syndrome.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive compulsive disorder (OCD), bulimia nervosa, and clinical depression.

Depression

Cognitive behavioural therapy has been shown as an effective treatment for clinical depression. The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioural therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder. One etiological theory of depression is Aaron T. Beck’s cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations.

Beck also described a negative cognitive triad. The cognitive triad is made up of the depressed individual’s negative evaluations of themselves, the world, and the future. Beck suggested that these negative evaluations derive from the negative schemata and cognitive biases of the person. According to this theory, depressed people have views such as “I never do a good job”, “It is impossible to have a good day”, and “things will never get better”. A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalisation, magnification, and minimisation. These cognitive biases are quick to make negative, generalised, and personal inferences of the self, thus fuelling the negative schema.

A 2001 meta-analysis comparing CBT and psychodynamic psychotherapy suggested the approaches were equally effective in the short term. In contrast, a 2013 meta-analyses suggested that CBT, interpersonal therapy, and problem-solving therapy outperformed psychodynamic psychotherapy and behavioural activation in the treatment of depression.

Anxiety Disorders

CBT has been shown to be effective in the treatment of adults with anxiety disorders. A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure. CBT-exposure therapy refers to the direct confrontation of feared objects, activities, or situations by a patient. Results from a 2018 systematic review found a high strength of evidence that CBT-exposure therapy can reduce PTSD symptoms and lead to the loss of a PTSD diagnosis.

For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears. Likewise, a person with social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech. This “two-factor” model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this harmful conditioning can be “unlearned” (referred to as extinction and habituation). Studies have provided evidence that when examining animals and humans that glucocorticoids may possibly lead to a more successful extinction learning during exposure therapy. For instance, glucocorticoids can prevent aversive learning episodes from being retrieved and heighten reinforcement of memory traces creating a non-fearful reaction in feared situations. A combination of glucocorticoids and exposure therapy may be a better improved treatment for treating patients with anxiety disorders.

A 2015 Cochrane review also found that CBT for symptomatic management of non-specific chest pain is probably effective in the short term. However, the findings were limited by small trials and the evidence was considered of questionable quality.

Bipolar Disorder

Many studies show CBT, combined with pharmacotherapy, is effective on improving depressive symptoms, mania severity and psychosocial functioning with mild to moderate effects, and that it is better than medication alone.

Psychosis

In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses. Meta-analyses confirm the effectiveness of metacognitive training (MCT) for the improvement of positive symptoms (e.g., delusions).

Schizophrenia

A Cochrane review reported CBT had “no effect on long‐term risk of relapse” and no additional effect above standard care. A 2015 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia and determined that there is no clear advantage over other, often less expensive, interventions but acknowledged that better quality evidence is needed before firm conclusions can be drawn.

With Older Adults

CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age. Of the small number of studies examining CBT for the management of depression in older people, there is currently no strong support.

Prevention of Mental Illness

For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalised anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes. In another study, 3% of the group receiving the CBT intervention developed generalised anxiety disorder by 12 months postintervention compared with 14% in the control group. Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT. Use of CBT was found to significantly reduce social anxiety prevalence.

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older. Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles. A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.

For people at risk of psychosis, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT.

Pathological and Problem Gambling

CBT is also used for pathological and problem gambling. The percentage of people who problem gamble is 1-3% around the world. Cognitive behavioural therapy develops skills for relapse prevention and someone can learn to control their mind and manage high-risk cases. There is evidence of efficacy of CBT for treating pathological and problem gambling at immediate follow up, however the longer term efficacy of CBT for it is currently unknown.

Smoking Cessation

CBT looks at the habit of smoking cigarettes as a learned behaviour, which later evolves into a coping strategy to handle daily stressors. Because smoking is often easily accessible, and quickly allows the user to feel good, it can take precedence over other coping strategies, and eventually work its way into everyday life during non-stressful events as well. CBT aims to target the function of the behaviour, as it can vary between individuals, and works to inject other coping mechanisms in place of smoking. CBT also aims to support individuals suffering from strong cravings, which are a major reported reason for relapse during treatment.

In a 2008 controlled study out of Stanford University School of Medicine, suggested CBT may be an effective tool to help maintain abstinence. The results of 304 random adult participants were tracked over the course of one year. During this program, some participants were provided medication, CBT, 24 hour phone support, or some combination of the three methods. At 20 weeks, the participants who received CBT had a 45% abstinence rate, versus non-CBT participants, who had a 29% abstinence rate. Overall, the study concluded that emphasizing cognitive and behavioural strategies to support smoking cessation can help individuals build tools for long term smoking abstinence.

Mental health history can affect the outcomes of treatment. Individuals with a history of depressive disorders had a lower rate of success when using CBT alone to combat smoking addiction.

A Cochrane review was unable to find evidence of any difference between CBT and hypnosis for smoking cessation. While this may be evidence of no effect, further research may uncover an effect of CBT for smoking cessation.

Substance Abuse Disorders

Studies have shown CBT to be an effective treatment for substance abuse. For individuals with substance abuse disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimising and catastrophising thought patterns, with healthier narratives. Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication.

Eating Disorders

Though many forms of treatment can support individuals with eating disorders, CBT is proven to be a more effective treatment than medications and interpersonal psychotherapy alone. CBT aims to combat major causes of distress such as negative cognitions surrounding body weight, shape and size. CBT therapists also work with individuals to regulate strong emotions and thoughts that lead to dangerous compensatory behaviours. CBT is the first line of treatment for Bulimia Nervosa, and Eating Disorder Non-Specific. While there is evidence to support the efficacy of CBT for bulimia nervosa and binging, the evidence is somewhat variable and limited by small study sizes.

Internet Addiction

Research has identified Internet addiction as a new clinical disorder that causes relational, occupational, and social problems. Cognitive behavioural therapy (CBT) has been suggested as the treatment of choice for Internet addiction, and addiction recovery in general has used CBT as part of treatment planning.

Prevention of Occupational Stress

A Cochrane review of interventions aimed at preventing psychological stress in healthcare workers found that CBT was more effective than no intervention but no more effective than alternative stress-reduction interventions.

With Autistic Adults

Emerging evidence for cognitive behavioural interventions aimed at reducing symptoms of depression, anxiety, and obsessive-compulsive disorder in autistic adults without intellectual disability has been identified through a systematic review. While the research was focused on adults, cognitive behavioural interventions have also been beneficial to autistic children.

Access and Delivery of CBT

Therapist

A typical CBT programme would consist of face-to-face sessions between patient and therapist, made up of 6-18 sessions of around an hour each with a gap of 1-3 weeks between sessions. This initial programme might be followed by some booster sessions, for instance after one month and three months. CBT has also been found to be effective if patient and therapist type in real time to each other over computer links.

Cognitive behavioural therapy is most closely allied with the scientist-practitioner model in which clinical practice and research is informed by a scientific perspective, clear operationalisation of the problem, and an emphasis on measurement, including measuring changes in cognition and behaviour and in the attainment of goals. These are often met through “homework” assignments in which the patient and the therapist work together to craft an assignment to complete before the next session. The completion of these assignments – which can be as simple as a person suffering from depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change. The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment. Effective cognitive behavioural therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance. Unlike many other forms of psychotherapy, the patient is very involved in CBT. For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first. The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.

Computerised or Internet-Delivered

Although computerised cognitive behavioural therapy (CCBT) has been a topic of sustained controversy, it has been described by NICE as a “generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system”, instead of face-to-face with a human therapist. It is also known as internet-delivered cognitive behavioural therapy (ICBT). CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist. In this context, it is important not to confuse CBT with ‘computer-based training’, which nowadays is more commonly referred to as e-Learning.

CCBT has been found in meta-studies to be cost-effective and often cheaper than usual care, including for anxiety. Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods. A review of current CCBT research in the treatment of OCD in children found this interface to hold great potential for future treatment of OCD in youths and adolescent populations. Additionally, most internet interventions for posttraumatic stress disorder use CCBT. CCBT is also predisposed to treating mood disorders amongst non-heterosexual populations, who may avoid face-to-face therapy from fear of stigma. However presently CCBT programmes seldom cater to these populations.

A key issue in CCBT use is low uptake and completion rates, even when it has been clearly made available and explained. CCBT completion rates and treatment efficacy have been found in some studies to be higher when use of CCBT is supported personally, with supporters not limited only to therapists, than when use is in a self-help form alone. Another approach to improving the uptake and completion rate, as well as the treatment outcome, is to design software that supports the formation of a strong therapeutic alliance between the user and the technology.

In February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication, and CCBT is made available by some health systems. The 2009 NICE guideline recognised that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product.

A relatively new avenue of research is the combination of artificial intelligence and CCBT. It has been proposed to use modern technology to create CCBT that simulates face-to-face therapy. This might be achieved in cognitive behaviour therapy for a specific disorder using the comprehensive domain knowledge of CBT. One area where this has been attempted is the specific domain area of social anxiety in those who stutter.

Smartphone App-Delivered

Another new method of access is the use of mobile app or smartphone applications to deliver self-help or guided CBT. Technology companies are developing mobile-based artificial intelligence chatbot applications in delivering CBT as an early intervention to support mental health, to build psychological resilience and to promote emotional well-being. Artificial intelligence (AI) text-based conversational application delivered securely and privately over smartphone devices have the ability to scale globally and offer contextual and always-available support. Active research is underway including real world data studies that measure effectiveness and engagement of text-based smartphone chatbot apps for delivery of CBT using a text-based conversational interface.

Reading Self-Help Materials

Enabling patients to read self-help CBT guides has been shown to be effective by some studies. However one study found a negative effect in patients who tended to ruminate, and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional).

Group Educational Course

Patient participation in group courses has been shown to be effective. In a meta-analysis reviewing evidence-based treatment of OCD in children, individual CBT was found to be more efficacious than group CBT.

Types

BCBT

Brief cognitive behavioural therapy (BCBT) is a form of CBT which has been developed for situations in which there are time constraints on the therapy sessions. BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed on soldiers overseas in active duty by David M. Rudd to prevent suicide. Breakdown of treatment:

  • Orientation:
    • Commitment to treatment.
    • Crisis response and safety planning.
    • Means restriction.
    • Survival kit.
    • Reasons for living card.
    • Model of suicidality.
    • Treatment journal.
    • Lessons learned.
  • Skill focus:
    • Skill development worksheets.
    • Coping cards.
    • Demonstration.
    • Practice.
    • Skill refinement.
  • Relapse prevention:
    • Skill generalisation.
    • Skill refinement.

Cognitive Emotional Behavioural Therapy

Cognitive emotional behavioural therapy (CEBT) is a form of CBT developed initially for individuals with eating disorders but now used with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. It combines aspects of CBT and dialectical behavioural therapy and aims to improve understanding and tolerance of emotions in order to facilitate the therapeutic process. It is frequently used as a “pre-treatment” to prepare and better equip individuals for longer-term therapy.

Structured Cognitive Behavioural Training

Structured cognitive behavioural training (SCBT) is a cognitive-based process with core philosophies that draw heavily from CBT. Like CBT, SCBT asserts that behaviour is inextricably related to beliefs, thoughts and emotions. SCBT also builds on core CBT philosophy by incorporating other well-known modalities in the fields of behavioural health and psychology: most notably, Albert Ellis’s rational emotive behaviour therapy. SCBT differs from CBT in two distinct ways. First, SCBT is delivered in a highly regimented format. Second, SCBT is a predetermined and finite training process that becomes personalized by the input of the participant. SCBT is designed with the intention to bring a participant to a specific result in a specific period of time. SCBT has been used to challenge addictive behaviour, particularly with substances such as tobacco, alcohol and food, and to manage diabetes and subdue stress and anxiety. SCBT has also been used in the field of criminal psychology in the effort to reduce recidivism.

Moral Reconation Therapy

Moral reconation therapy, a type of CBT used to help felons overcome antisocial personality disorder (ASPD), slightly decreases the risk of further offending. It is generally implemented in a group format because of the risk of offenders with ASPD being given one-on-one therapy reinforces narcissistic behavioural characteristics, and can be used in correctional or outpatient settings. Groups usually meet weekly for two to six months.

Stress Inoculation Training

This type of therapy uses a blend of cognitive, behavioural and some humanistic training techniques to target the stressors of the client. This usually is used to help clients better cope with their stress or anxiety after stressful events. This is a three-phase process that trains the client to use skills that they already have to better adapt to their current stressors. The first phase is an interview phase that includes psychological testing, client self-monitoring, and a variety of reading materials. This allows the therapist to individually tailor the training process to the client. Clients learn how to categorize problems into emotion-focused or problem-focused, so that they can better treat their negative situations. This phase ultimately prepares the client to eventually confront and reflect upon their current reactions to stressors, before looking at ways to change their reactions and emotions in relation to their stressors. The focus is conceptualisation.

The second phase emphasizes the aspect of skills acquisition and rehearsal that continues from the earlier phase of conceptualisation. The client is taught skills that help them cope with their stressors. These skills are then practised in the space of therapy. These skills involve self-regulation, problem-solving, interpersonal communication skills, etc.

The third and final phase is the application and following through of the skills learned in the training process. This gives the client opportunities to apply their learned skills to a wide range of stressors. Activities include role-playing, imagery, modelling, etc. In the end, the client will have been trained on a preventive basis to inoculate personal, chronic, and future stressors by breaking down their stressors into problems they will address in long-term, short-term, and intermediate coping goals.

Activity-Guided CBT: Group-Knitting

A newly developed group therapy model based on Cognitive Behavioural Therapy (CBT) integrates knitting into the therapeutic process and has been proven to yield reliable and promising results. The foundation for this novel approach to CBT is the frequently emphasized notion that therapy success depends on the embeddedness of the therapy method in the patients’ natural routine. Similar to standard group-based Cognitive Behavioural Therapy, patients meet once a week in a group of 10 to 15 patients and knit together under the instruction of a trained psychologist or mental health professional. Central for the therapy is the patient’s imaginative ability to assign each part of the wool to a certain thought. During the therapy, the wool is carefully knitted, creating a knitted piece of any form. This therapeutic process teaches the patient to meaningfully align thought, by (physically) creating a coherent knitted piece. Moreover, since CBT emphasizes the behaviour as a result of cognition, the knitting illustrates how thoughts (which are tried to be imaginary tight to the wool) materialise into the reality surrounding us.

Mindfulness-Based Cognitive Behavioural Hypnotherapy

Mindfulness-based cognitive behavioural hypnotherapy (MCBH) is a form of CBT focusing on awareness in reflective approach with addressing of subconscious tendencies. It is more the process that contains basically three phases that are used for achieving wanted goals.

Unified Protocol

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a form of CBT, developed by David H. Barlow and researchers at Boston University, that can be applied to a range of depression and anxiety disorders. The rationale is that anxiety and depression disorders often occur together due to common underlying causes and can efficiently be treated together.

The UP includes a common set of components:

  • Psycho-education.
  • Cognitive reappraisal.
  • Emotion regulation.
  • Changing behaviour.

The UP has been shown to produce equivalent results to single-diagnosis protocols for specific disorders, such as OCD and social anxiety disorder. Several studies have shown that the UP is easier to disseminate as compared to single-diagnosis protocols.

Criticisms

Relative Effectiveness

The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments, many other researchers and practitioners have questioned the validity of such claims. For example, one study determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e. measures of general functioning) no significant differences have been typically found between CBT and other treatments.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e. either the subjects or the therapists in psychotherapy studies are not blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in. Pooled data from published trials of CBT in schizophrenia, major depressive disorder (MDD), and bipolar disorder that used controls for non-specific effects of intervention were analysed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.

Declining Effectiveness

Additionally, a 2015 meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Additional sub-analysis revealed that CBT studies where therapists in the test group were instructed to adhere to the Beck CBT manual had a steeper decline in effect sizes since 1977 than studies where therapists in the test group were instructed to use CBT without a manual. The authors reported that they were unsure why the effects were declining but did list inadequate therapist training, failure to adhere to a manual, lack of therapist experience, and patients’ hope and faith in its efficacy waning as potential reasons. The authors did mention that the current study was limited to depressive disorders only.

High Drop-Out Rates

Furthermore, other researchers write that CBT studies have high drop-out rates compared to other treatments. CBT drop out rates were found to be 17% higher than other therapies in one meta-analysis. This high drop-out rate is also evident in the treatment of several disorders, particularly the eating disorder anorexia nervosa, which is commonly treated with CBT. Those treated with CBT have a high chance of dropping out of therapy before completion and reverting to their anorexia behaviours.

Other researchers conducting an analysis of treatments for youths who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analysed several clinical trials that measured the efficacy of CBT administered to youths who self-injure. The researchers concluded that none of them were found to be efficacious.

Philosophical Concerns with CBT Methods

The methods employed in CBT research have not been the only criticisms; some individuals have called its theory and therapy into question.

Slife and Williams write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states: nowhere in CBT theory is agency, or free will, accounted for.

Another criticism of CBT theory, especially as applied to major depressive disorder (MDD), is that it confounds the symptoms of the disorder with its causes.

Side Effects

CBT is generally regarded as having very few if any side effects. Calls have been made by some for more appraisal of possible side effects of CBT. Many randomised trials of psychological interventions like CBT do not monitor potential harms to the patient. In contrast, randomised trials of pharmacological interventions are much more likely to take adverse effects into consideration.

However, a 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications. Nevertheless, CBT therapists do sometimes report ‘unwanted events’ and side effects in their outpatients with “negative wellbeing/distress” being the most frequent.

Socio-Political Concerns

The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with “the parallel rise of neoliberalism, with its focus on marketization, efficiency, quantification and managerialism”, and he questions the scientific basis of CBT, suggesting that “the ‘science’ of psychological treatment is often less a scientific than a political contest”. In his book, Dalal also questions the ethical basis of CBT.

Society and Culture

The UK’s National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense as part of an initiative called Improving Access to Psychological Therapies (IAPT). The NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed. Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes “a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money … Everyone has been seduced by CBT’s apparent cheapness.” The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT’s policies were undermining traditional psychotherapy and criticised proposals that would limit some approved therapies to CBT, claiming that they restricted patients to “a watered down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff”.

The NICE also recommends offering CBT to people suffering from schizophrenia, as well as those at risk of suffering from a psychotic episode.

What is Cognitive Therapy?

Introduction

Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one of the therapeutic approaches within the larger group of cognitive behavioural therapies (CBT) and was first expounded by Beck in the 1960s.

CT is based on the cognitive model, which states that thoughts, feelings and behaviour are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behaviour, and distressing emotional responses. This involves the individual working collaboratively with the therapist to develop skills for testing and modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviours. A tailored cognitive case conceptualisation is developed by the cognitive therapist as a roadmap to understand the individual’s internal reality, select appropriate interventions and identify areas of distress.

Brief History

Becoming disillusioned with long-term psychodynamic approaches based on gaining insight into unconscious emotions and drives, Beck came to the conclusion that the way in which his patients perceived, interpreted and attributed meaning in their daily lives – a process scientifically known as cognition – was a key to therapy. Albert Ellis had been working on similar ideas since the 1950s (Ellis, 1956). He called his approach Rational Therapy (RT) at first, then Rational Emotive Therapy (RET) and later Rational Emotive Behaviour Therapy (REBT).

Beck outlined his approach in Depression: Causes and Treatment in 1967. He later expanded his focus to include anxiety disorders, in Cognitive Therapy and the Emotional Disorders in 1976, and other disorders and problems. He also introduced a focus on the underlying “schema” – the fundamental underlying ways in which people process information – about the self, the world or the future.

The new cognitive approach came into conflict with the behaviourism ascendant at the time, which denied that talk of mental causes was scientific or meaningful, rather than simply assessing stimuli and behavioural responses. However, the 1970s saw a general “cognitive revolution” in psychology. Behavioural modification techniques and cognitive therapy techniques became joined together, giving rise to cognitive behavioural therapy. Although cognitive therapy has always included some behavioural components, advocates of Beck’s particular approach seek to maintain and establish its integrity as a distinct, clearly standardised form of cognitive behavioural therapy in which the cognitive shift is the key mechanism of change.

Precursors of certain fundamental aspects of cognitive therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Beck’s original treatment manual for depression states, “The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers”.

As cognitive therapy continued to grow in popularity, the Academy of Cognitive Therapy, a non-profit organisation, was created to accredit cognitive therapists, create a forum for members to share emerging research and interventions, and to educate consumer regarding cognitive therapy and related mental health issues.

Basis

Therapy may consist of testing the assumptions which one makes and looking for new information that could help shift the assumptions in a way that leads to different emotional or behavioral reactions. Change may begin by targeting thoughts (to change emotion and behavior), behavior (to change feelings and thoughts), or the individual’s goals (by identifying thoughts, feelings or behavior that conflict with the goals). Beck initially focused on depression and developed a list of “errors” (cognitive distortion) in thinking that he proposed could maintain depression, including arbitrary inference, selective abstraction, over-generalization, and magnification (of negatives) and minimization (of positives).

As an example of how CT might work: Having made a mistake at work, a man may believe, “I’m useless and can’t do anything right at work.” He may then focus on the mistake (which he takes as evidence that his belief is true), and his thoughts about being “useless” are likely to lead to negative emotion (frustration, sadness, hopelessness). Given these thoughts and feelings, he may then begin to avoid challenges at work, which is behaviour that could provide even more evidence for him that his belief is true. As a result, any adaptive response and further constructive consequences become unlikely, and he may focus even more on any mistakes he may make, which serve to reinforce the original belief of being “useless.” In therapy, this example could be identified as a self-fulfilling prophecy or “problem cycle,” and the efforts of the therapist and patient would be directed at working together to explore and shift this cycle.

People who are working with a cognitive therapist often practice the use of more flexible ways to think and respond, learning to ask themselves whether their thoughts are completely true, and whether those thoughts are helping them to meet their goals. Thoughts that do not meet this description may then be shifted to something more accurate or helpful, leading to more positive emotion, more desirable behaviour, and movement toward the person’s goals. Cognitive therapy takes a skill-building approach, where the therapist helps the person to learn and practice these skills independently, eventually “becoming his or her own therapist.”

Cognitive Model

The cognitive model was originally constructed following research studies conducted by Aaron Beck to explain the psychological processes in depression. It divides the mind beliefs in three levels:

  • Automatic thought.
  • Intermediate belief.
  • Core belief or basic belief.

In 2014, an update of the cognitive model was proposed, called the Generic Cognitive Model (GCM). The GCM is an update of Beck’s model that proposes that mental disorders can be differentiated by the nature of their dysfunctional beliefs. The GCM includes a conceptual framework and a clinical approach for understanding common cognitive processes of mental disorders while specifying the unique features of the specific disorders.

Consistent with the cognitive theory of psychopathology, CT is designed to be structured, directive, active, and time-limited, with the express purpose of identifying, reality-testing, and correcting distorted cognition and underlying dysfunctional beliefs.

Cognitive Restructuring (Methods)

Cognitive restructuring involves four steps:

  • Identification of problematic cognitions known as “automatic thoughts” (ATs) which are dysfunctional or negative views of the self, world, or future based upon already existing beliefs about oneself, the world, or the future.
  • Identification of the cognitive distortions in the ATs.
  • Rational disputation of ATs with the Socratic method.
  • Development of a rational rebuttal to the ATs.

There are six types of automatic thoughts:

  • Self-evaluated thoughts.
  • Thoughts about the evaluations of others.
  • Evaluative thoughts about the other person with whom they are interacting.
  • Thoughts about coping strategies and behavioural plans.
  • Thoughts of avoidance.
  • Any other thoughts that were not categorised.

Other major techniques include:

  • Activity monitoring and activity scheduling.
  • Behavioural experiments.
  • Catching, checking, and changing thoughts.
  • Collaborative empiricism:
    • Therapist and patient become investigators by examining the evidence to support or reject the patient’s cognitions.
    • Empirical evidence is used to determine whether particular cognitions serve any useful purpose.
  • Downward arrow technique.
  • Exposure and response prevention.
  • Cost benefit analysis.
  • Acting ‘as if’.
  • Guided discovery:
    • Therapist elucidates behavioural problems and faulty thinking by designing new experiences that lead to acquisition of new skills and perspectives.
    • Through both cognitive and behavioural methods, the patient discovers more adaptive ways of thinking and coping with environmental stressors by correcting cognitive processing.
  • Mastery and pleasure technique.
  • Problem solving.
  • Socratic questioning: involves the creation of a series of questions to
    • Clarify and define problems;
    • Assist in the identification of thoughts, images and assumptions;
    • Examine the meanings of events for the patient; and
    • Assess the consequences of maintaining maladaptive thoughts and behaviours.

Socratic Questioning

Socratic questions are the archetypal cognitive restructuring techniques. These kinds of questions are designed to challenge assumptions by:

  • Conceiving reasonable alternatives:
    • ‘What might be another explanation or viewpoint of the situation? Why else did it happen?’
  • Evaluating those consequences:
    • ‘What’s the effect of thinking or believing this?
    • What could be the effect of thinking differently and no longer holding onto this belief?’
  • Distancing:
    • ‘Imagine a specific friend/family member in the same situation or if they viewed the situation this way, what would I tell them?’
  • Examples of socratic questions include:
    • ‘Describe the way you formed your viewpoint originally.‘
    • ‘What initially convinced you that your current view is the best one available?‘
    • ‘Think of three pieces of evidence that contradict this view, or that support the opposite view. Think about the opposite of this viewpoint and reflect on it for a moment. What’s the strongest argument in favour of this opposite view?‘
    • ‘Write down any specific benefits you get from holding this belief, such as social or psychological benefits. For example, getting to be part of a community of like-minded people, feeling good about yourself or the world, feeling that your viewpoint is superior to others’, etc Are there any reasons that you might hold this view other than because it’s true?‘
    • ‘For instance, does holding this viewpoint provide some peace of mind that holding a different viewpoint would not?‘
    • ‘In order to refine your viewpoint so that it’s as accurate as possible, it’s important to challenge it directly on occasion and consider whether there are reasons that it might not be true. What do you think the best or strongest argument against this perspective is?‘
    • What would you have to experience or find out in order for you to change your ‘mind about this viewpoint?‘
    • Given your thoughts so far, do you think that there may be a truer, more accurate, or more nuanced version of your original view that you could state right ‘now?‘

False Assumptions

False assumptions are based on ‘cognitive distortions’, such as:

  • Always Being Right: “We are continually on trial to prove that our opinions and actions are correct. Being wrong is unthinkable and we will go to any length to demonstrate our rightness. For example, “I don’t care how badly arguing with me makes you feel, I’m going to win this argument no matter what because I’m right.” Being right often is more important than the feelings of others around a person who engages in this cognitive distortion, even loved ones.”
  • Heaven’s Reward Fallacy: “We expect our sacrifice and self-denial to pay off, as if someone is keeping score. We feel bitter when the reward doesn’t come.”

Awfulising and Must-ing

Rational emotive behaviour therapy (REBT) includes awfulising, when a person causes themselves disturbance by labelling an upcoming situation as ‘awful’, rather than envisaging how the situation may actually unfold, and Must-ing, when a person places a false demand on themselves that something ‘must’ happen (e.g. ‘I must get an A in this exam’.)

Types

Cognitive Therapy

based on the cognitive model, stating that thoughts, feelings and behaviour are mutually influenced by each other. Shifting cognition is seen as the main mechanism by which lasting emotional and behavioural changes take place. Treatment is very collaborative, tailored, skill-focused, and based on a case conceptualisation.

Rational Emotive Behaviour Therapy (REBT)

Based on the belief that most problems originate in erroneous or irrational thought. For instance, perfectionists and pessimists usually suffer from issues related to irrational thinking; for example, if a perfectionist encounters a small failure, he or she might perceive it as a much bigger failure. It is better to establish a reasonable standard emotionally, so the individual can live a balanced life. This form of cognitive therapy is an opportunity for the patient to learn of their current distortions and successfully eliminate them.

Cognitive Behavioural Therapy (CBT)

A system of approaches drawing from both the cognitive and behavioural systems of psychotherapy. CBT is an umbrella term for a group of therapies, where as CT is a discrete form of therapy.

Application

Depression

According to Beck’s theory of the aetiology of depression, depressed people acquire a negative schema of the world in childhood and adolescence; children and adolescents who experience depression acquire this negative schema earlier. Depressed people acquire such schemas through a loss of a parent, rejection by peers, bullying, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles the original conditions of the learned schema in some way, the negative schemas of the person are activated.

Beck’s negative triad holds that depressed people have negative thoughts about themselves, their experiences in the world, and the future. For instance, a depressed person might think, “I didn’t get the job because I’m terrible at interviews. Interviewers never like me, and no one will ever want to hire me.” In the same situation, a person who is not depressed might think, “The interviewer wasn’t paying much attention to me. Maybe she already had someone else in mind for the job. Next time I’ll have better luck, and I’ll get a job soon.” Beck also identified a number of other cognitive distortions, which can contribute to depression, including the following:

  • Arbitrary inference;
  • Selective abstraction;
  • Overgeneralisation;
  • Magnification; and
  • Minimisation.

In 2008 Beck proposed an integrative developmental model of depression that aims to incorporate research in genetics and neuroscience of depression. This model was updated in 2016 to incorporate multiple levels of analyses, new research, and key concepts (e.g. resilience) within the framework of an evolutionary perspective.

Other Applications

Cognitive therapy has been applied to a very wide range of behavioural health issues including:

  • Academic achievement.
  • Addiction.
  • Anxiety disorders.
  • Bipolar disorder.
  • Low self-esteem.
  • Phobia.
  • Schizophrenia.
  • Substance abuse.
  • Suicidal ideation.
  • Weight loss.

Criticisms

A criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e. neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.