Is Cognitive Behavioral Therapy (CBT) an effective treatment and does it involve medication? I've heard that people use it for panic attacks and depression. What evidences are there for the effectiveness?
I came across a similar question in Psychology.SE whilst researching CBT for a course I was studying in University.
The short answer
As I will cover in the long answer, there has been a lot of articles stating that CBT is very effective, and there are articles which have stated that it is not as effective as has been claimed.
CBT is not a single model of therapy, applicable to all clients in all situations. This has been one of the criticisms levelled at CBT, that its 'one size fits all' approach to the complex nature of human problems will, inevitably, fail to meet the needs of many, or (at best), simply focus on symptom reduction. (Reeves, 2013)
There are a fair few factors which can prevent CBT from becoming effective, and a trained and certified CBT practitioner will be able to assess the suitability of CBT. If they operate ethically, they will not go ahead with providing CBT to someone who it would not benefit.
One of the biggest factors which doesn't allow CBT to work is that if the client is not willing or able to challenge their thoughts and behaviours, then CBT will not be effective.
For the long answer, which will help to explain some of the reasons why CBT may not work with some people, I will be using a lot of the work I put into an essay I had to write for my psychotherapy course which covered Cognitive Behavioural Therapy (CBT) and integrative approaches to therapy.
CBT is an integrative model of approach and we had to look at how an integrative approach may be used to support the client within a case study provided.
Case study provided
Hassan has been referred to you for work-related stress and anxiety. He has a management position and is finding it difficult to cope. At present the information you have is that he is a 42 years old Muslim man, married with 2 children. He has lived in the UK since the age of 5 when his parents travelled here. His father died two years later and Hassan, as the eldest son, has felt responsible for the wellbeing of his mother and sisters as well as his own family.
Your referral is through an employee assistance scheme. Hassan’s assessment shows high level of anxiety without depression. He is otherwise fit and healthy. You may offer him six sessions with a further six sessions if appropriate.
An article (Dhami & Sheikh, 2000) adapted from a chapter in Caring for Muslim Patients, published by Radcliffe Medical Press, Oxford, England; provides key insights needed to allow Muslim clients' concerns to be adequately heard. The vignettes section of the article gives a few sayings of Muhammad regarding relationships with parents and one of them points out that you should “strive to serve them”.
If the client has had the opportunity to fully integrate with the western culture they are living in, they may be more open to challenging their thoughts and beliefs, however we need to be mindful that as therapists, just like we are not here to judge, for an example, on sexuality (Pink Therapy, 2016) (UKCP, 2015), we are not in a position to judge whether a cultural or religious belief is right or wrong, especially when we are not priests, vicars, rabbis, imams or the like. Not only that, if the client is devout in their religious beliefs, then we are not going to change those beliefs very easily, if at all. (Babilonia, 2015)
The only time when we can intervene in any religious or cultural beliefs is when it is believed that laws may be broken such as the FGM Act (Home Office, 2016) (Crown Prosecution Service, n.d.), in which case, we would refer the legal case to the necessary authorities and it would be down to the legal profession and not the therapist.
Strengths and Limitations of integrative approaches to counselling
Integrative counselling and psychotherapy can be seen as one of the most effective approaches within counselling. (The Counselling Directory, 2013) The idea behind the integrative approach is that no single approach suits every client and therefore you use different approaches and models of therapy to suit the situation and client. The article within The Counselling Directory cited also states that integrative therapy has four different categories:
- common factors
Looking at the common tools available in each approach that can be useful in the therapy. Therapist/Client rapport, therapist qualities – positive regard, and congruence etc. – emotional release, and clarification etc.
- technical eclecticism
The therapist looks at and selects the best interventions by relying on experience and knowledge of what has worked in the past for others, through theories and research literature.
- theoretical integration
The combination of two approaches with a common philosophy. The combined ideas are theoretically the same as each other. For example, cognitive behavioural therapy (CBT) is part of the theoretical integration category, as it is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013), plus, cognitive analytical therapy is also a theoretical integration of psychodynamic therapy and cognitive therapy.
- assimilative integration
The therapist primarily sticks to one therapeutic approach, for example Humanistic or psychodynamic, but the therapist will use strategies and models from other therapeutic approaches as well. The combination of ideas will assimilate the pure form of the primary therapeutic approach.
The limitations of any integrative therapy depend on the category of integration.
One problem identified in theoretical integration is that it is difficult to integrate some theories; for example, it is difficult to integrate psychodynamic theory and behavioural theory. The psychodynamic approach suggests that our early experiences from birth onwards and their impacts lead to our psychological problems, where behaviour theory sees problems as much more agreeable to change (Reeves, 2013). These differences result in incompatibilities between these theories.
With this kind of integration, there is no balance compared to the other forms of integration. Where the therapist is primarily psychodynamic or humanistic, for example, they will pick and choose ideas from other approaches which may not be put forward by their primary approach, but can work very effectively and contribute to the treatment or treatment plan.
This shares similarities and differences with assimilative integration, but it has no theoretical underpinning to the approach. (The Counselling Directory, 2013)
As CBT is a theoretical integrative model, and it is difficult to integrate some theories, CBT cannot and does not incorporate any psychodynamic theories. However, if you are going to work in a fully integrative manner, you need to bear in mind the theories within the psychodynamic approach too. If therapy seems to need some psychodynamic interventions, then you may need to drop CBT sessions sometimes and concentrate on the psychodynamic interventions, maybe through Cognitive Analytical Therapy instead, before continuing with CBT.
The basic concept of CBT
Cognitive Behavioural Therapy (CBT) was developed by Aaron Temkin Beck, and as mentioned before, CBT is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013). CBT helps to change how you think, hence the word Cognitive, and what you do, hence the word Behaviour.
A difficult life situation, relationship or practical problem can lead to:
- Altered thinking
- Altered emotions and feelings
- Altered behaviour
- Altered physical feelings or symptoms
Things can happen the other way too. Any of the above alterations can lead to a difficult life situation, relationship or practical problem (Royal College of Psychiatrists, n.d.).
CBT works by trying to get the client to think about a situation in a more helpful way in order to move forward using more helpful behaviours.
The basic concept of REBT
Rational Emotive Behaviour Therapy (REBT) has generally been put under the same umbrella as CBT, however although it has similarities, REBT is different. Where CBT was developed by Aaron Beck, REBT was developed by Albert Ellis when he started to lose faith in the type of psychoanalysis he was using.
REBT is a practical and action-led model of therapy and personal growth. It doesn’t just focus on the client’s behaviours, but also allows the client to understand the behaviours of others and provide techniques that will help to solve future problems.
Although REBT looks primarily at our current beliefs and behaviours, it also looks at the cause and effect of past experiences and beliefs which create our present beliefs and behaviours. It does this whilst aiming to change irrational beliefs into rational ones quickly rather than slowly, however, one key point to note is that the therapist does not impose rational beliefs on the client, but accepts there are non-rational beliefs that may help people achieve happiness. That way, the therapist is accepting the client’s value system.
REBT, uses an A-B-C-D-E formula.
- Activating Experience
Also referred to by some as the Initial Sensitising Event (ISE), this is the root cause of our unhappiness
Irrational self-defeating beliefs that are the source of our unhappiness, or come about as a result of the ISE
The neurotic symptoms and negative feelings and emotions that result from the ISE and/or Beliefs
We must dispute and challenge these irrational beliefs in order for the client to enjoy a balanced outlook in life
The client must learn to enjoy the effects of the new rational beliefs and get used to the changes, letting them become the new norm.
The shortfalls of CBT
As mentioned before, One of the ideas put forward about CBT is that it is a suitable form of therapy for all human problems. This idea can be damaging in some respects, as CBT is not suitable for all psychological conditions.
Interestingly, whilst researching the overall efficacy of CBT, I came across a few items of note.
- Carl Rogers emphasised the quality of the therapeutic relationship as a necessary and sufficient condition for successful therapy (Rogers, 1957) whereas CBT therapists tend to see the alliance as more instrumental in ensuring the patient’s adherence to the treatment protocol (e.g. Dunn, et al., 2006) (Goldsmith, et al., 2015)
- The Countess of Mar in the House of Lords suggested the results of a trial into the effectiveness of CBT and GET (graded exercise therapy) had been artificially inflated (BACP, 2013)
- An international team of researchers (Cuijpers, et al., 2016) concludes that
…CBT is ‘probably effective’ with major depression, general anxiety disorder, panic disorder and social anxiety disorder, but not as effective as has been claimed, due to publication bias, poor quality of studies, and the use of waiting list control groups as a comparator. (BACP, 2016)
- CBT is as much based on the development of a therapeutic alliance as it is in a psychodynamic and humanistic approach. The success of therapy will be, at least partly, informed by the nature of the therapeutic process, and not simply the application of particular theoretical ideas, as some suggest (Reeves, 2013)
- Recent literature provides fairly strong evidence that CBT in addition to antipsychotic medication is effective in the management of acute as well as chronic schizophrenia (Rathod & Turkington, 2005). However, I would stress that CBT was not used alone in any of these studies from what I have seen. It was used carefully in conjunction with psychiatric help and antipsychotic medication.
Either way, if the client is not able or willing to challenge their thoughts and behaviours, then CBT will not be effective.
Babilonia, S., 2015. Challenging religious privilege in public life. [Online] Available at: http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/ [Accessed 5 May 2017].
BACP, 2013. Policy. Therapy Today, 24(2), p. 52. BACP, 2016. News. Therapy Today, 27(8), p. 6. Crown Prosecution Service, n.d. Female Genital Mutilation Legal Guidance. [Online] Available at: http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02 [Accessed 5 May 2017].
Cuijpers, P. et al., 2016. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), pp. 245-258.
Dhami, S. & Sheikh, A., 2000. The Muslim family: predciament and promise. The Western Journal of Medicine, 173(5), pp. 352-356.
Dunn, H., Morrison, A. P. & Bentall, R. P., 2006. The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clinical Psychology & Psychotherapy, 13(3), pp. 145-152.
Goldsmith, L. P., Lewis, S. W., Dunn, G. & Bentall, R. P., 2015. Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. Psychological Medicine, 45(11), pp. 2365-2373.
Home Office, 2016. Mandatory reporting of female genital mutilation: procedural information. [Online] Available at: https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information [Accessed 5 May 2017].
Pink Therapy, 2016. Why I am resigning from the British Association for Counselling and Psychotherapy. [Online] Available at: https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/ [Accessed 5 May 2017].
Rathod, S. & Turkington, D., 2005. Cognitive behaviour therapy for schizophrenia: a review. Current Opinion in Psychiatry, 18(2), pp. 159-163. Reeves, A., 2013. An Introduction to Counselling and Psychotherapy: From Theory to Practice. London: SAGE Publications Ltd..
Reeves, A., 2013. An Introduction to Counselling and Psychotherapy: From Theory to Practice. London: SAGE Publications Ltd..
Rogers, C., 1957. The Necessary and Sufficient Conditions of Therapeutic Personality Change. [Online] Available at: http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf [Accessed 15 March 2016].
Royal College of Psychiatrists, n.d. 5 Areas Assessment. [Online] Available at: https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx [Accessed 5 May 2017].
The Counselling Directory, 2013. Integrative Psychotherapy as an Effective Form of Counselling. [Online] Available at: http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach [Accessed 5 May 2017].
UKCP, 2015. Memorandum of Understanding (MoU) on Conversion Therapy in the UK. [Online] Available at: https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf [Accessed 5 May 2017].
Cognitive Behavioral Therapy is a clinically approved method to treat depression, without the usage of medication.
Cognitive behavioral therapy (CBT) is a common and well-studied form of psychotherapy, combining cognitive and behavioral therapy.
The goal is to reveal and change false and distressing beliefs, because it is often not only the things and situations themselves that cause problems, but the importance that we attach to them too.
For example, a dangerous thought pattern might be when somebody immediately draws negative conclusions from an occurrence, generalizes them and applies them to similar situations. In psychology, this generalized way of thinking is called “over-generalizing.” Another distressing error in reasoning is “catastrophizing”: If something disturbing happens, people immediately draw exaggerated conclusions about the scope of the supposed disaster ahead.
Such thought patterns can sometimes develop into self-fulfilling prophecies and make life difficult for the people affected. Cognitive therapy helps people learn to replace these thought patterns with more realistic and less harmful thoughts. It also helps people to think more clearly and to control their own thoughts better.
How does behavioral therapy work?
Behavioral therapy assumes that human behavior is learned and can therefore be unlearned or relearned and aims to find out whether certain behavioral patterns make your life difficult or intensify your problems. In the second step you work on changing these behavioral habits.
For example, people who have developed depressive thoughts often tend to withdraw and give up their hobbies. As a result, they feel even more unhappy and isolated. Cognitive therapy helps to identify this mechanism and find ways to become more active again.
Cognitive behavioral therapy focuses on current problems and finding solutions for them. It is much more concerned with dealing with current problems. The most important thing is helping people to help themselves: They should be able to cope with their lives again without therapy as soon as possible. This does not mean that cognitive behavioral therapy completely ignores the influence of past events. But it mainly deals with identifying and changing current distressing thought and behavioral patterns.
As an example, in anxiety disorders, behavioral therapy often includes learning methods to help you calm down. For example, you can learn to reduce anxiety by consciously breathing in and out deeply so that your body and breathing can relax. When doing this you concentrate on your breathing instead of what is bringing on your anxiety. These kinds of techniques can help you to calm down instead of getting all worked up with anxiety.
When is cognitive behavioral therapy an option?
Cognitive behavioral therapy is used to treat conditions such as depression, anxiety and obsessive-compulsive disorders, and addictions.
Cognitive behavioral therapy requires the patient's commitment and own initiative. Therapy can only be successful if the patient actively takes part in the treatment and also works on their problems between sessions. This can be a considerable challenge, especially with severe conditions such as depression or anxiety disorders. That is why medication is sometimes used at first to quickly relieve the worst symptoms so that psychotherapy can be started.
Choosing a certain kind of psychotherapy also depends on the goals. If you feel the need for deep insight into the causes of your problems, cognitive behavioral therapy is probably not the right choice. It is particularly useful if you are mainly interested in tackling specific problems and are only secondarily concerned with the “why.”
How long does it take?
It is important that you and your psychotherapist have a close and trusting working relationship. It can sometimes take a while to find the right therapist.
In the first session, you will briefly explain your current problems and outline your expectations. That forms the basis for discussing the goals of therapy and the therapy plan. The plan can be adjusted if your personal goals change over the course of therapy.
Therapy often includes recording your own thoughts in a journal over a certain period of time. The therapist will then check the following things with you: Do I perceive things appropriately and realistically? What happens if I behave differently than I normally do in a certain situation? You will regularly discuss any problems you may have and progress that you have made.
Cognitive behavioral therapy also uses relaxation exercises, stress and pain relief methods, and certain problem-solving strategies.
Some people already feel much better after a few sessions, while others need treatment for several months. This depends on the kind and severity of the problems, among other things. An individual session lasts about an hour. Sessions usually take place once a week. Cognitive behavioral therapy is offered in psychotherapy practices, hospitals and rehabilitation clinics- sometimes also offered as group therapy.
Can cognitive behavioral therapy also have side effects?
Side effects resulting from psychotherapy cannot be ruled out. Being directly confronted with your problems or anxieties may be very stressful at first, and relationships might also suffer as a result. It is crucial to speak openly with your psychotherapist if any difficulties come up during therapy.
'We saw that a third of people had a difficult memory resurface, had more anxiety, or felt stressed. It was also not uncommon to have a poor relationship with the therapist or low-quality treatment.' - Science Daily study of internet-based CBT
The same study from Science Daily mentions:
"The general finding of the present thesis is that negative effects do occur in ICBT[Internet Cognitive Behavioral Therapy] and that they are characterized by deterioration, non-response, and adverse and unwanted events, similar to psychological treatments delivered face-to-face."
Additionally, there are several studies of CBT's long term effects which point out:
Psychological therapy services need to recognise that anxiety disorders tend to follow a chronic course and that good outcomes with CBT over the short term are no guarantee of good outcomes over the longer term.
Is it actually effective??? Yes, current medical studies seem to indicate so.
In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.
When is CBT NOT suitable?
Immediate crises in which an individual is at-risk of hurting themselves or others are commonly addressed with rapid-acting medication, since CBT might not be fast enough, relative to the situation. Sometimes, the side-effects and other risks of taking medications will out-weigh the risk of that person taking dangerous actions.
Additionally, an article reviewing the suitability of CBT notes:
Clients with unfocused, multiple, or very chronic problems, including those with a diagnostic label of severe personality disorder, are unlikely to benefit from short-term CBTs
All in all, it's worth considering.
Cognitive behavior therapy (CBT) is efficacious in the acute treatment of depression and may provide a viable alternative to antidepressant medications (ADM) for even more severely depressed unipolar patients when implemented in a competent fashion.
CBT does appear to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment, something that cannot be said for medications.
CBI was found to be superior to [Behavioral Intervention] in the reduction of panic symptoms, behavioral avoidance, safety behaviors, and cognitions. A large percentage of the CBI group patients met the criteria for clinically significant change with a large magnitude of change.