Brief Cognitive-Behavioral Interventions
The essence of CBTs is the union of behavioral and cognitive strategies to help people. Often cognitive-behavioral strategies are designed to be brief interventions that include the use of treatment manuals or guidelines for the implementation of interventions. These manuals have clearly described psychotherapy strategies. An advantage of treatment manuals is that they ease the facilitation of training for counselors and make replication of research easier. Treatment manuals for CBT for a variety of psychological problems are available, and the material on this grows continuously. Barlow's (2008) text on treatment of psychological disorders, for example, contains chapters on cognitive-behavioral approaches to treating a variety of anxiety disorders (panic disorder and agoraphobia, posttiaumatic stress disorder, social anxiety disorder, and obsessive-compulsive disorder); mood disorders (depression, bipolar disorder); and other disorders including substance abuse, eating disorders, sexual dysfunction, and personality disorders. A good reference for treatment manuals that are based on research can be found at psychologicaltreatments.org.
Beck's Cognitive Therapy
The primary principle underlying cognitive theory is that affect and behavior are determined by the way individuals cognitively structure the world. First developed to treat depression, cognitive therapy was later extended as a treatment for anxiety and is now being used to treat other psychological problems such as panic disorder and agoraphobia, drug abuse, and eating disorders. Interested readers are referred to full descriptions of cognitive therapy in Cognitive Therapy of Depression (Beck et al., 1979), Anxiety Disorders and Phobias (Beck & Emery, 1985), Cognitive Therapy of Personality Disorders (Beck, Freeman, & Associates, 2003), and Cognitive Therapy of Substance Abuse (Beck et al., 1993).
Beck and Emery (1985) identified the following 10 principles of cognitive therapy:
1. It is based on the cognitive model of emotional disorders.
2. It is brief and time limited.
3. It is based on a sound therapeutic relationship, which is a necessary condition.
4. It is a collaborative effort between the client and the counselor or therapist.
5. It uses primarily Socratic questioning.
6. It is structured and directive.
7. It is problem oriented.
8. It is based on an educational model.
9. Its theory and techniques rely on the inductive model.
10. It uses homework as a central feature.
The cognitive model of disturbance asserts that cognitions play a central role in human emotional problems. In cognitive therapy, there is an emphasis on internal thoughts, feelings, and attitudes rather than on behavior, although behavioral techniques are used in conjunction with cognitive therapy to help clients test their maladaptive cognitions and assumptions. Cognitive restructuring is used to identify automatic thoughts, evaluate their content, test the hypothesis that is generated, and identify underlying assumptions.
Unlike some dynamic therapies, cognitive therapy is time limited; treatment of anxiety disorders may take from 5 to 20 sessions (Beck & Emery, 1985), and treatment for moderate to severe depression may take 20 sessions over 15 weeks (Beck et al., 1979). The pace of intervention is rapid, and longer term therapy is viewed as unnecessary to facilitate change. Some guidelines useful for keeping the counseling or psychotherapy process brief include keeping treatment specific and concrete, stressing homework, and developing the expectation that interventions will be brief for both the client and the counselor or therapist (Beck & Emery, 1985).
The therapeutic relationship is highly valued in cognitive therapy. In order for the cognitive methods to work well, the counselor or therapist must work to establish good rapport with the client. Accurate empathy and warmth are necessary to enable the client to engage in a relationship with the practitioner such that cognitive techniques can be implemented. Using cognitive therapy requires a collaboration between the counselor or therapist and the client. It is the practitioner's role to provide structure and expertise in solving the problems presented by the client, but this process involves teamwork. Cognitive therapy has been described as using collaborative empiricism, which is a continual process used by the counselor or therapist and the client to identify, reality test, and correct cognitive distortions. Clients are encouraged to be active in the process of learning how maladaptive thoughts interfere with desirable behavior change.
The Socratic (or inductive) questioning method is one in which the counselor or therapist leads the client through a series of questions to become aware of thoughts, identify the distortions in thinking, and find and implement more adaptive replacements for the distortion. Beck et al. (1979) provided the following interaction, which illustrates the use of questions to assist the client in disputing irrational thoughts:
Patient: I think anyone who isn't concerned with what others think would be socially retarded and functioning at a pretty low level.
Therapist: Who are the two people you admire most? (The therapist knew the answer from previous discussion.)
P: My best friend and my boss.
T: Are these two over concerned with others' opinions?
P: No, I don't think that either one cares at all what others think.
T: Are they socially retarded and ineffective?
P: I see your point. Both have good social skills and function at high levels, (pp. 265-266)
This example shows how the counselor or therapist can use examples and questions to guide the client to the conclusion that the initial statement was inaccurate.
Cognitive therapy is a structured and directive approach to counseling and psychotherapy. Treatment manuals have been developed that are used to structure the counseling and psychotherapy process. Treatment plans are developed for each individual, and each session has an agenda to organize the discussion of specific problems. It is clear that cognitive therapy is problem oriented, which means that the focus is on solving present problems. Cognitive therapy is based on an educational model; because it assumes that people learn inappropriate ways of coping with life, the process of change involves learning new ways of learning and thinking.
The inductive method is essential to cognitive therapy because it involves a scientific way of thinking about problems (Hollon & Beck, 2004). This means that clients are taught to think of their beliefs as hypotheses that require testing and verification. Counselors or therapists are trained to help the clients disconfirm maladaptive beliefs by confronting them with evidence contrary to those beliefs. Hypotheses often require behavioral assignments to test assumptions outside of the counseling or psychotherapy session, and clients report on their experiences. In addition, cognitive therapy requires that the client do regular homework assignments. This involves the client applying the techniques learned in the counseling or psychotherapy in the real world and reporting the results to the counselor or therapist. Homework is used to reinforce the learning and to give the client a place to try out new behaviors.