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Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj.
© 2008 John Wiley & Sons, Ltd. ISBN 978-0470-06571-6.
The cognitive and behavioral therapies have evolved as an
alternative to more traditional nondirective and insight-
oriented modes of psychotherapy (Beck 1991 , Wolpe
1982 , Kazdin 1982 , Robins and Hayes 1993 ). The family
of cognitive and behavioral therapies includes a diverse
group of interventions. Nevertheless, the treatments share
several pragmatic and theoretical assumptions. First,
these therapies emphasize psychoeducation: patients learn
about the nature of their dif culties and are provided
reasons for use of particular treatment strategies. Second,
the cognitive and behavioral therapies typically employ
homework and self-help assignments to provide patients the
opportunity to practice therapeutic methods that enhance
the generalization of newly acquired skills outside of the
therapy hour. Third, objective assessment of psychiatric
illness is an integral part of treatment, and the selection of
therapeutic strategies derives logically from such assessments.
Fourth, the therapeutic methods used are structured and
directive, and as such require a high level of therapist activity
(often they are described in treatment manuals). Fifth,
for most disorders, the cognitive and behavioral therapies
are time-limited interventions. Sixth, and perhaps most
important, these therapies are built on empirical evidence
that validates their theoretical orientation and guides the
choice of therapeutic techniques. Speci cally, learning
theories (i.e., classical, operant, and observational models of
learning) and the principles of cognitive psychology are relied
on heavily in constructing cognitive–behavioral treatment
models.
Cognitive Model
The basic theories of the cognitive model are rooted
in a long tradition of viewing cognitions as primary
determinants of emotion and behavior. Cognitive therapy
concepts have been traced as far as the writings of the
Greek Stoic philosophers (Beck 1976 , Ellis 1989 , Dobson
and Block 1988 ) and have been linked to a number of
other in uences, including the phenomenological school of
philosophy, Albert Ellis’ rational emotive therapy, and the
contributions of Adler and other neofreudians (Wright et al.
2003 , Wright et al. 2006 ). However, the greatest impetus for
the development of cognitively oriented therapy has been
the work of Aaron T. Beck (Beck 1991 , Beck 1976 , Beck
1963 , Beck 1964 , Beck 1967 , Beck 1993 ). For reviews of
the historical bases of cognitive therapy, see Dobson and
Block ( 1988 ), Clark et al. ( 1999 ), and Wright et al. ( 2006 ).
Clark et al. ( 1999 ) also provide an excellent review of the
philosophical and theoretical assumptions of the cognitive
theory of depression.
At the time Beck began to formulate his theories, the
predominant treatment approach was psychoanalytically
oriented psychotherapy. Freud conceived of depression as the
result of anger turned inward (Freud 1950 ). However, when
Beck attempted to study depression from this perspective,
he noted that stereotypical patterns of pessimistic and
self-critical thinking and distorted information processing
were essential characteristics of depression (Beck 1963 ).
This early work led to development of a cognitive model of
depression (Beck 1964 ), the description of speci c treatment
interventions, and a substantial research effort to study
cognitive functioning and treatment outcome in a variety of
disorders (Beck 1976 , Beck et al. 1979 , Beck and Rush 2000 ,
Wright et al. 2003 ).
Along the way, contributions from cognitive
psychologists, behavioral therapists, and other clinical
practitioners have been incorporated into the cognitive
model (Meichenbaum 1977 , Nelson and Craighead 1977 ,
Hollan and Kendall 1980 , Lewinsohn et al. 1982 , Clark
1986 , Dobson and Shaw 1986 , Barlow and Cerny 1988 ,
Wright and Thase 1992 ). The description of cognitive
Cognitive and
Behavioral Therapies
Edward S. Friedman1
Michael E. Thase1
Jesse H. Wright2
1Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
2 Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine,
Louisville , KY , USA
CHAPTER
91
Chapter 91 • Cognitive and Behavioral Therapies 1921
theories given here is based largely on Beck’s concepts. This
model of therapy tends to give somewhat more emphasis to
cognitive than behavioral factors in treatment interventions,
but both are considered to be integral parts of the model
(Figure 91–1 ).
Depending on the case formulation and the phase of
therapy, attention may be directed primarily at cognitive
or behavioral aspects of the disorder. In most cases, a
combination of cognitive and behavioral techniques is
used. For this reason, we use the term cognitive–behavioral
therapy (CBT) throughout the chapter unless referring to a
speci c form of behavioral treatment.
Figure 91–2 displays a simplified model for
understanding the relationships between environ-
mental events, cognitions, emotion, and behavior (Wright
et al. 2003 , Wright 1988 , Friedman and Thase 2006 ). This
model is based on the theoretical assumption that environ-
mental stimuli trigger cognitions associated with personal
meaning that elicit subsequent physiological and affec-
tive arousal (emotions). These emotions, in turn, have
a potent reciprocal effect on cognitive content and infor-
mation processing, stimulating dysfunctional thoughts and
worsening negative affect. Thus, the individual’s behavio-
ral responses to stimuli and thoughts are viewed as both a
product and a cause of maladaptive cognitions. In doing
CBT, treatment interventions may be targeted at any or all
components of the model.
Of course, many other factors are involved in psychiatric
disorders, including genetic predisposition, state-dependent
neurobiological changes, and various interpersonal
variables. These in uences are also included in the case
conceptualization in CBT. Wright and Thase ( 1992 ) have
outlined an expanded cognitive-biological model that can be
used for synthesizing cognitive and neurobiological factors
in a combined therapy approach. Contemporary psychiatric
research is striving to understand how best to combine and/
or sequence CBT and pharmacotherapy, and relate CBT
technique to new understandings in cognitive neuroscience.
Nevertheless, the working model in Figure 91–2 can be used
as a practical template to guide the therapist’s case formu-
lation and interventions.
Automatic Thoughts and Schemas
Dysfunctional information processing is apparent
in many psychiatric disorders at two major levels of
cognition-automatic thoughts and schemas (Beck 1976 ,
Dobson and Shaw 1986 , Teasdale 1983 , Segal 1988 , Alfrod
and Correia 1994 ). Automatic thoughts are cognitions
that stream rapidly through an individual’s mind, either
spontaneously or in response to some prompt or stimulus.
Automatic thoughts may be triggered by affective arousal
(i.e., anger, anxiety, or sadness), or conversely, affective
shifts are generally accompanied by automatic negative
thoughts (Teasdale 1983 ). Their automatic nature refers
to their speed of entry into awareness and their implicit
truthfulness. In this way, automatic thoughts have
emotional validity (Friedman and Thase 2006 ). For most
people, before therapy, automatic thoughts are usually
not examined carefully for validity. In fact, many people
susceptible to anxiety or depression often use an affectively
biased manner of thinking referred to as emotional
reasoning (i.e., “I feel that this is correct, therefore it is
correct”). Although we all experience automatic thoughts,
in depression, anxiety, and other psychiatric disorders the
thoughts are distinguished by their greater intensity and
frequency (LeFebvre 1981 ).
Beck ( 1967 ) coined the term negative cognitive triad
to describe the content of automatic negative thoughts.
Typically, automatic negative thoughts may be grouped
by themes pertaining to (1) self, (2) world (i.e., signi cant
others or people in general), and (3) future. As described
subsequently, the themes revealed in one’s characteristic
automatic negative thoughts can be used to infer deeper
levels of cognition: beliefs, rules, and schemas. Once they
are comfortable recognizing their automatic negative
thoughts, patients can be taught to examine their beliefs
and the operational rules that underlie beliefs. Although
patients are not fully aware of their schemas (relatively
stable cognitive patterns that are the product of ones beliefs,
attitudes, and behavioral responses), these cognitions are
usually accessible through the questioning techniques used
in CBT (Wright et al. 2003).
Event
Cognitive
appraisal
(distorted)
Emotion
(depressed
and/or anxious)
Behavioral
inclination
(helpless and/or
avoidance)
Behavior
(maladaptive)
Figure 91–1 Reprinted with permission from the American Psychiatric
Association.
Perception of event
Activation of relevant schema
Altered information processing
Automatic thoughts
Behavioral
symptoms
Emotional
symptoms
Figure 91–2 Cognitive model of information processing.
1922 Section VII • Psychotherapeutic and Psychosocial Treatments
Beck and coworkers (Beck et al. 1979 , Beck and
Emery 1985 , Wright and Beck 1983 ) have noted that
stereotypic errors in logic (termed cognitive errors
or cognitive distortions) also shape the content of
automatic thoughts. Examples of these processes include
personalization, magni cation and minimization, all-or-
nothing thinking, jumping to conclusions and ignoring
the evidence (e.g., disregarding the positive, or selective
abstraction). De nitions of a number of common cognitive
errors are included in Table 91–1 . Cognitive errors help
to translate between the “surface” level of cognition
(revealed in automatic negative thoughts) and deeper
cognitive structures such as basic assumptions, rules and
schemas (Friedman and Thase 2006 , Segal 1988 , Young
and Lindermann 1992 ). It has been proposed that such
apparently illogical thinking during times of heightened
emotion may have had evolutionary value (Friedman
and Thase 2006 ). Speci cally, cognitive distortions
during periods of affective arousal tend to narrow one’s
focus of attention, simpli fy in for mation processing, and
intensify behavioral responses. Thus, the individual may
be primed to respond decisively to the crisis at hand.
This is consistent with recent ndings that elucidate the
neurocircuitry of brain fear pathways (distinct affective
and cog nitive pathways). LeDoux has shown that activat ion
of the fear pathway causes a sequential activation
of affective (limbic-amygdala branch) and cognitive
(hippocampal-cortical branch) pathways. However,
the affective pathway is shorter allowing activation
milliseconds before the cognitive pathway. This primes
the system with a sequenced affective/cognitive response
to fearful environmental stimuli (LeDoux 1988 ).
Schemas represent the sum of one’s beliefs and atti-
tudes. They are the basic assumptions or unspoken rules
that act as templates for screening and decoding infor-
mation from the environment (Segal 1988 , Wr ig ht and
Beck 1983 , Young and Lindermann 1992 ). Psychological
wellbeing may be understood to represent the develop-
ment of a set of schemas that yield realistic appraisals
of self in relation to world (e.g., “I’m reasonably attrac-
tive, but looks aren’t everything,” “I can be loved under
the right circumstances,” or “I must work harder to
compensate for an average intellect”). Although unspo-
ken, schemas may be inferred from one’s beliefs and atti-
tudes. In the cognitive model, dysfunctional attitudes are
the structural “bridge” between pathological schemas
and automatic negative thoughts. Schemas pertaining to
safety, vulnerability to threat, self-evaluation, one’s lov-
ability, and one’s competence or self-ef cacy contain the
ground rules for personal behavior that are particularly
relevant to the understanding of disorders such as anxiety,
depression, or personality disorders (Segal 1988 . Young
and Lindermann 1992 , Blackburn et al. 1986a , Beck et al.
1990 ). A number of schemas relevant to psychiatric illness
are listed in Table 91–2 . Bowlby has noted that most psy-
chopathologically relevant schemas are developed early
in life, when the individual is relatively powerless and
dependent on caregivers (Bowlby 1985 ).
The cognitive model of psychiatric illness emphasizes
the concept of stress-diathesis (Friedman and Thase 2006 ,
Metalsky et al. 1987 ). From this perspective, a schema such
as “I must be loved to have worth,” might remain latent
until activated by a relevant life stressor (i.e., a romantic
breakup). Thus, being “dumped” by a romantic partner
may trigger marked emotional response in a person with
a “matching” schematic vulnerability but only a normal
amount of sadness in someone with a healthier schema (e.g.,
“The fact that she dumped me means I’m worthless” versus
“I am still a worthwhile person that someone else can love”)
(Hammen et al. 1989 ). Some schemas may be in uenced by
neurobiological factors. In panic disorder, exquisite sensi-
tivity to neurobiological signals, such as the evolutionarily
ancient “suffocation alarm,” may simultaneously trigger
noradrenergic arousal and fearful cognitions (Klein 1993 ).
This combination may underpin the schema “I am weak
and unable to cope with distress.” In recurrent depression,
neurobiological changes may exaggerate stress responsivity,
undermine the individual’s hardiness in the face of adversity,
and dampen hedonic capacity (Wright and Thase 1992 ). As
a result, the individual may develop the dysfunctional atti-
tude “I am powerless to change my destiny.”
Underlying schemas may be buttressed by either
maladaptive or adaptive attitudes (e.g., “No matter how
hard I try, I’m bound to fail” versus “I’m a survivor; if I
just hang in there things will be okay”), but many of these
cognitive structures have mixed features (Wright et al. 2003 ).
Schemas such as “If I’m not perfect, I will fail” may lead
to driven obsessional behavior, rigid attitudes and beliefs,
Table 91–1 Common Patterns of Irrational Thinking in
Anxiety and Depression
Cognitive Error Defi nition
Overgeneralization Evidence is drawn from one experience or
a small set of experiences that reach an
unwarranted conclusion with far-reaching
implications.
Catastrophic
thinking
An extreme example of overgeneraliza-
tion, in which the impact of a clearly
negative event or experience is ampli ed
to extreme proportions, e.g., “If I have a
panic attack, I will lose all control and go
crazy (or die).”
Maximizing and
minimizing
The tendency to exaggerate negative
experiences and minimize positive experi-
ences in one’s activities and interpersonal
relationships.
All-or-none (black
or white, absolut-
istic) thinking
An unnecessary division of complex or
continuous outcomes into polarized
extremes, e.g., “Either I am a success at
this, or I’m a total failure.”
Jumping to
conclusions
Use of pessimism or earlier experiences of
failure to prematurely or inappropriately
predict failure in a new situation; also
known as fortune telling.
Personalization Interpretation of an event, situation,
or behavior as salient or person-
ally indicative of a negative aspect of self.
Selective negative
focus –
“ignoring the
evidence”
“mental lter”
Undesirable or negative events, memories,
or implications are focused on at the
expense of recalling or identifying other,
more neutral or positive information; in
fact, positive information may be ignored
or disquali ed as irrelevant, atypical, or
trivial.
Adapted from Beck et al. (1979).
Chapter 91 • Cognitive and Behavioral Therapies 1923
Derived from human studies of the learned helplessness
paradigm, (Seligman 1975 ) attributional style refers to
the characteristic way that people explain the causality,
controllability, and impact of events. People susceptible
to depression are more likely to have an attributional style
in which negative events are perceived to be personally
controllable (i.e., internality), far-reaching (i.e., globality),
and enduring (i.e., stability) (Peterson et al. 1985 , Abramson
et al. 1989 , Sweeney et al. 1986 ). There is an obvious parallel
between the depressogenic attributional style of Abramson
and colleagues ( 1978 ) and Beck’s negative cognitive triad.
In general, studies of people suffering from depression
and anxiety have con rmed that pathological information
processing is an important part of these disorders. Negative
automatic thoughts and cognitive errors have been found
to be more common in depressed patients than in control
subjects (Dobson and Shaw 1986 , Blackburn et al. 1986b ,
LeFebvre 1981 , Watkins and Rush 1983 ). Similarly,
automatic thoughts concerning uncontrollability, threat,
or danger have been documented in patients with high
levels of anxiety (Kendall and Hollon 1989 , Ingram and
Kendall 1987). In clinical studies, depressed subjects also
demonstrated elevated levels of dysfunctional attitudes
(Blackburn et al. 1986b , Simons et al. 1984 , DeRubeis et al.
1990 ), distorted attributions to life events (Abramson et al.
1978 , Peterson et al. 1985 , Sweeney et al. 1986 , Zautra et
al. 1985 , Deutscher and Cimbolic 1990 ), and negatively
biased responses to feedback (DeMonbreun and Craighead
1977 , Rizley 1978 , Wenzloff and Grozier 1988 ). Anxious
individuals have been found to have an unrealistic view of
the danger or threat in situations (Mathews and MacLeod
1987 , Fitzgerald and Phillips 1991 ), an attentional bias
toward threatening stimuli (Mathews and MacLeod 1987 ),
and an enhanced memory for anxiety-provoking situations
(Ingram and Kendall 1987 , Cloitre and Liebowitz 1991 .
Taken together, the results of these studies suggest
that disturbances in information processing are essential
features of depression and anxiety. Theoretical assumptions
and treatment strategies for CBT of many other conditions,
including the eating disorders, substance abuse, personality
disturbances, and psychoses, have been articulated. The reader
is referred to publications on these topics for descriptions
of how the cognitive model can be adapted for treatment
of a wide variety of psychiatric disorders (Beck et al. 1990 ,
Linehan et al. 1993, Freeman et al. 1989 , Beck et al. 1993 ,
Wright et al. 1993, Kingdon and Turkington 1995 , Wilkes
et al. 1994 , Beck and Emery 1985 , Wright 2004 ). Speci c
applications of cognitive and behavioral treatment strategies
are described later in the chapter.
Behavioral Model
The learning theories underpinning the behavioral
therapies date to the work of Pavlov (Pavlov and Gantt
1928 ) and Skinner ( 1938 ). Voluminous laboratory research
on learning in animals subsequently established certain
lawful relationships in the acquisition and maintenance of
behavior (Hull 1943 , Mowrer 1947 , Spence 1956 ). Moreover,
demonstrations that abnormal or “neurotic” behaviors
in animals could be either induced by repeated pairings
of a noxious stimulus with a neutral one (i.e., classical
conditioning) or shaped by controlling reinforcement
schedules (i.e., operant conditioning) suggested that these
and frequent bouts of dysphoric or irritable moods. On
the other hand, perfectionistic beliefs tempered by realistic
expectations and actual achievement can also result in high
levels of performance and success.
The concept of attributional style (Hammen et al.
1989 ) describes an alternative view of cognitive vulnerability.
Table 91–2 Proposed Maladaptive Schemas
Autonomy
Dependence The belief that one is unable to function
with the constant support of others
Subjugation-lack
of individuation
The voluntary or involuntary sacri ce of
one’s own needs to satisfy others’ needs
Vulnerability to
harm or illness
The fear that disaster (i.e., natural,
criminal, medical, or nancial) is about
to strike at any time
Fear of losing self-
control
The fear that one will involuntarily lose
control of one’s own impulses, behavior,
emotions, mind, and so on
Emotional
Deprivation
The expectation that one’s needs for
nurturance, empathy, or affect will never
be adequately met by others
Abandonment-loss The fear that one will imminently lose
signi cant others or be emotionally
isolated forever
Mistrust The expectation that others will hurt, abuse,
cheat, lie, or manipulate you
From Thase ME, Beck AT: An overview of cognitive therapy. In Wright JH,
Thase ME, Beck AT, Ludgate JW (eds): Cognitive Therapy with Inpatients:
Developing a Cognitive Milieu. New York: Guilford Press, 1992:9. Adapted from
Young J: Schema-focused cognitive therapy for personality disorders. Unpublished
manuscript, Cognitive Therapy Center of New York, 1987.
Connectedness
Defectiveness-
unlovability
The assumption that one is inwardly
defective or that, if the aw is exposed,
one is fundamentally unlovable
Social
undesirability
The belief that one is outwardly undesirable
to others (e.g., ugly, sexually undesirable,
low in status, dull, or boring)
Incompetence-
failure
The assumption that one cannot perform
competently in areas of achievement,
daily responsibilities, or decision-making
Worthiness
Social isolation/
alienation
The belief that one is isolated from the
rest of the world, is different from other
people, or does not belong to any group
or community
Guilt-punishment The conclusion that one is morally bad or
irresponsible and deserving of criticism
or punishment
Shame-
embarrassment
Recurrent feelings of shame or self-
consciousness experienced because one
believes that one’s inadequacies (as
re ected in the preceding maladaption
schemas of worthiness) are totally
unacceptable to others
Unrelenting
standards
The relentless striving to meet extremely
high expectation of oneself at all costs
(i.e., at the expense of happiness, pleasure,
health, or satisfactory relationships)
Entitlement Insistence that one should be able to
do, say, or have whatever one wants
immediately
Limits and standards
1924 Section VII • Psychotherapeutic and Psychosocial Treatments
approaches were relevant to psychiatric illness as well
(Watson and Rayner 1920 , Masserman 1943 , Skinner 1948 ,
Wolpe 1952 , Lindsley 1956 ).
By the late 1950s, there was considerable dissatisfaction
with the medical and psychoanalytic models of
psychopathological processes and treatment, particularly
from within academic clinical psychology (Kazdin 1982 ).
Such ferment was underpinned by the low levels of
diagnostic reliability, even for well-established illnesses
such as schizophrenia, (Kanfer and Saslow 1965 , Mischel
1968 ) as well as by the lack of evidence supporting the
effectiveness of psychodynamic psychotherapy (Eysenck
1952 , Zubin 1953 ). Moreover, the revolution that has become
modern psychopharmacology was still in its infancy and
no alternative paradigm at the time had adequate scienti c
currency. The behavioral therapy movement was thus born,
emphasizing the use of scienti c principles of investigation
with a focus on learned and measurable behaviors
(Kazdin 1982 , Beck et al. 1990 ). Further demonstrations of
the utility of operant conditioning (i.e., behavior modi cation
experiments in institutionalized, chronically mentally ill
patients by use of contingent reinforcement or extinction
(Ayllon and Azrin 1968, Ullmann and Krasner 1965 ) and
counter-conditioning treatment of anxiety disorders (such
as systematic desensitization (Marks and Gelder 1965 ,
Paul 1966 ) triggered a surge of enthusiasm for these more
objective treatment methods. By the late 1970s, behavioral
therapy had become the most academically in uential model
of treatment outside of the medical setting (Kazdin 1982 ,
Beck and Emery 1985 ).
The behavioral model is based on the relatively
straightforward “chain” of events and responses illustrated
in Figure 91–3 . Through the years, considerable effort and
debate have concerned whether stimulus-response and
response-reinforcement relationships could be invoked to
account for the complexity of human behavior (Kazdin
1982 , Staats 1964 ). In its maturity, behavioral therapy has
broadened beyond an exclusive focus on observable behaviors
(i.e., radical behaviorism) and now incorporates cognitive
processes and other individual variables that affect learning
(Bandura 1977a , Goldfried and Davison 1994 ). For example,
in observational learning, the stimulus-response contingency
relationship is established vicariously, by watching, reading
about, or imagining the event in question. Reinforcement
does not have to take place explicitly; it may occur vicariously,
or it may simply be imagined. Other factors, such as the
individual’s past history, inherent talents, or skillfulness of
his or her pertinent response repertoire, help account for the
wealth of inter-individual variability in stimulus-response
relationships. Bandura’s cognitive–behavioral formulation
of self-ef cacy is one example of a “mental” construct
that has abiding behavioral implications. This modi able
attitude or belief (roughly akin to self-con dence) in uences
persistence, willingness to try new things, optimism, and
capacity to endure setbacks (Bandura 1977b ).
One of the most important enduring experimental
models of depression (learned helplessness) is the direct
descendant of studies of animal learning (Seligman 1975 ,
Maier and Seligman 1976 , Miller and Seligman 1975 ).
Learned helplessness is a state of behavioral passivity and
apparent apathy induced by repeated exposure to noxious,
yet inescapable, stimuli. The learned helplessness paradigm
is based on a modi cation of escape or avoidance con-
ditioning. A wide variety of species, ranging from gold sh
to humans, can readily learn to avoid or escape from a set-
ting when given advance notice (i.e., a light or tone) of an
impending noxious event (i.e., a painful shock) (Maier and
Seligman 1976 ). However, when escape is impossible (e.g., a
dog is harnessed, or the walls of the experimental box are
too high to be scaled), the animal is observed to be passive
and inactive. During such “helplessness training,” the ani-
mal’s affect and behavior shift progressively from a state of
apprehensive arousal (perhaps similar to human anxiety?)
to one that may be analogous to depression. After repeated
pairings, the animal will become unable or unwilling to
escape from the stimulus when unharnessed. The parallels
to human experiences are obvious, although it is not known
if the animal cognates helpless thoughts (“It won’t work…
why bother to try…I’m better off just to be still”) (Oakes
and Curtis 1982 ). Nevertheless, neurochemical and phar-
macological studies underscore the phenomenological simi-
larities between learned helplessness and depression (Weiss
and Simson 1985 , Willner 1991 ). Further, “helpless” dogs
can be retrained to escape with techniques much like those
used in behavioral therapy (Klein and Seligman 1976 ).
Over the past decade, several researchers have attempted
to distinguish the extent to which the behavioral com-
ponents of CBT are responsible for its therapeutic effect.
The BA approach derives from the work of Ferster ( 1973 ),
Lewinsohn ( 1974 ) and Rehm ( 1977 ). They hypothesized a
link between avoidant (and withdrawal) behavior and the
maintenance of depression. They recommended activation
strategies that undermine avoidance, reduce antidepressant
reinforcers, and increase positive reinforcement from the
environment (Dimidjian et al. 2006 ). Recently, Dimidjian
and colleagues ( 2006 ) described an “expanded BA model”
that included increased focus on assessment and treatment
of avoidance behaviors, the establishment/maintenance of
regular routines, and behavioral strategies for targeting
rumination. This latter strategy emphasizes the functional
impact of ruminative thinking and moves away from the
analysis of content toward a focus on direct, immediate
experience (Dimidjian et al. 2006 ).
Cognitive and Behavioral
Treatment Strategies
The cognitive and behavioral therapies are well known
for their use of speci c treatment techniques. Commonly
used CBT procedures are directly linked to the theoretical
constructs and empirical research of this school of therapy.
Although techniques are given somewhat more emphasis
in CBT than in some other forms of psychotherapy, there
is still considerable room for therapists to be creative and
exible in developing a treatment plan. In fact, novice
therapists sometimes focus too much on applying techniques
at the expense of nurturing the therapeutic alliance and
case formulation (Rush and Beck 1995 ). Development of
a productive therapeutic relationship and an individualized
case conceptualization should always take precedence over
the implementation of speci c cognitive or behavioral
Stimulus (Organism) ContingencyResponse
Figure 91–3 Chain of events.
Chapter 91 • Cognitive and Behavioral Therapies 1925
techniques. A number of the more important CBT strategies
are described brie y here. More detailed accounts of CBT
interventions can be found elsewhere (Beck et al. 1979 ,
Beck 1995, Barlow and Cerny 1988 , Freeman et al. 1989 ,
Persons 1989 ).
Collaborative Empiricism
As in all effective psychotherapies, the therapeutic relationship
is important in CBT. However, interchanges between
therapist and patient often differ from those observed in
supportive or dynamically oriented treatment. One difference
is that the therapist is responsible for managing the pace
of the session. Using and adhering to an agenda makes
each session as ef cient as possible. Another difference is
that CBT therapists adopt a therapeutic relationship that
emphasizes: 1) a high degree of collaboration and 2) a
scienti c attitude toward testing the validity or usefulness of
particular cognitions and behavior. This therapeutic stance
is referred to as collaborative empiricism. The empirical
nature of the relationship re ects that therapist and patient
work together as an investigative team to develop hypotheses
about cognitive or behavioral patterns, examine data, and
explore alternative ways of thinking or behaving. At rst,
therapists usually spend more time teaching and explaining
in CBT than in other forms of therapy, yet in the course of
therapy, patients are actively engaged to become increasingly
involved in the direction and the work of treatment.
Critics of CBT sometimes suggest that the patient-
therapist relationship is compromised by the therapist’s
attempt to “replace” negative thoughts with positive ones.
One jaded senior colleague referred to CBT as a “feel good
therapy,” and another stated that CBT’s unspoken strategy
was to teach people to lie to themselves. CBT is a cautiously
optimistic therapy, but effective therapists do not use a
“Pollyanna” approach to treatment. The data demonstrating
CBT’s ef cacy, discussed below, is the basis for our prognostic
optimism. The collaborative empirical stance requires that
the therapist and patient work together to honestly appraise
the validity of cognitions as well as of the adaptive or
maladaptive aspects of beliefs and behaviors. If a negative
assessment proves to be accurate (e.g., the patient actually
has made serious mistakes, the individual’s spouse is highly
likely to leave, or the patient has engaged in a repetitive self-
defeating behavior pattern), then the therapist and patient
need to work together in a problem-solving mode to develop
a plan to cope with the problems at hand or practice more
adaptive strategies for use in the future.
Wright and Beck, and others, have recommended
several strategies for enhancing collaborative empiricism
(Wright et al. 2003 , Clark et al. 1999 ). These include: 1)
adjusting the therapist’s level of activity to match the
patients’ symptom severity or the phase of treatment; 2)
encouraging the use of self-help procedures; 3) attending
to the “nonspeci c” variables important in all therapeutic
relationships (e.g., empathy, respect, equanimity, kindness,
and good listening skills); 4) promoting frequent two-way
feedback; 5) devising coping strategies to help deal with
real losses or implementing a plan of action to address
maladaptive behavior; 6) recognizing transference
phenomena; 7) customizing therapeutic interventions; and
8) using humor judiciously. It is also important to recognize
and account for the wide variety of individual differences
in cultural backgrounds, social attitudes, and expectations
that each patient brings to the therapy encounter (Wright
and Davis 1994 ).
Psychoeducation
Most forms of CBT integrate explicit psychoeducational
procedures as a core element of the treatment process.
Psychoeducational procedures are typically blended into
treatment sessions in a manner that de-emphasizes formal
teaching. There is a concerted effort to teach the patient
why it is important to challenge automatic thoughts, identify
cognitive errors, and practice implementing a more rational
thinking style. Behavioral interventions are also preceded by
psychoeducation to convey the background for principles
such as extinction, reinforcement, self-monitoring, exposure,
and response prevention.
There are a number of ways in which therapists employ
psychoeducation in CBT. Perhaps the most important is the
demonstration of basic concepts, which usually begins in
the rst therapy session (Beck et al. 1979 , Thase and Wright
1991 ). Patients are more likely to grasp and implement
therapy concepts when cognitive–behavioral principles are
applied to situations that are personally signi cant. On
occasion, therapists may give “mini-lectures,” (Epstein et al.
1988 ) but an interactive and guided method of instruction,
called Socratic questioning usually predominates (Beck
et al. 1979 , Overholser 1993a , 1993b , 1993c ).
In the early phases of treatment, special attention
is paid to socializing the patient to CBT. The basic
cognitive-behavioral model is demonstrated, and expec-
tations for both patient and therapist are conveyed. Some
of the frequently used psychoeducational procedures in
CBT include brief, impromptu explanations (often written
on a chalkboard or a pad of paper to increase the chances
of comprehension and retention) and reading assignments
(bibliotherapy), such as Coping with Depression (Beck and
Greenberg 1974 ), Feeling Good (Burns 1980 ), or Mind Over
Mood (Greenberger and Padesky 1995), or Getting Your
Life Back (Wright and Basco 2001). Psychoeducational
initiatives typically become more complex as therapy pro-
ceeds. For example, detailed explanations and repeated
exercises may be needed before the patient fully grasps
abstract concepts such as attributional style or schemas.
As therapy progresses, homework assignments continue to
explicitly reinforce and expand upon material covered dur-
ing therapy sessions.
As in other forms of learning, individual differences
in homework compliance may in uence the progress
of therapy. For example, some evidence suggests that
homework compliance is correlated with treatment outcome
(Whisman 1993 , Burns and Spangler 2000 ). We have found
that homework compliance is in uenced partly by the
therapist’s consistency, enthusiasm, and ability to integrate
the assignments into the treatment plan.
Because psychoeducation can be time consuming
and is a routine part of therapy, several investigators have
developed computer programs that provide education
on cognitive therapy, encourage homework completion,
and actively involve patients in self-help exercises. One of
the earliest programs, developed by Selmi and coworkers
( 1990 , 1991 ), was found to be ef cacious in the treatment
of depression. Although this software relies completely on
1926 Section VII • Psychotherapeutic and Psychosocial Treatments
written text for conveying information and is not available
for clinical use, it demonstrated the potential bene ts
of computer tools for CBT. More recently, Wright and
coworkers ( 1995 , 2002 , 2005 ) have introduced a multimedia
form of computer-assisted CBT (“Good Days Ahead”)
that uses full screen video and vivid graphics to engage
users in the learning process. Research with this program
has demonstrated strong effects on learning, high levels
of acceptance by patients, and evidence for ef cacy in the
treatment of depression (Wright et al. 2002 , 2005 ). Marks
and coworkers (Shaw et al. 1999 , Kenwright et al. 2001 ) have
been using a text-based computer program (Fear Fighter) in
Great Britain for treating anxiety disorders with exposure
therapy. This group has reported signi cant increases in
treatment ef ciency when the computer program is used to
provide psychoeducation and involve patients in exposure
protocols (Kenwright et al. 2001 ). The use of computers as
treatment adjuncts has been reviewed in several publications
(Locke and Rezza 1996 , Wright and Wright 1997, Wright
2004 ). Computer-assisted treatment is still in the early
stages of development, but there appears to be considerable
potential for using these new technologies to augment the
process of psychotherapy.
Modifying Automatic Thoughts
The rst step in changing automatic thoughts is to help the
patient recognize when she or he is having them. The therapist
is often able to illustrate the presence of automatic negative
thoughts during the initial session by gently calling attention
to a change in the patient’s mood. Such “mood shifts”
can be excellent learning experiences that give personally
relevant illustrations of the linkage between cognitions and
feelings. Use of a mood shift to identify automatic thoughts
is illustrated in the following interchange.
Therapist: I noticed a moment ago that your mood
appeared to change. All of a sudden, you looked very
sad. Do you mind if we talk about what was going
through your mind?
Patient: No…but I’m not really sure what you
mean…I guess I just felt that this therapy might be
too hard to handle.
Therapist: I’d like to make a distinction between
what you thought and what you felt. It looked like
you were sad. Am I right? (patient nods) And,
at about that time, you had the thought that this
therapy might be too dif cult? (patient nods) This
could be an example of what we call a negative
automatic thought. Let’s spend a few minutes to see
if it is one, and if so, what it might mean.
One common misconception of CBT is that its
practitioners disregard the role of affect or feelings in the
etiology and treatment of psychiatric disorders. Actually,
one of the principal components of CBT is the stimulation
and modulation of emotion (see, for example, Figure 91–1 ).
In fact, Beck referred to emotion as “the royal road to
cognition” (Beck 1991 ). In contrast to experiential therapies,
variations in emotion are used in CBT to establish links with
cognition and identify errors in information processing.
Getting in touch with feelings is thus not a goal in CBT but
only a means by which therapy helps patients to gain greater
control over the processes that in uence their moods and
behaviors.
Socratic Questioning
The most frequently used technique to uncover and modify
automatic negative thoughts is Socratic questioning (or
guided discovery) (Beck et al. 1979 , Overholser 1993a ,
1993b , 1993c ). Socratic questioning teaches the use of
rationality and inductive reasoning to ascertain whether
what is thought or felt is actually true. The therapist models
the use of Socratic questioning and encourages the patient
to start raising questions about the accuracy and validity
of his or her thinking. There are few formal guidelines for
Socratic questioning (Overholser 1993a ). Rather, therapists
learn to use their experience and ingenuity to frame good
questions that engage the patient in a process aimed at
recognizing and modifying a biased or distorted cognitive
style. Typical questions include: What ran through you mind
at that time? What is the evidence that your impression is
accurate? Could there be any alternative explanations? If
this were true, what would be the worst thing that would
happen? When guided discovery methods are not suf cient
to draw out automatic thoughts, the therapist may turn to
several alternative ways of eliciting dysfunctional cognitions,
as described in the following.
Imagery Techniques and Role-Playing
Imagery techniques and role-playing are used when direct
questioning does not fully reveal important underlying
cognitions. When imagery is used, the therapist sets the
scene by asking the patient to visualize the situation that
caused distress. Although some patients can readily imagine
themselves in a previous scene, many need prompts or
imagery induction to encourage their active participation in
the exercise. Several types of questions can be used to help
frame the scene. These include inquiries about (1) the physical
details of the setting, (2) occurrences immediately before
the interaction, and (3) descriptions of the other people
in the scene (Wright et al. 2003 ). In role-playing exercises,
the therapist and patient act out an interpersonal vignette to
uncover automatic thoughts or to try out a revised pattern
of thinking. This technique is used less frequently than
imagery by most cognitive–behavioral therapists and may
be reserved for situations in which transference distortions
are unlikely (Wright et al. 2003 ).
Thought Recording
Thought recording is one of the most useful procedures
for identifying and changing automatic thoughts. This
technique is rst presented in relatively simple two- or
three-column versions in the early stages of therapy. When
the two-column procedure is used, patients are instructed
to write down events in one column and thoughts in the
other. Alternatively, they can record events, thoughts, and
emotions in the three columns. The purpose of this exercise
is to encourage patients to begin to use self-monitoring
to increase awareness of their thought patterns. Next,
the strength of the emotion and the believability of the
automatic negative thoughts are rated on a scale of 0 to
100. In subsequent sessions, a more complex ve-column
thought record, the thought change record (TCR) is
introduced (Figure 91–4 ). The fourth column of the TCR
Chapter 91 • Cognitive and Behavioral Therapies 1927
encourages the patient to develop rational alternatives that
rebut the automatic negative thoughts; the fth column used
for a reevaluation of the mood and cognitive ratings. Work
on identifying cognitive errors can also be included in this
form of thought recording.
Examining the Evidence
The examining the evidence procedure is a collaborative
exercise used to test the validity of automatic negative
thoughts. Cognitions are set forth as hypotheses rather
than established facts. The patient is encouraged to write
down evidence that either supports or refutes the automatic
thought using a two-column form (i.e., pros and cons). For
example, examining the evidence for the automatic thought
“everyone always looks down on me” might reveal data in
support of both sides of the question. It is likely that the
patient will recall many times when he or she felt looked
down on, treated disrespectfully, or criticized unfairly. On
the other hand, it would be virtually impossible that others
always perceive the individual in this way. Speci c evidence
of good job performance, positive relationships with
relatives and friends, and successes in school or recreational
activities may then be used to help counterbalance the
patient’s negatively biased and overgeneralized automatic
thought. More ambiguous examples may also be revealed
in which the evidence does not clearly point in one direction
or the evidence is not clear. In these situations, the therapist
may suggest homework to collect additional information.
Cognitive errors such as overgeneralization, catastrophic
thinking, maximizing or minimizing, personalization, and
all-or-nothing thinking are frequently revealed in these
situations (see Table 91–1 ).
Next, the therapist helps the patient to revise the
automatic negative thought in light of the evidence (e.g., “I
often feel inferior to others, even when there’s no good
evidence that I should feel that way” or “I have had a
number of dif culties with my teachers and employers, but
not all relationships have been bad and some have been
very good”). The process thus moves from the patient’s
general and globally negative interpretations to more
speci c, factually based statements.
When an honest appraisal uncovers evidence in
support of negative cognitions, the therapist may choose
to focus on the patient’s attributions of causality or
internality. The patient who posits a negative attribution
for poor work evaluation (e.g., “My performance was
poor because I don’t have what it takes”) can usually be
aided to consider a more neutral attribution (e.g., “My
performance was poor because I was not prepared . . . my
depression and lack of motivation contributed to this
too”). The treatment plan may also be revised to develop
better methods of coping in similar situations or to work
on ways of remediating skill de cits. Sometimes, particular
dif culties cannot be changed (e.g., physical handicaps,
Date Event Automatic thoughts Emotions Rational thoughts Outcome
a. Describe actual event
preceding unpleasant
emotion or
b. Stream of thoughts,
daydream, or
memories preceding
unpleasant emotion.
a. Write automatic thought(s)
that led to emotion(s).
b. Rate of belief in automatic
thought(s), 0_100%.
a. Specify sad, anxious,
angry, tense, and so
on.
b. Rate degree of
emotion, 0_100.
a. Identify cognitive errors.
b. Write rational response
to automatic thought(s).
c. Rate belief in rational
response, 0_100%.
a. Specify and rate
subsequent
emotion(s), 0_100.
My boss asks for a
progress report.
1/30/95
My son comes home
late from a party.
Nobody listens to me. (90)
He doesn't care. (75)
What's the use of trying? (80)
I'm in big trouble. (85)
I can't handle this job. (90)
I've messed
everything up. (95)
Anxious (95)
Sad (80)
Angry (75)
Sad (85)
Angry (30)
Sad (25)
Magnification, ignoring
the evidence,
overgeneralization.
I'm slightly behind
schedule, but I
can catch up. (95)
I've had a good track
record with this job. (100)
I'm doing O.K. in some
other areas of my life. (95)
All or none thinking,
ignoring the evidence,
personalizing.
My son pays attention a
fair amount of the time,
but he doesn't always do
what I want. (90)
There's plenty of evidence
that he cares about
me. (100)
We need to improve how
we communicate. (95)
I need to tell him that
I'm angry. (100)
Anxious (40)
Sad (20)
Figure 91–4 Daily record of dysfunctional thoughts.
1928 Section VII • Psychotherapeutic and Psychosocial Treatments
markedly unattractive physical looks, or severe nancial
limitations). A trainee once remarked to one of us, “I’m
not sure that CBT is the right treatment for my patient. He
really is ugly and dumb, and as far as I can tell, no one has
ever loved him!” Before turning supervisory attention to the
patient’s problems, the therapist-in-training was engaged in
a guided discovery exercise to clarify his assumptions and
beliefs about the essential importance of physical beauty,
intelligence, and romantic love. Subsequently, the patient
was able to address these issues successfully in therapy
as well.
Generating Alternatives
If automatic thoughts prove to be largely dysfunctional,
the patient is encouraged to generate alternatives that are
more accurate or factual. Many of the techniques discussed
earlier can be used to help generate alternatives to automatic
thoughts. Socratic questioning is used in therapy sessions
to help the patient start to think more creatively. Also,
psychoeducational procedures may be employed to teach
brainstorming techniques. For example, the patient may be
taught to use “expert testimony” or the opinions of someone
who knows her or him well (i.e., a sibling, spouse, or best
friend) to help develop less emotional and more rational
alternatives. Thought records are often used to record
alternatives to automatic thoughts. We often encourage
patients to collect their thought records in notebook form
for ongoing use. Figure 91–4 illustrates the use of rational
alternatives during CBT for a depressed patient.
Many patients with depression, anxiety, and related
conditions have relatively rigid cognitive styles that
perpetuate dysfunctional thought and behavior patterns.
For example, an individual who was given the homework
assignment of challenging the automatic negative thought
“I am a loser” presented the “realistic alternative” that
“whenever I start thinking about how I’m a loser, I will force
myself to stop thinking about it”. These thoughts about
thoughts tend to undermine the credibility of the rational
responses and may dampen the patient’s enthusiasm for
using the procedure. The therapist may notice a particular
facial expression or a change in the patient’s posture that
suggests the existence of second-order thoughts. In such
cases, more active therapeutic assistance may be needed.
For example, the therapist may need to act as a teacher or
coach in the area of adaptive cognitive functioning, rapidly
rebutting automatic thoughts as they arise. Coping cards,
which are index cards with helpful reminders on the use of
CBT methods (in this case, rational responses to repetitive
automatic negative thoughts), may be written during sessions
and carried by the patient in his or her pocket, wallet, or
purse for later use.
Cognitive–Behavioral Rehearsal
Cognitive–behavioral rehearsal is a treatment strategy that
is particularly useful for preparing patients to put their
experiences in CBT to work in real-life circumstances.
After automatic thoughts have been elicited and modi ed
through procedures described before, the therapist guides
the patient in a series of rehearsal exercises to try out
alternative cognitions in a variety of situations. By using
imagery and role-playing scenarios to practice generating
more adaptive cognitions, the patient may become aware
of problems that could interfere with implementation of
the new style of thinking. Further practice and targeted
homework assignments may then be needed before
alternative cognitions can be fully used. For example, the
effects of cognitive–behavioral rehearsal may be extended
to real situations by assigning homework to test use of the
modi ed automatic thoughts.
Modifying Schemas
The emphasis in the early phases of therapy is usually on
behavioral activation, identifying and changing automatic
thoughts, and the reduction of symptoms. However, as the
patient gains knowledge of cognitive–behavioral principles
and acute symptoms begin to subside, the focus of the
treatment sessions usually shifts toward work on the schema
level. Schemas are relatively stable cognitive patterns that
are the product of one’s beliefs, attitudes, and behavioral
responses. Because schemas serve as underlying templates
for the processing of new information, they play a major role
in the modulation of more super cial cognitions (automatic
thoughts), regulation of affect, self-esteem, and control
of behaviors. Thus, schema modi cation is an important
component of cognitively oriented therapies.
With Axis I disorders such as major depressive disorder
and panic disorder, schema revision efforts are directed at
correcting dysfunctional attitudes that may predispose the
patient to symptomatic recurrences. After several months
of productive therapy, schema modi cation may be placed
in the context of reducing future vulnerability. CBT of
personality disorders typically requires that a major
portion of therapy be devoted to modifying schemas and
related patterns of behavioral dysfunction (Beck et al.
1990 ). When schematic work cannot be fully addressed in
time-limited therapy, the model of ongoing change may be
introduced. Thus, the patient may begin to change her or
his “life course” by development of a long-term self-help
plan. Jarrett has proposed continuation and maintenance
phases of CBT treatment of depression, and she argues for
focusing on schema change in these phases of treatment if it
is not accomplished in the acute phase of treatment (Jarrett
et al. 2001 ).
Many of the techniques used to test and modify
automatic thoughts are also used to identify and revise
schemas. Psychoeducational interventions are usually
required as a rst step. Most patients are not aware of their
“guiding principles,” so the therapist may need to begin
by introducing and illustrating this concept. It is often
useful to review the connection between automatic negative
thoughts, basic assumptions, core beliefs, personal rules,
and behavior patterns using material from the patient’s own
experience (Wright et al. 2003 ). Socratic questioning is the
core procedure used for schema modi cation (Beck et al.
1979 , Overholser 1993c ).
The downward arrow technique (Figure 91–5 ) is a
particularly powerful way to move from surface cognitions
to deeper cognitive structures (Friedman and Thase 2006 ).
This technique describes asking the patient a question such
as: “If this automatic thought were true, what would it
mean about you as a person?” Another useful approach is
to examine patterns of automatic thoughts from thought
records to sort out common themes. The therapist may
suggest themes based on her or his knowledge of the patient’s
Chapter 91 • Cognitive and Behavioral Therapies 1929
automatic negative thoughts. In some situations, it may be
helpful to have patients review a description of common
pathological schemas to recognize some of their core beliefs
(see Table 91–2 ). On occasion, it may be useful to have
the patient write a brief autobiography to help elucidate
the historical antecedents of the schema. Computerized
learning programs can also be employed to help patients
uncover their schemas and may be particularly useful in
teaching patients how to change core beliefs (Wright et al.
2002 , 2005 ). A study comparing computer-assisted cognitive
behavior therapy (CCBT) with standard CBT found that
depressed persons treated with CCBT had statistically
greater change in dysfunctional attitudes than those treated
with standard CBT (Wright et al. 2005).
Because schemas are so strongly held (in essence, they
have helped de ne reality and mold behavior for years),
they may require intensive work in a number of therapy
sessions to undergo signi cant change. Sometimes long-term
continuation and maintenance CBT is required to accomplish
schematic restructuring. Therapists can select from a number
of CBT techniques, including examining the evidence, listing
advantages and disadvantages, generating alternatives,
cognitive response prevention, and cognitive–behavioral
rehearsal, as they attempt to modify schemas (Wright et al.
2003 ). Examining the evidence, generating alternatives, and
cognitive–behavioral rehearsal were described earlier as
methods of changing automatic thoughts.
Cognitive Response Prevention
In cognitive response prevention, the patient agrees to
complete a homework assignment in which she or he must
behave in a way that is inconsistent with the pathological
schema. For example, a person with perfectionist attitudes
may be assigned a task in which she or he must perform in
a “so-so” manner. This is intended to activate the schema
that is triggering automatic negative thoughts (e.g., “They’ll
think I’m a sloth” or “I’ll never be trusted with an important
assignment again”). By not responding to the perfectionist
demands dictated by the schema, the individual, thus,
has the opportunity to cope with the automatic negative
thoughts consequent to this “rule violation.”
Listing Advantages and Disadvantages
The listing advantages and disadvantages procedure is
particularly useful when a schema appears to have both
adaptive and maladaptive features. Schemas that have
damaging effects are often maintained because they also
have a positive side. For example, the schema “I must be
perfect to be accepted” can have signi cant bene ts (e.g.,
hard work and attention to detail often lead to success in
work or school). Nevertheless, because perfection is seldom
possible, the individual may remain vulnerable to setbacks.
Other schemas, such as “I’m a complete loser,” may not
seem to have any advantages at rst glance. However, even
such a markedly negative basic assumption can reinforce
other behaviors associated with it. For example, a person
who believes that he or she is a loser may avoid making
commitments, withdraw from challenging assignments,
or refuse to exert a sustained effort to solve a dif cult
problem. This strategy may thus protect the person from
painful setbacks at the expense of achieving successes. The
advantages and disadvantages analysis provides the patient
and therapist with essential information for planning
modi cations. Schemas are most likely to be revised when
they take into account both the maladaptive and the adaptive
features of the old basic assumption.
In general, it is recommended that patients keep a list
of the schemas as they have been identi ed. The schema
Patient Therapist
"I think the date went poorly (chuckles with
gallows humor). . . I'm so depressed!"
"No__It's true. He didn't mention another date
and hasn't called me since."
"Stuff like this happens to me a lot!"
"There is something seriously wrong with me."
"I must be a reject . . . a social basket case . . . I'm
so pathetic!" (tearful)
"It says that no one will ever love me . . . I'll be
lonely forever . . . an old maid . . . " (more tears)
(There is a visible shift in affect.)
"Is it true that the date went poorly? Could
this be an example of how negative thinking is
involved with feeling depressed?"
"Okay . . . that sounds convincing enough. So, if
the date went badly, what's that really say
about you?"
"And, if that's true?"
"Such as . . . "
"And, if that's true, which we still have to test
out, what does that say about your world
and future?"
"I can see from your tears that these thoughts
really hit you where it hurts. I've written down
some of the more dramatic and hurtful
statements. Do you feel up to taking a look at
them and testing their accuracy?"
Figure 91–5 The downward arrow
technique.
1930 Section VII • Psychotherapeutic and Psychosocial Treatments
list helps to focus the patient’s attention on the overarching
nature of these maladaptive principles. Because schemas
often become manifest only during periods of increased
stress or symptom expression, they may appear to fade in
signi cance as the patient begins to improve. For example,
behavioral treatment programs that neither endorse nor aim
to modify schemas are generally as effective as CBT in the
short run. However, there may be a false security engendered
by symptom relief. The cognitive model posits that the
individual will remain vulnerable to the depressogenic
impact of “matching” life events unless schema revision is
accomplished (Friedman and Thase 2006 ).
Behavioral Techniques
In CBT, behavioral methods are usually integrated with
cognitive restructuring in a comprehensive treatment plan.
Behavioral strategies may be given a greater emphasis earlier
in therapy with more severely symptomatic patients such
as those with intense depression, bipolar symptoms, or
schizophrenia (Beck et al. 1979 , Thase and Wright 1991 ,
Kingdon and Turkington 1995 , Basco and Rush 1996 , Scott
and Wright 1997 ). Some cognitive-behavior therapists may
rely primarily on behavioral interventions for conditions
such as obsessive-compulsive disorder (OCD) or simple
phobias. Commonly used behavioral strategies are described
here in alphabetical order.
Activity Scheduling, Graded Tasks, and
Mastery-Pleasure Exercises
Depressed people may spend excessive amounts of time
alone or have tangible reductions of pleasurable activity.
One of the earliest behavioral formulations of depression
viewed the disorder as an “extinction state” resulting from
the loss of reinforcers (Ferster 1973 ). Neurobiological
changes accompanying prolonged stress may also dampen
hedonic capacity, which in turn reduces the salience
of reinforcers (Weiss and Simson 1985 , Willner 1991 ).
Thus, the learned helplessness paradigm brings together
behavioral and neurobiological domains. Depressed
operant (i.e., goal-directed) behavior may elicit negative
cognitions as well (Teasdale 1983 ). For example, depressed
people often procrastinate against performing potentially
“overwhelming” chores or tasks. Procrastination, in turn,
elicits guilty thoughts and self-criticisms. Moreover, the
depressive cognitive state increases the likelihood that
individuals will minimize the positive value of the activities
they are able to complete. As a result, it may also be said that
depressed people suffer from a de cit of self-reinforcement
(Rehm 1977 ).
One key to the behavioral approach for treatment
of depression is the interruption of the downward spiral
linking mood, inactivity, and negative cognition (Beck et
al. 1979 , Lewinsohn et al. 1982 ) (Figure 91–6 ). Completing
an activity schedule is often the rst behavioral homework
assignment used in CBT (Beck and Greenberg 1974 ).
Depressed patients are asked to begin to keep a daily log
that is used to chart the relationship between their moods
and their activities (Figure 91–7 ).
The nature of the activities is examined, and de cits in
activities that might elicit pleasure or feelings of competence
are identi ed. Next, assignments are made to engage in
discrete pleasurable activities (or, in the case of an anhedonic
individual, activities that were rewarding before becoming
depressed). If needed, a Pleasant Events Schedule can be
used to identify a “menu” of reinforcers (Lewinsohn et al.
1982 ). Following operant principles, activities that have been
“high-grade” reinforcers in the past are scheduled during
times of low moods or decreased activity. Next, subjective
ratings of mastery or competence and pleasure are added to
the activity schedule by use of a simple scale (i.e., 0 to 5), to
avoid the tendency of dichotomous thinking. In this way,
achieving a small degree of pleasure or mastery during a
scheduled activity may be framed as an accomplishment,
particularly early in the course of therapy.
0700 hours: Alarm rings, low mood,
tired (diurnal variation)
0745 hours: Automatic negative
thoughts (ANTs) while
lying in bed: "Another
rotten day."
0900 hours: Procrastination, morning
chores go undone,
naps intermittently
1100 hours: Mood further
worsens; crying;
emotionally triggered
memories re: past
rejections
1230 hours: Cancels plan for
afternoon tennis match;
senses anger from
disappointed friend,
ANT: "I'm driving
everyone away."
1245 hours: Despondent;
future looks bleak;
passive suicidal ideation
Shuts off alarm;
decides to stay in bed
Mood worsens;
ANT: "Why bother?"
Increased ANTs (self-criticism
re: undone chores); decides to
play stereo instead of showering
More ANTs; thoughts of
loneliness and isolation;
feels miserable
Figure 91–6 The downward spiral:
interaction of affect, behavior, and cognition
in severe depression. ANTs, Automatic
negative thoughts.
Chapter 91 • Cognitive and Behavioral Therapies 1931
The activity schedule may also be used, prospectively,
to begin to tackle overdue chores or other dreaded activities.
The graded task approach is based on the premise that in
a depressed state, many normal activities are indeed too
demanding for depressed patients to complete according to
their usual standards or with their characteristic ef ciency.
Thus, the task is broken down into units or components.
The rst homework assignment is typically to identify and
complete a minimally acceptable initial step. For example,
a depressed businessman had concealed from his family
that he was 6 months behind in paying their income taxes.
When he tried to tackle the project, he thought, “I’m too
tired to do it now…I can’t concentrate on this stuff…I’ll
get more depressed if I try and fail.” These cognitions were
so discouraging that he invariably postponed working on
the taxes. As a result, he felt some relief immediately (a
reinforcer for procrastination). However, within minutes
he was plagued by automatic negative thoughts about
the implications of putting off such an important task
yet again. He also had shameful thoughts about what his
family or friends would think about him when his secret
was discovered. In this case, the man estimated that the
task would require at least 10 hours if he were well . He
also estimated that he had only about 50% of his normal
energy and ability to concentrate. Therefore, 20 hours of
work was planned in small blocks spaced out for the next
20 days. The rst assignment was for the man to spend
only 15 minutes organizing the forms necessary to do the
overdue income taxes. The use of self-instruction and
visual imagery can help patients to initiate action, and
self-reinforcement after completion of each step furthers
therapeutic momentum.
Breathing Control
An important component of CBT for anxiety disorders
involves teaching the patient breathing exercises that may be
used to counteract hyperventilation and/or reduce tension
(Clark et al. 1985 ). Slow, deep breathing can have a calming
effect not unlike progressive muscle relaxation (Bernstein
and Borkovec 1973 ). These exercises also help to distract
the patient from autonomic cues. After initial instruction
and practice, the breathing skills are then applied anxiety-
provoking situations of increasing intensity.
A note of caution is in order when teaching patients
breathing control exercises. We have seen many patients who
have misunderstood instructions and who have developed
a pattern of overly deep breathing in response to stress.
Instead of reducing anxiety, their breathing changes may
increase the likelihood of hyperventilation. Thus, we typi-
cally recommend teaching patients about the pace and form
of normal breathing patterns. Next clinicians can model
normal, calm breathing as compared to rapid breathing
typical of an anxiety attack. A second hand of a watch
can be used to time breaths to slow them to a normal rate.
Positive, calming images can also be used to reduce anxi-
ety during the breathing exercises. Finally, we suggest that
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Mastery, accomplished, achieved something
Pleasure, fun, amusement, enjoyment
Scale: 0_5; 0, none, 5, most
Note: Grade activities M for mastery and P for pleasure
Figure 91–7 Weekly activity schedule.
1932 Section VII • Psychotherapeutic and Psychosocial Treatments
patients regularly practice breathing exercises to reinforce
their mastery of this anxiety management technique.
Contingency Contracting and Behavior
Exchange
These strategies use the principles of operant conditioning
(Skinner 1938 ) to modify the probability of occurrence
of either undesired or desired behaviors. Malott and
colleagues ( 1993 ) have written an excellent introduction
to these methods. One key to applied behavioral analysis
is understanding the control over the contingencies or
reinforcers. Another important factor is that the terms
of the contract are negotiated and should be speci c and
relatively straightforward. The positive contingency or
reinforcer should be desirable and available shortly after
the terms of the contract have been met. A paycheck is a
good example of a contingency contract. Another common
strategy is to chain, or pair, a high-frequency behavior
(e.g., reading, watching television, or listening to music)
to a low-frequency one (e.g., doing paperwork, doing
housework, spending time with the children). Contingencies
should generally start out relatively “rich” (e.g., 1 hour of
video game time after 15 minutes of paperwork) and may
be progressively “thinned” in time (Malott et al. 1993 ).
Punishments or “response cost” contingencies are less
widely used because of their negative affective responses
(Azrin and Holz 1966 ).
Behavior exchange contracts are used with couples
or families. For example, a distressed couple may voice
dissatisfaction about two distinctly different behavioral
tendencies, as illustrated.
Partner 1 : You never help me out around the house.
Partner 2 : That’s not true, I’m always pitching in.
My problem is that on the weekends you never
want to go out and have fun.
Partner 1 : That’s partly true…but if I wasn’t so
sick and tired of being stuck with all the housework,
maybe I’d feel more like going out.
Rather than join the debate to ascertain which partner
is right about what, the therapist suggests a contract to
objectify the communication and increase the likelihood
of mutually rewarding experiences. The contingencies used
in the contract represent an exchange of desired behaviors.
In the example, partner 1 desires assistance with speci c
household tasks (e.g., wash the dishes, fold the laundry).
A desired frequency is also determined (e.g., nightly). For
partner 2, a weekend outing is speci ed, and a mutually
acceptable activity is chosen. The contract is written and
signed by both parties and the therapist. Consequences for
nonadherence may also need to be formulated.
Behavioral contracts may be particularly useful
for assisting patients with medication adherence. For
example, the therapist may help the patient identify
barri ers to t aki ng me dic at ion a s pre scr ibed and then work
out behavioral solutions that are written in contract form.
Behavioral methods may include pairing medication
taking with routine activities such as brushing teeth
or meals, reminder systems, and reinforcement from
signi cant others. We recommend explicit discussion of
adherence problems and mutual agreement on a plan
for taking medications when patients have dif culty in
following the pharmacotherapy plan.
Desensitization and Relaxation Training
Systematic desensitization (Wolpe 1958 ) was one of the rst
behavioral strategies to gain wide acceptance. Systematic
desensitization relies on exposure through a progressive
hierarchy of fear-inducing situations. This procedure may
use pairing of progressive deep muscle relaxation and
visualization of the target behavior to decondition fearful
responses. Systematic desensitization is useful for treatment of
simple phobias, social phobia, panic attacks, and generalized
anxiety (Wolpe 1982 ). Some evidence suggests that the active
ingredient of systematic desensitization is exposure to the
feared situation, rst in imagination and later in reality,
rather than an actual counterconditioning through the
relaxation response (Kazdin and Wilcoxin 1976 ). Progressive
deep muscle relaxation is also useful as a self-directed coping
strategy and for treatment of sleep-onset insomnia (Goldfried
and Davison 1994 , Bernstein and Borkovec 1973 ).
Exposure and Flooding
The purpose of these strategies is to speed extinction of
conditioned fear or anxiety responses. Behavioral theory
dictates that fearfulness is reinforced by avoidance and
escape behaviors (Rachman et al. 1986 ). Because the basis
of the fear or phobia is irrational, the optimal strategy
is to increase exposure to the feared activity without
aversive consequences. In obsessive-compulsive disorder,
the ritualistic behavior (e.g., hand washing or checking) is
hypothesized to be reinforced by the relief of the anxiety
associated with the compulsion (e.g., hand washing
temporarily relieves the fear of contamination) (Rachman
et al. 1986 ). In exposure, there are at least three means of
fear reduction: autonomic habituation, recognition that
the fear is irrational, and explicit enhancement of morale
or self-ef cacy that accompanies mastering the previously
dreaded activity.
In graded or progressive exposure, a hierarchy is
established, ranging from least-to-most anxiety-provoking
situations. The individual is taught one or more ways to
cope with anxiety (e.g., relaxation or self-instruction), and
with the help of the therapist, the items on the hierarchy are
worked through, one item at a time. Mastery is predicated
on maintaining a suf cient duration of exposure for the fear
to extinguish or dissipate. In some cases, imagery (exposure
“in vitro”) is used before moving to exposure to the actual
feared stimulus. Exposure may also be enhanced by guided
support (i.e., the therapist’s presence during the session) or
by use of coping cognitions for the duration of the exposure
exercise.
Flooding, which relies on the same principles,
dispatches with the hierarchical approach. The individual
is exposed to the maximal level of anxiety as quickly as
possible. The rationale for this accelerated approach is
that it may hasten autonomic habituation. To be effective,
ooding needs to be accompanied by response prevention.
In response prevention treatment of obsessive-compulsive
disorder, the individual agrees not to perform the compulsion
despite strong urges to do so. Because obsessions are more
private than compulsions, there can be less certainty that
Chapter 91 • Cognitive and Behavioral Therapies 1933
the individual has fully participated in response prevention
exercises (Stern 1978 ).
Participant modeling or contact desensitization is an
accelerated form of exposure that produces rapid response
in the treatment of simple phobias. The therapist serves as
a supportive coach or guide and assists the patient through
a progressively more demanding level of exposure to the
feared situation. In most cases, lifelong fears of air travel,
tunnels, heights, matches, dogs, water, or insects can be fully
treated in a few hours of guided exposure.
Social Skills Training
Satisfactory interpersonal relationships require a complex
set of skills, including reciprocity, respect for another’s
opinion, appropriate modulation of self-disclosure, the
tempered ability to yield on some occasions and to set
limits at other times, the natural use of social reinforcers,
and the capacity to express anger and resolve con icts in a
constructive manner (Lewinsohn et al. 1982 , Hersen et al.
1984 ). Many people with psychiatric disorders suffer from
either a state-dependent deterioration of these social skills
or lifelong de cits of such skills. Once established, social
skills de cits can increase the likelihood of experiencing
stressful life events as well as “turn off” family members
and other sources of social support that may help to buffer
people against stressors (Coyne et al. 1987 ).
Problems as diverse as lack of assertiveness,
temper “attacks,” excessive self-disclosure, monopolistic
conversational style, under-reinforcement of signi cant
others, and splitting (i.e., playing one against another) are
amenable to social skills training. The methods employed
include modeling (i.e., the therapist demonstrates a more
effective alternative approach), role playing and role reversal,
behavior rehearsal, and speci c practice assignments. Often,
the interpersonal anxiety and lack of self-con dence that go
hand in hand with social skills de cits lessen in response to
successful mastery of targeted assignments.
Thought Stopping and Distraction
Automatic negative thoughts and repetitive, intrusive
ruminations are sometimes too intense to address with
purely cognitive interventions. The technique of thought
stopping capitalizes on the individual’s ability to use a
selectively narrowed attentional focus to suppress the
intrusive cognitions. For example, a ruminative individual
may be asked to visualize a large red stop sign, including its
octagonal shape and white lettering. The command Stop! is
paired with the image. The image and command are then used
to interrupt a “run” of ruminations. At rst, the technique
is practiced in sessions at times when automatic thoughts
or ruminations are mild. After initial success, the technique
is next applied to more intensely disturbing cognitions. For
individuals who nd visualization dif cult or ineffective, a
rubber band may be worn on the wrist as a distractor. In a
manner similar to that described before, the command Stop!
is paired with a brisk snap of the rubber band.
Anxious patients may bene t from use of other
distraction techniques to cope with panicky thoughts or
increased sensitivity to interoceptive cues. Speci cally,
patients susceptible to panic often have a heightened
awareness of otherwise normal physiological cues
(e.g., alterations in heart rate, dryness in the throat, muscular
tightness in the chest, or increased peristalsis). In turn, such
sensitivity triggers automatic negative thoughts about an
imagined impending calamity. Distractions such as counting
backward, praying, or imagining a calming scene may be
applied to direct attention away from the internal stimuli.
Distraction techniques thus help the individual exert some
control over the symptoms, permitting greater exposure and
a growing sense of self-ef cacy.
Formulation of Treatment
Indications for Treatment
The cognitive and behavioral therapies are indicated
as primary treatments for adults suffering from several
nonpsychotic, nonorganic Axis I disorders in the Diagnostic
and Satistical Manual of Mental Disorders , fourth Edition
(DSM-IV). These include major depressive disorder,
dysthymic disorder, panic disorder, social phobia, OCD,
PTSD, generalized anxiety disorder and bulimia nervosa
(Wright et al. 2002 ). Cognitive and behavioral therapies are
also useful as adjunctive treatments for patients with bipolar
disorder (Basco and Rush 1996 , Basco and Thase 1998 , Lam
et al. 2000 , 2005b , Scott et al. 2003 , and Zaretsky et al. 1999 )
and schizophrenia (Mueser 1998 , Kingdon and Turkington
1995 , Sensky et al. 2000 ). Although not extensively studied,
cognitive and behavioral therapies incorporating coping skills
training and relapse prevention strategies may also improve
the outcome of individuals with substance abuse disorders
(Wright et al. 2002 ).
Cognitive and behavioral therapies, like most other
types of treatment, have not been studied widely in patients
with Axis II disorders. However, the CBT approach to
problem speci cation and explicit training in coping skills
may be well suited for treatment of individuals willing
to work on changing these habitual, ingrained patterns
of thinking and behavior (Beck et al. 1990 ). Speci c
cognitive-behavioral formulations have been developed for
each of the personality disorders, and modi cations of
CBT methods have been described for working with patients
with Axis II problems (Beck et al. 1990 ). Linehan’s model
of CBT (dialectical behavior therapy) has been shown to
be ef cacious in reducing parasuicidal behavior in patients
with borderline personality disorder (Linehan et al. 1991 ,
Linehan et al. 1993, 2006).
Selection of CBT Treatment
Perhaps the greatest “rate-limiting step” in selection of CBT
is having access to a well-trained therapist. However, there are
a growing number of training programs in CBT, and centers
for CBT are available in many cities throughout the world.
Cognitive-behavior therapy is now a required element in the
education of psychiatry residents and is the major orientation
of many psychology graduate programs. The Academy
of Cognitive Therapy (academyofct.org) is a nationally
recognized body that certi es therapists in this approach.
Selection of CBT for an individual patient should be
based on the appropriateness of cognitive-behavior therapy
for the treatment situation. Relevant questions include:
Is the patient psychotic? If so, are there speci c target
behaviors and has psychopharmacological treatment been
optimized? Does the patient suffer from a disorder for which
there is evidence for the ef cacy of CBT? Within groups of
1934 Section VII • Psychotherapeutic and Psychosocial Treatments
patients with potentially treatable disorders, other indicators
of responsivity include chronicity, severity, and comorbidity
(Whisman 1993 , Thase et al. 1993 ). A good general rule is
that patients with acute, mild to moderately severe, mood
and anxiety disorders are the best candidates for treatment
with traditional CBT alone (Thase 1995 ). Patients with
more chronic, severe, or complicated illnesses may be better
candidates for combined treatment strategies than for CBT
alone (Wright and Thase 1992 , Thase and Howland 1994 ,
Friedman 1997 , Friedman et al. 2006 ). McCullough ( 2000 )
has developed a variant of CBT for chronic depression
that has shown much promise alone and combined with
antidepressant medication.
An outpatient trial of acute phase CBT typically
ranges from 10 to 20 weekly treatment sessions (Wright
and Beck 1983 , Beck et al. 1979 , Barlow and Cerny 1988 ,
Persons 1989 ). However, shorter courses of treatment have
been shown to be ef cacious in some situations (Wright
et al. 2005 ). Deterioration or noncompliance of the patient
may warrant early termination of a treatment trial, and for
certain chronic conditions such as borderline personality
disorder and bipolar disorder, longer courses of therapy may
be indicated (Beck et al. 1990 , Linehan et al. 1993 , 2006 ,
Basco and Rush 1996 ). Jarrett and Kraft (Jarrett and Kraft
1997 , Jarrett et al. 2001 ) have conceptualized treatment
across the acute, continuation, and maintenance phases
of the depressive disorder. We will discuss these phases
of treatment in greater detail below. During treatment of
major depressive disorder and panic disorder, a majority
of patients who will bene t from CBT will show a signi cant
reduction in symptoms within 6–8 weeks of starting therapy
(Ilardi and Craighead 1994 ). Moreover, those who show a
late response to CBT (i.e., between weeks 12 and 16) may be
at high risk for subsequent relapse (Thase et al. 1992 ).
Issues of Gender, Race, and Ethnicity
The cognitive and behavioral therapies appear equally
effective for men and women and people of various races
(Dobson 1989 , Thase et al. 1994a ). As with other forms of
psychotherapy, a productive CBT working alliance is based
on mutual respect for individual differences (Wright and
Davis 1994 ). For some persons with gender, racial, or
ethnically related issues, it may be useful to select therapists
with special skills or experiences (e.g., therapists specializing
in gay and lesbian issues or posttraumatic stress syndromes
due to rape or incest). It has been recommended that
cognitive–behavioral therapists receive special training and
supervision in methods of responding to gender, race, and
ethnicity variations (Wright and Davis 1994 ).
Case Formulation
An individualized case conceptualization is used for directing
the course of CBT. An analysis of cognitive–behavioral
elements is combined with assessment of biological, social,
interpersonal, and other possible in uences on symptoms
in order to produce a comprehensive formulation and
treatment plan (Wright et al. 2006 ). Both cross-sectional
(typical cognitive–behavioral responses to current
environmental stressors) and longitudinal (developmental
and life history contributions to develop schemas and core
behavioral strategies) perspectives are considered. Details
of how to perform cognitive–behavioral case formulations
are provided in a basic CBT text with video illustrations
(Wright et al. 2006 ). Also, the Academy of Cognitive
Therapy Website (academyofct.org) has examples of written
case conceptualizations.
Preparation of the Patient
The cognitive and behavioral therapies explicitly incorporate
strategies to increase involvement and preparedness of
the patient for therapy. Patients are typically encouraged
to read relevant written materials describing the theory
and strategies of the therapy; for common disorders, such
as major depressive disorder and panic disorder, self-
help manuals for patients are now available (Burns 1990 ,
Greenberger and Padesky 1995 , Wright and Basco 2002). It
is likely that multimedia programs will have an increasing
role in therapy preparation (Locke and Rezza 1996 , Wright
and Wright 1995, Wright et al. 2002 ). Regardless of the
mode of application, patients beginning CBT need to
become acculturated to the following: 1) they will be active
participants in trying out new strategies; 2) they will be
expected to do homework; 3) the outcome of therapy will
be measured and strategies will be altered if they are not
helping; 4) therapy will be focused on symptoms and social
functioning and generally will be time limited in nature; and
5) the chances of success after treatment termination can be
gauged by the patients’ incorporation of the therapy into
their day-to-day life.
Phases of Treatment
Most cognitive and behavioral therapies may be viewed
as using a three-stage process. The initial phase includes
the processes of clinical assessment, case formulation,
establishment of a therapeutic relationship, socialization of
the patient to therapy, psychoeducation, and introduction
to treatment procedures. The middle stage involves the
sequential application and mastery of cognitive and
behavioral treatment strategies. The second stage ends
when the patient has obtained the desired symptomatic
outcome. The nal phase of therapy is characterized by
preparation for termination. The frequency of sessions is
reduced, and there is a steady transfer of the responsibility
for the continued use of therapeutic strategies from the
therapist to the patient. The third stage of treatment also
focuses on relapse prevention. Strategies used at this point
include anticipation of reaction to future stressors or high-
risk situations, identification of prodromal symptoms,
rehearsal of self-help procedures, and establishment of
guidelines for return to treatment (Otto et al. 1993 , Thase
1993 ). The failure to achieve a remission of depressive
symptoms after 16–20 weeks of treatment may indicate a
need for continuation phase treatment to achieve these goals
and maintenance phase treatment for relapse prevention.
Incomplete symptomatic remission after 20 weeks of CBT
may also indicate the need for adding pharmacotherapy to
the treatment plan as we discuss in greater detail below.
Intensity of Treatment
Outpatient CBT is normally conducted once or twice a week.
In selected cases, three times weekly or even daily sessions
may be useful, but the cost-effectiveness of such a labor-
intensive approach is uncertain. One of the authors (J.H.W.),
who often uses CBT in combination with pharmacotherapy
Chapter 91 • Cognitive and Behavioral Therapies 1935
and computer-assisted treatment, has found that he can
reduce sessions for ambulatory patients to every other week
or to a shortened time frame (i.e., 20-25-minute sessions)
when a good therapeutic relationship has been established
and the patient has started to make signi cant progress.
When patients are seen in a day treatment hospital
or inpatient setting, sessions are typically provided on
a daily or every-other-day basis. Many programs blend
individual and group therapies (Wright et al. 1993 ). In
our experience, holding sessions more frequently helps to
offset symptom severity and demoralization in severely ill
patients (Thase and Wright 1991 ). The cost-effectiveness of
more or less intensive cognitive–behavioral strategies has
not been systematically studied. Nevertheless, we believe
that therapists should adjust the frequency and intensity of
treatment according to the needs of patients as well as the
therapy resources that are available.
Duration of Treatment
In most cases, treatment is conducted in a period of 3–6 months.
For those who begin therapy as inpatients, a similar period
of aftercare is strongly recommended (Thase 1993 ). Unsuc-
cessful therapy (e.g., failure to effect signi cant sympto-
matic improvement) should generally not continue past
12–16 weeks for outpatients. Therapy should not be ter-
minated until patients have achieved symptomatic remis-
sion. Ideally, at least two or three sessions are planned on an
every-other-week basis in preparation for termination.
Outcome Assessment
Cognitive and behavioral therapies are, in part, distinguished
by their integrated use of objective assessment methods. For
depression and the anxiety disorders, a number of well-
established rating scales are available. Therapist-administered
scales include the Hamilton Anxiety Rating Scale (Hamilton
1959 ) and the Hamilton Depression Rating Scale (Hamilton
1960 ) as well as the Yale-Brown Obsessive-Compulsive Scale
(Goodman et al. 1989 ). Self-report assessments of symptoms
include the Beck Depression Inventory (Beck et al. 1961 ), the
Beck Anxiety Inventory (Beck et al. 1988 ), the Fear Survey
Schedule (Wolpe and Lang 1964 ), the Fear Questionnaire
(Marks and Matthews 1979 ), and the Hopkins Symptom
Checklist (Derogatis et al. 1974 ). These scales are typically
administered before treatment and repeated periodically (e.g.,
weekly or monthly) to monitor progress. The Dysfunctional
Attitudes Scale, the Attributional Style Questionnaire, and the
Automatic Thoughts Questionnaire may be used to evaluate
distorted cognitions (Dobson and Shaw 1986 ). As suggested
earlier, high residual levels of cognitive symptoms most
likely convey an increased risk for relapse after termination
of treatment (Thase et al. 1992 , Simons et al. 1986 , Fava et
al. 1998a ). Similarly, high scores on the Hopelessness Scale
(Beck et al. 1974 ) have been associated with a high risk for
subsequent suicidal behavior (Beck et al. 1985 ).
Augmentation of Therapy
One of the major methods of augmenting a cognitive
and behavioral therapy is to add an appropriate form of
pharmacotherapy. For example, a depressed or agoraphobic
person who has not bene ted much from eight weeks or
more of CBT alone should probably be considered for
pharmacotherapy. In such cases, the neurobiological substrate
of the illness may be too severely disturbed to be responsive
to the CBT without concomitant pharmacotherapy (Wright
and Thase 1992 , Jindal et al. 2002 ). In clinical practice,
psychiatrists who are trained in CBT often combine
cognitive therapy and pharmacotherapy from the beginning
of treatment unless the patient expresses a strong desire to
receive only a single form of therapy.
There are no contraindications to combining CBT and
pharmacotherapy (Wright and Thase 1992 ). In fact, these
modalities are highly compatible in theory and practice. As
noted earlier, pharmacological stabilization is a prerequisite
for CBT for some Axis I disorders (e.g., psychotic depressions,
schizophrenia, and bipolar disorder). When these treatments
are used in combination, the treatment team should have a
well-de ned division of labor, open lines of communication,
and an explicit sense of collaboration. Treatment of patients
with severe, refractory, or incapacitating mood and anxiety
disorders may represent the best use of combined therapies
(Thase and Howland 1994 , Bowers 1990 , Otto et al. 1994 ,
Scott 1992 , Whisman et al. 1991 ). Other strategies used to
enhance CBT include increasing the frequency of visits,
switching emphasis (i.e., from cognitive to behavioral or
vice versa), or involving the spouse or signi cant others in
the therapy (Beach et al. 1994 , Emmelkamp and Gerlsma
1994 ). The last strategy has been shown to be particularly
useful in cases of depression associated with marital discord
(Jacobson et al. 1991 , Beach and O’Leary 1992 ). Computer
augmentation is a new addition to the tools available for
CBT (Selmi et al. 1991 , Wright and Wright 1997, Kenwright
et al. 2001 , Wright et al. 2002 , Wright et al. 2005 ). Greater
availability of personal computers with multimedia capability
and increased pressure to reduce the cost of treatment may
make this form of therapy augmentation a more common
practice in clinical settings.
Continuation and Maintenance Phase CBT
When Beck and associates (Beck et al. 1979 ) described CBT
in the late 1970’s depression researchers were primarily
concerned with the issue of response to treatment—is
psychotherapy or pharmacotherapy effective in reducing
the symptoms of the disorder over a given time period
(generally 1 month to 10 weeks for ef cacy studies of the
tricyclic antidepressants, 6–12 weeks for ef cacy studies of
SSRI’S and 12–20 weeks for studies of psychotherapies)?
This phase of treatment has come to be called the “acute
phase.” Because some patients do not completely achieve
a remission of symptoms (their return to premorbid well
state) and because many patients experience depression as
a recurring illness, there is a need for longer-term treatment
methods for major depression (Kupfer et al. 1986 ).
Furthermore, incomplete remission of depression leads
to recurrence, and this conveys many adverse economic,
interpersonal and medical consequences (Thase 1992 ).
Over the past 18 years, studies conducted by Thase and
coworkers at the University of Pittsburgh have identi ed
and replicated correlates of relapse (return of symptoms
during continuation phase treatment) and recurrence (return
of symptoms after one year of remission of the illness)
following the termination of acute phase CT (A-CT). Failure
to achieve a complete remission of the index episode by the
sixth week of A-CT is associated with a 3–5-fold increase
in the subsequent risk of relapse or recurrence. Thase and
1936 Section VII • Psychotherapeutic and Psychosocial Treatments
coworkers have found that between 50 and 60% of A-CT
responders meet this criteria for risk and Jarrett’s group
has demonstrated that an 8-month course of continuation-
CBT essentially neutralizes this higher risk of relapse. C-
CT focuses on the vulnerabilities for recurrent depression
in three domains: biologic (genetics, biology, familial, and
developmental), psychosocial (personality, interpersonal,
and social), and cognitive (Jarrett et al. 2001 ). By identifying
and modifying risks and vulnerabilities and learning more
effective ways of managing mood symptoms, C-CT helps
prevent relapse and recurrence.
Fava (Fava et al. 1994 ) has developed another interesting
approach to reduce the risk of relapse, the sequencing of
treatment depending upon the degree of response following
acute therapy. He found that a 12-session course of CBT
focusing on healthy lifestyle changes signi cantly reduced
depressive symptoms (Fava et al. 1994 ), increased the
likelihood of successfully withdrawing from antidepressants
(Fava et al. 1996 , Fava et al. 1998b ), and decreased the risk
of subsequent relapse after withdrawing anti-depressant
medications (Fava et al. 1998a ). Other studies (Blackburn
and Moore 1997 , Paykel et al. 1999 ) support the strategy of
using a short course of focused CBT to offset the risks of
relapse and recurrence of major depression.
Ef cacy of CBT
The cognitive and behavioral therapies are, as a class, the
best studied type of psychotherapy. Numerous research
studies have demonstrated the ef cacy for a variety of Axis
I disorders.
Mood Disorders
Most of the evidence for the effectiveness of Beck’s model of
CBT for mood disorders is derived from studies of outpatients
with major depressive disorder (nonbipolar, nonpsychotic
subtype). There is no doubt that CBT is an effective
treatment of major depression compared with a waiting list
control condition (Thase 1995 , Dobson 1989 , Depression
Guideline Panel 1993 ). Dating to an initial study by Rush and
associates (Rush et al. 1977 ), one major research focus has
been to establish the ef cacy of CBT vis-á-vis antidepressant
pharmacotherapy. At this time, eight controlled trials
contrasting CBT and tricyclic antidepressants have been
completed (McCullough 2000 ), as have a legion of studies
using other designs and other comparison groups (Thase
1995 , Jarrett and Rush 1994 ). Several meta-analytical reviews
have been published (Dobson 1989 , Depression Guideline
Panel 1993 , Gloaguen et al. 1998 , Butler et al. 2006 ). Dobson
found CBT to be superior to untreated controls, wait-list
participants, pharmacotherapy with tricyclic antidepressants,
and other therapies (Dobson 1989 ). Gloaguen et al. ( 1998 )
reported CBT was superior when compared with wait-list
and placebo control conditions; modestly superior to other
therapies. Recently Butler and colleagues ( 2006 ) reviewed
meta-analyses of CBT and report that CBT was somewhat
superior to antidepressants in the treatment of adult
depression, OCD and several other disorders.
Thase and coworkers ( 2000 ) have reported on a
retrospective comparison of consecutive cohorts treated
with CBT or supportive counseling and pill-placebo. The
ndings of this analysis suggest that CBT has greater
therapeutic effects than this competently administered
control condition, the ideal comparator for pharmacology
ef cacy studies.
The results of the National Institute of Mental Health
Treatment of Depression Collaborative Research Program
(TDCRP) (Elkin et al. 1989 ), a large, controlled three-site
clinical trial, initially appeared to be inconsistent with these
ndings. The study reported that CBT was as effective as the
tricyclic antidepressant imipramine in the full sample, but
neither CBT nor imipramine was signi cantly more effective
than the control condition, supportive clinical management
and pill-placebo. Furthermore, in the more severely ill patients
or in patients with greater functional impairment, CBT
appeared to be less effective than imipramine. Moreover, the
study results suggested that CBT was slightly, although not
statistically, less effective than interpersonal psychotherapy
(IPT), especially when recovery (stable symptomatic remission
lasting greater than 8 consecutive weeks) was the outcome
measure examined. However, when this same cohort was
observed over the course of 18 months of follow-up (Shea
et al. 1992 ), it was determined that there was no signi cant
difference among any of the treatments with respect to the
number of patients that recovered and remained well. When
the follow-up outcome of the CBT patients was reviewed,
the authors found that CBT patients had the lowest rates
of receiving some kind of treatment during the follow-up
period and CBT patients had the lowest rates of relapse after
18 months. This led the authors to be encouraged about the
prophylactic value of CBT.
Ablon and Jones ( 2002 ) also question the validity of
the results of the psychotherapy ndings of the Treatment
of Depression Collaborative Research Program. The authors
used actual transcripts of the IPT and CBT sessions and
rated CBT and IPT sessions with respect to therapy process,
therapy technique, and intervention styles. They report that
both the IPT and CBT sessions adhered most strongly to the
ideal prototype of CBT. In addition, adherence to the CBT
prototype yielded more positive correlations with outcome
measures across both types of treatment.
The acute-phase treatment ndings of the Treatment
of Depression Collaborative Research Program have raised
questions about the suitability of CBT as a treatment
of severe depression (American Psychiatric Association
1993 ). Alternatively, the adequacy of CBT provided in the
Treatment of Depression Collaborative Research Program
trial has been challenged by some who believe CBT therapists
may need a longer period of training than that required to
become pro cient at interpersonal psychotherapy (Thase
1994 ). Nevertheless, in other groups’ hands, CBT is fully the
equal of pharmacotherapy (Blackburn et al. 1981 , Murphy
et al. 1984 , Hollon et al. 1992 ). A recent three-site study
by DeRubeis and colleagues randomized 240 moderately
to severely depressed patients to CBT, antidepressant
medication therapy (paroxetine), or placebo. Overall, CBT
was shown to be as effective as antidepressant medication
in the treatment of moderate to severe depression when
provided by highly experienced cognitive therapists (there
was a signi cant difference in site treatment interaction at
one site) (DeRubeis et al. 2005 ). Furthermore, CBT has
also been demonstrated to be effective for inpatients with
severe and chronic depression (DeJong et al. 1986 ). An
intensive CBT protocol has been demonstrated to be an
effective treatment of 60% to 70% of unmedicated depressed
Chapter 91 • Cognitive and Behavioral Therapies 1937
inpatients suffering from nonpsychotic major depression
(Thase et al. 1993 , Thase et al. 1991 ).
There is additional evidence for the effectiveness of
CBT in the treatment of severely ill depressed patients. In a
large multisite randomized clinical trial of a dif cult cohort
of severe and chronically depressed patients, McCullough’s
CBT-based treatment, The Cognitive–behavioral Analysis
System for Psychotherapy , (Keller et al. 2000 , McCullough
2000 ) has shown equal efficacy to the serotonin-
norepinephrine reuptake inhibitor, nefazodone, each being
effective in 55% of cases, but the combination of the two
treatments produced an impressive response rate of 85% at
the end of 12 weeks of treatment. Thus, a version of CBT
modi ed to speci cally address the problems of severe and
chronic depression has shown ef cacy. Further evidence
supporting the use of CBT in severe depression is found in
a study that suggests a bene t for CBT in preventing suicide
attempts. These investigators compared CBT to enhanced
treatment as usual in patients who recently attempted suicide.
The CBT subjects had a signi cantly lower reattempt rate,
were 50% less likely to reattempt suicide than the control
group, and reported less severe depression and hopelessness
in follow-up (Brown et al. 2005 ).
More recently, results of the multi-site, NIMH-
sponsored Sequenced Treatment Alternatives to Relieve
Depression (STAR*D) trial compared CBT as a second-
step treatment in patients with unipolar major depression
who did not receive bene t from an adequate trial of
the SSRI medication citalopram (Thase et al. In press).
In one comparison, participants were randomized to
augmentation of citalopram with either CBT or medication
(either bupropion SR or buspirone). CBT augmentation
was as effective as medication augmentation, but the latter
was associated with a more rapid response. In the second
comparison patients were switched to CBT or medication
(sertraline, bupropion SR, or venlafaxine XR). There were
also no differences in the effectiveness of switch to CBT or
medications, although pharmacotherapy was associated
with signi cantly more adverse side effects. The authors
conclude that for patients without adequate bene t from
citalopram, CBT was an effective pharmacotherapy
whether used as a switch or augmentation strategy (Thase
et al. 2007).
Regarding the efficacy of combining CBT and
medications, a meta-analysis of studies that examined
treatment with medication alone (including tricyclics
amitriptyline, chlomipramine, nortriptyline, desipramine,
and nefazodone) versus medication combined with CBT,
Friedman and colleagues ( 2006 ) found the bene t favoring
combination treatment over pharmacotherapy alone to be
almost twice as great.
Interestingly, group CBT strategies for treatment
of depression have been found to be nearly as effective
as individual treatment in both direct comparisons
(Ross and Scott 1985 ) and composite meta-analytical
comparisons (Depression Guideline Panel 1993 , DeRubeis
and Crits-Christoph 1998 ). These studies, which have not
yet dramatically affected practice habits, suggest that a
signi cant savings in cost-effectiveness might be gained by
more regular use of group treatments. One study (Ravindran
et al. 1999 ) in dysthymic patients compared the ef cacy of
sertraline and group cognitive behavioral therapy, alone or
in combination. These authors found the group CBT to be
less effective than sertraline in alleviating clinical symptoms.
However, CBT augmented the effects of sertraline with
respect to some functional changes, and in a subgroup
of patients it attenuated the functional impairments
characteristic of dysthymia.
Marital CBT also appears to be as effective as
individual CBT in treatment of depression associated with
marital discord (Jacobson et al. 1991 , Beach and O’Leary
1992 ). When effective, this marital therapy also typically
produces concomitant improvement in dyadic adjustment,
whereas effects of individual CBT are primarily limited
to symptom variables (Jacobson et al. 1991 , Beach and
O’Leary 1992 ). Because marital discord plays a major role
in the pathogenesis of many depressive episodes, greater
use of couples treatment strategies may be indicated
(Beach et al. 1994 , Baucom et al. 1990 ) and such strategies
have been described (Baucom and Epstein 1990 ).
Some evidence suggests that CBT reduces the risk for
relapse after termination of treatment (vis-á-vis patients
withdrawn from antidepressants) (Simons et al. 1986 , Evans
et al. 1992 , Blackburn et al. 1986a ). In the study of Evans and
colleagues, (Evans et al. 1992 ) CBT responders had the
same degree of prophylaxis against relapse at more than
1 year of follow-up as did antidepressant responders treated
with continuation phase pharmacotherapy (Figure 91–8 ).
The risk for relapse after CBT may be particularly low for
patients who achieve a complete remission before ending
treatment (Thase et al. 1992 ). The use of CBT for relapse
prevention by Fava’s group has been discussed (Fava et al.
1994 ). In a 12-month naturalistic follow-up study of patients
who responded to acute phase treatment (see DeRubeis
et al. 2005 , discussed above), it was found that compared
to successfully treated pharmacotherapy patients, CBT
patients were signi cantly less likely to relapse, suggesting a
possible enduring prophylactic effect for CBT (Hollon et al.
1992 ). These ndings are supported by a study comparing
patients with recurrent major depression who achieved
remission and were assigned to continued treatment as
usual with pharmacotherapy compared to such treatment
augmented with a brief course of CBT over 2 years duration.
These investigators found the addition of CBT resulted
Figure 91–8 Risk of relapse after cognitive therapy and
pharmacotherapy, singly or in combination. (From Evans MN, Hollon
SD, DeRubeis RJ, et al: Differential relapse following cognitive therapy
and pharmacotherapy for depression. Arch Gen Psychiatry 1992;
49:802-808. Copyright 1992. American Medical Association.)
100
80
60
40
20
0
04812
Months in follow-up
16 20 24
50%
32%
21%
15%
% First relapse
Drug. No continuation (n = 10)
Drug plus continuation (n = 11)
Cognitive therapy (n = 10)
Combined cognitive pharmacotherapy (n = 13)
1938 Section VII • Psychotherapeutic and Psychosocial Treatments
in a signi cant protective effect, which intensi ed with
the number of previous depressive episodes experienced
(Bockting et al. 2005).
Other models of cognitive and behavioral therapy
have also been studied in randomized clinical trials of
major depressive disorder, and they have generally matched
or exceeded the results of the antidepressant condition
(McLean and Hakstian 1979 , Wilson 1982 , Hersen et al.
1984 ). In two studies, the combination of behavioral therapy
and antidepressants resulted in signi cantly more rapid
improvement (Wilson 1982 , Roth et al. 1982 ). Behavioral
strategies emphasizing self-control skills, problem-solving
skills, and increased pleasant activities have also been
consistently found to be superior to waiting list control
conditions (Thase 1995 , Depression Guideline Panel 1993 ).
Jacobson and colleagues ( 1996 ) performed a randomized
trial comparing standard CBT with behavioral activation
(BA), a condition in which cognitive interventions were
proscribed. They found that BA produced as much
symptomatic improvement as did the full CBT treatment.
When the relapse rate in these groups was examined after
2 years, there was also no difference between the treatments
(Gortner et al. 1998 ). More recently, Dimidjian and
colleagues ( 2006 ) compared an “expanded BA model” to
standard CBT and antidepressant medication (ADM)
in a randomized placebo controlled design in adults with
nonpsychotic major depression. In the less severe patients
there was no difference between the treatments but among
the more severely depressed patients, BA was comparable
to ADM and both signi cantly outperformed CBT (in this
condition behavioral techniques were proscribed). These
results support the contention that more severely depressed
patients require BA techniques to achieve symptomatic
improvement and that BA is the preferred focus initially
in such cases. As a result of these studies, Dimidjian and
colleagues ( 2006 ) question the necessity of targeting negative
thinking to achieve therapeutic response.
Anxiety Disorders
Controlled studies have established the ef cacy of cognitive
and behavioral therapies for generalized anxiety disorder,
obsessive-compulsive disorder, simple phobia, social phobia,
panic disorder, and agoraphobia (Wolpe 1982 , Clum et al.
1993 , Beck and Zebb 1994 , Chambless and Gillis 1993 ,
Durham and Allan 1993 , Butler et al. 1991 , Barlow et al.
2000 , Clark et al. 2006 , Haby et al. 2006 , Schuurmans et al.
2006 ). CBT has also been shown in a randomized clinical
trial to be an effective treatment for anxiety disorders in
older adults at the end of therapy and over 12 months of
follow-up. These authors included patients with a wide
range of anxiety disorders to allow generalization of their
ndings to a greater “real-world” population (Barrowclough
et al. 2001 ).
CBT is very effective for simple phobias . The cognitive
and behavioral treatments emphasizing progressive (graded)
exposure, systematic desensitization, relaxation training,
and the use of homework assignments are well established
and are considered the psychotherapeutic treatment of rst
choice for the simple phobias (Wolpe 1982 , Rachman and
Wilson 1980 , Chambless and Gillis 1993 ).
CBT interventions are effective and frequently used
interventions for the treatment of Obsessive-compulsive
disorder (OCD). Whereas OCD is often refractory to
traditional psychosocial treatments, response rates of 50%
to 70% are typically reported in CBT trials (Emmelkamp
and Beens 1991 , Foa et al. 1992 , Stekette 1994 , Rufer et al.
2005 ). Behavioral strategies generally take precedence over
cognitive interventions, with the paired strategies of exposure
and response prevention proving particularly useful
(Emmelkamp and Beens 1991 , Foa et al. 1992 , Salkovskis and
Westbrook 1989 ). In a recent study, Whittal and colleagues
( 2005 ), found exposure and relapse prevention (ERP) to be
equally effective as CBT in 59 completers at 3-months of
follow-up. Although comparative studies are fewer, therapies
emphasizing exposure and response prevention have been
found to be comparable to antiobsessional pharmacological
agents (such as clomipramine) in patients with behavioral
compulsions (Foa et al. 1992 , Marks et al. 1988 ). Interestingly,
in a small study by Baxter and colleagues ( 1992 ), behavioral
treatment of obsessive-compulsive disorder produced
a change in glucose metabolism in the caudate nucleus (a
putative neurobiological marker of obsessive-compulsive
disorder) comparable to that observed in patients treated with
pharmacotherapy. Several studies have examined whether
pharmacological and cognitive–behavioral strategies can be
used fruitfully in combination or in sequence (Kampman
et al. 2002 , Marks et al. 1980 , Turner et al. 1980 , van Oppen
et al. 2005 ). Van Oppen et al. ( 2005 ) studied the long-term
effectiveness of CBT alone, exposure in vivo and response
prevention (ERP) alone, and CBT or ERP plus uvoxamine.
They concluded that (1) the prevalence of OCD declined
in all three treatment conditions, (2) that these bene ts
were maintained for 5 years, (3) OCD complaints were
more severe for treatment drop-outs than for completers,
and 4) about half of the uvoxamine patients continued
antidepressant use. Regarding the question of treatment
sequencing, Kampman and colleagues ( 2002 ) found the
addition of CBT was effective in uoxetine nonresponders.
Generalized anxiety disorder and social phobia are
common and protean conditions, often presenting with
much depressive and Axis II comorbidity. CBT emphasizing
relaxation training, cognitive coping skills, social skills
training, and graded exposure to feared situations has
generally been shown to be superior to waiting list or
nonspeci c therapy control conditions (Blowers et al. 1987 ,
Borkovec et al. 1987 , Borkovec and Mathews 1988 , Borkovec
and Costello 1993 , Butler et al. 1991 , Durham et al. 1994 ,
Heimberg 1990, Linden et al. 2005 ). An average of 60% to
80% of patients treated in clinical trials have responded to
cognitive and behavioral methods (Gelernter et al. 1991 ,
Power et al. 1990 ). In a controlled trial of patients with
generalized anxiety disorder comparing CBT to behavioral
therapy (BT) and a wait-list control group, results show a
clear advantage for CBT over BT. There was a consistent
pattern of change favoring CBT in measures of anxiety,
depression, and cognition. A randomized, controlled trial
in older adults with GAD of CBT versus a nondirective
supportive psychotherapy found no signi cant differences
between the treatments although both reduced worry
anxiety and depression (Stanley et al. 1997 ). Linden and
colleagues ( 2005 ) randomized 72 outpatients with GAD to
either CBT or a contact control group and after the control
period these patients were treated with CBT as well. They
reported that CBT signi cantly reduced anxiety and that
Chapter 91 • Cognitive and Behavioral Therapies 1939
the clinical effect remained stable over 8 months of follow-
up. Their conclusion was that CBT is an effective treatment
for GAD with an effect size comparable or larger than
those reported for antidepressant medications. These results
are supported by an 8-14 year follow-up study of CBT
treatment which concluded that CBT and the complexity
and severity of presenting problems appear to in uence
the long-term outcome of GAD (Durham et al. 2003 ).
Another interesting study randomized 61 patients to either
CBT or a nonspeci c therapy control group to facilitate
benzodiazepine discontinuation. They reported that 75%
of patients in the CBT group ceased benzodiazepine use
versus 37% in the control group and that a greater number
of patients in the CBT group no longer met GAD criteria.
However, discontinuation rates were twice as high in the
CBT condition (Gosselin et al. 2006 ).
The comparative ef cacy of cognitive and behavioral
treatments and pharmacotherapy for panic disorder and
agoraphobia is currently a topic of intensive investigation
(Clark et al. 1994 , Clum et al. 1993 , Beck and Zebb 1994 ,
Margraf et al. 1993 , National Institutes of Health 1991 ,
Ost et al. 2004 , Otto and Deveney 2005 ). These treatments
teach patients to disregard or deemphasize internal cues
linked to sensitivity to anxiety while mastering behavioral
self-control strategies such as breathing exercises and deep
muscle relaxation. Cognitive strategies are also used in these
models to decrease exaggerated thinking patterns (e.g.,
catastrophization) and reduce worrying.
In general, between 70% and 90% of patients treated
with CBT become panic free within 2 to 4 months of
beginning therapy (Clum et al. 1993 , Chambless and Gillis
1993 , National Institutes of Health 1991 , Otto and Deveney
2005 ). The speci c models of CBT introduced by Beck and
Emery ( 1985 ), Clark ( 1986 ), and Barlow and Cerny ( 1988 )
have been shown to be superior to waiting list or nonspeci c
control conditions (Margraf et al. 1993 , Barlow et al. 1989 ,
Beck et al. 1992 ). In a study using an across-subjects design,
CBT is signi cantly superior to information-based therapy
in reducing panic attacks in patients with panic disorder and
secondary depression (Laberge et al. 1993 ). Meta-analyses
(Beck et al. 1985 , Chambless and Gillis 1993 ) suggest
comparability of CBT and pharmacotherapy (i.e., tricyclic
antidepressants or potent benzodiazepines) during acute
phase therapy. In one trial, the selective serotonin reuptake
inhibitor uvoxamine was superior to CBT (Black et al.
1993 ). However, in other studies, similar advantages favored
CBT (Margraf et al. 1993 , Klosko et al. 1990 , Marks et al.
1993 ). In this regard, Heldt and colleagues ( 2006 ) found
sustained signi cant bene t after one year in 63 patients
who completed group CBT for panic disorder after failing
to respond adequately to previous pharmacotherapy.
Even if it is comparably effective, the cost ef ciency
of pharmacologic treatment may be reduced (relative to
CBT) by high rates of relapse after discontinuation of
pharmacotherapy (DuPont et al. 1992 , Noyes et al. 1991 ,
Pollack et al. 1993 ). Evidence collected to date suggests that
there may be fewer relapses after cessation of CBT compared
with relapse rates after medication discontinuation (Otto
and Deveney 2005 ). This prophylactic effect may be related
to signi cant changes in neurophysiological sensitivity (Beck
and Zebb 1994 ). For example, Shear and colleagues ( 1991 )
found that successful CBT resulted in a signi cant reduction
in patients’ sensitivity to sodium lactate, a biological probe
that reliably induces panic attacks in a signi cant number of
patients susceptible to panic.
As with treatment of depression, CBT has shown value
when it is used sequentially to reduce the risk of relapse
after withdrawal of pharmacotherapy (Otto et al. 1993 ,
Spiegel et al. 1994 ). To date, evidence does not indicate that
the combination of CBT and pharmacotherapy yields a
strongly synergistic effect (Clum et al. 1993 , Marks et al.
1993 , Hegel et al. 1994 , Mavissakalian and Michelson 1986 ,
Gelder 1998 ).
There is also interest in the application of CBT to
posttraumatic stress disorder. A recent review of controlled
outcome studies indicated that CBT is the psychological
treatment of choice and that is more effective than eye
movement desensitivization and reprocessing (Bryant and
Friedman 2001 ).
Eating Disorders
Many research studies have demonstrated the ef cacy of
CBT for bulimia nervosa (Agras et al. 1992 , 1994 , 2000 ,
Fairburn et al. 1991 , 1992 , 1993 , 1995 , Garner 1992 ,
Goldbloom et al. 1997 , Walsh et al. 1997 ). Reviews of
controlled studies of CT have found strong evidence for
the ef cacy (Wilson 1999 , Ricca et al. 2000 ) and theoretical
utility (Reas and Grilo 2004 ) of CBT. Combined cognitive
and behavioral therapy has been shown to be superior to
a behavior therapy alone approach to bulimia (Thackwray
et al. 1993). At the six-month follow-up assessment after
treatment, 69% of the subjects who received CBT reported
no binge eating and purging as compared to 38% abstinence
in the behavior therapy group and 15% abstinence in the
attention placebo group. In a comparison of CBT and a
guided self-help condition, subjects in both treatment
conditions showed a signi cant decrease over time in binge
eating and vomiting frequencies (Bailer et al. 2004 ). Reviews
of research on combined CBT and pharmacotherapy for
bulimia have found that CBT has an additive effect to
antidepressant therapy (Wilson 1999 , Ricca et al. 2000 ).
But, there appears to be no advantage to adding medication
to CBT for anorexia nervosa. In addition, CBT has also
been advocated for binge eating disorder (Vaidya 2006 ).
Bipolar Disorders
There are several randomized control trials of CBT in
patients with bipolar disorder. Cochran (1984) studied
whether CBT improved lithium compliance at 6 and 12
months after treatment as compared to a control group. The
results indicated no difference in lithium compliance on the
self-reports, informant-reports, or serum lithium levels, but
the physician (who was not blind to which group the patient
belonged) reported more compliance. Scott et al. (2001)
reported the results of a pilot study of cognitive therapy
in patients with bipolar I ( n = 34) and bipolar II ( n = 8)
disorders. Half the patients were assigned to immediate CBT
or 6-month wait-list control, which was then followed by a
course of CBT. At six-month follow-up, subjects who had
CBT showed statistically signi cantly greater improvement
in symptoms and functioning than those in the waiting-list
control group. In the 29 patients who eventually received
CBT, relapse rates in the 18 months after commencing CBT
showed a 60% reduction in comparison with the 18 months
1940 Section VII • Psychotherapeutic and Psychosocial Treatments
prior to commencing CBT. Seventy percent of the subjects
who commenced CBT found it to be a highly acceptable
form of treatment. Immediately after receiving CBT
changes in symptoms and functioning were signi cant but
these changes were not maintained at 6 months after CBT
was nished. Interestingly, in the CBT group, reductions
in depressive symptoms were more robust than reductions
in manic symptoms. Interestingly, this same group (Scott
et al. 2006 ) recently reported on a subsequent study of 253
bipolar subjects, which found no overall bene t of CBT,
compared to treatment as usual, in reducing relapse rates.
However, CBT was effective in preventing relapse in persons
who had fewer than 12 previous bipolar episodes.
Another line of research into the bene t of CBT for
bipolar patients examines using CBT to prevent relapse
in patients with bipolar disorder who are taking mood
stabilizer medications. The authors modi ed CBT by (1) a
psychoeducational component that modeled bipolar illness
as a stress-diathesis illness; (2) adaptive CBT shills to cope
with producers (identifying the onset of symptoms of bipolar
disorder characteristic of the patient’s illness pattern);
(3) promoting the importance of circadian regularity by
emphasizing the importance of routine and sleep; and (4)
dealing with the long-term vulnerabilities and dif culties
of the illness. Therapy consisted of 12–20 sessions and
lasted 6 months and outcomes were measured at 6- and
12-month points. The CBT group had signi cantly fewer
bipolar episodes, higher social functioning, better coping
strategies for bipolar problems, evidence of less uctuation
in symptoms of mania and depression, less hopelessness,
better medication compliance, and they used signi cantly
less neurologic medication (Lam et al. 2000 ). Recently, Lam
and colleagues ( 2005a ) reported on the 30-month follow-up
of this cohort. They report that over 30 months the CBT
group had signi cantly better outcome in terms of time to
relapse. Patients in the CBT group also had signi cantly fewer
days in bipolar episodes. However, there was no signi cant
additional CBT effect in relapse reduction over the last 18
months of the study period, suggesting the need for booster
or maintenance CBT treatment sessions. Additionally, this
group found that CBT plus mood stabilizers was superior
to mood stabilizers alone in terms of cost-effectiveness for
those with frequent relapses of bipolar disorder (Lam et
al. 2005b ).
Another recent study by Ball et al. ( 2006 ) observed that
6 months of CBT for bipolar disorder had clinical bene t
in reducing depression, dysfunctional attitudes, and global
ratings of symptom severity. There was a trend for lower
relapse rates in patients treated with CBT. These authors
note that the short-term effects of CBT treatment were
greater than the long-term effects, which may suggest that
maintenance phase therapy may be needed to sustain the
therapeutic effects of CBT in bipolar patients. In the recent,
multisite, NIMH-sponsored study of the effectiveness of
treatments in bipolar disorder, the Systematic Treatment
Enhancement Program for Bipolar Disorder (STEP-BD)
study, several intensive psychotherapies were compared to
a minimal psychosocial intervention (called collaborative
care) (Miklowitz et al. 2007 ). The intensive psychotherapies
included CBT, family-focused treatment (FFT) and the
Interpersonal and Social Rhythm Therapy (IPSRT). These
investigators found that despite equal rates of attrition
across groups, patients receiving intensive psychotherapy
had signi cantly higher year-end recovery rates and shorter
times to recovery than patients in the collaborative care
group. These patients were also 1.58 times more likely to
be clinically well during any study month than those in
collaborative care. No statistically signi cant differences were
observed in the outcomes of the three intensive therapies.
Other Disorders
Although CBT is not as well established as a primary
treatment for other disorders, promising preliminary data
are available in studies of borderline personality disorder
(Linehan et al. 1991 , Linehan et al. 1993 , Salkovskis et al.
1990 ). Cognitive and behavioral therapies have also been
studied in substance abuse disorders and tend to be more
effective than standard counseling approaches only with
patients with concomitant psychiatric illness (Woody et al.
1984 , Carroll et al. 1994 , Higgins et al. 1994 ). The directive
methods employed by cognitive–behavioral therapists
may help to lessen the resistance characteristic of more
sociopathic substance-abusing patients, who may have
limited ability to make use of re ective and insight-oriented
strategies (Kadden et al. 1989 ).
For the psychotic Axis I disorders, including
schizophrenia and bipolar disorder, the cognitive and
behavioral therapies have been shown to be useful adjunctive
treatments for patients stabilized with appropriate
psychotropic agents. The rst trials of CBT for psychosis
were uncontrolled but suggested that this treatment approach
could be used effectively for hallucinations, delusions, and
other symptoms of schizophrenia (Fowler and Morley 1989 ,
Chadwick and Birchwood 1994 , Kingdon and Turkington
1991 ). Subsequently, several randomized controlled trials
have found that CBT can add to the effect of medication
(Drury et al. 1996a , 1996b , Kuipers et al. 1997 , Tarrier et al.
1993 , Sensky et al. 2000 ).
For example, Drury and coworkers ( 1996a , 1996b )
observed that positive symptoms improved more in
hospitalized patients who received CBT than those patients
receiving nonspeci c and supportive treatment. This
research group also observed reduced time required for
recovery in those treated with CBT. Sensky and coworkers
( 2000 ) studied 90 patients with schizophrenia who had
persistent, drug resistant symptoms. In this study both forms
of psychotherapy (CBT and an equal amount of time in
“befriending”) were effective at the end of active treatment.
However, 9 months after treatment subjects who received
CBT had signi cantly lower ratings on measures of positive
and negative symptoms.
Conclusion
The cognitive and behavior therapies are based on well-
articulated theories that have a strong empirical basis.
These therapies emphasize objective assessments and use
of directive interventions aimed at reducing symptomatic
distress, enhancing interpersonal skills, and improving social
and vocational functioning. Cognitive interventions are
focused primarily on identifying and modifying distorted
thoughts and pathological schemas. Behavioral techniques
to increase exposure, increase activity, enhance social skills,
and improve anxiety management are useful modalities,
and can complement or amplify the effects of cognitive
Chapter 91 • Cognitive and Behavioral Therapies 1941
strategies. Similarly, the cognitive perspective can add depth
to behavioral models for therapy by teaching patients how
to recognize and modify their attitudinal vulnerabilities.
The cognitive and behavioral therapies are the
best-studied psychological treatments of major depressive,
panic, generalized anxiety, and obsessive-compulsive
disorders. Overall, there is good evidence for the effectiveness
of these interventions within these indications. Cognitive
and behavioral therapies are being adapted for adjunctive
use with pharmacotherapy for treatment of bipolar disorder
and schizophrenia. There are no contraindications for use
in combination with pharmacotherapy. The cognitive and
behavioral therapies have become one of the standard
psychosocial treatment approaches for mental disorders.
Acknowledgement
This work is supported by grants MH-30915 (Mental
Health Intervention Research Center), MH-58356 (Relapse
Prevention), and MH-41884 (PRD).
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