Cognitive-Behavioral Therapy
ScienceDirect Behavior Therapy 47 (2016) 785–803
www.elsevier.com/locate/bt
Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy
Lorenzo Lorenzo-Luaces John R. Keefe
Robert J. DeRubeis University of Pennsylvania
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Since the introduction of Beck’s cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive- behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders.Despite this, the relative contributionof cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.
Keywords: cognitive-behavioral therapy; cognitive theory; psychotherapy processes; depression; anxiety
THE ORIGIN OF COGNITIVE-BEHAVIORAL THERAPIES (CBTs) as a family of interventions can be traced to the advent of behavioral treatments for psychopa- thology in the 1950s and, later, the so-called “cognitive revolution” of the 1950–1960s (Dobson, 2009). Consequently, CBTs blend techniques that are emphasized in behavioral therapies (BTs) and cogni- tive therapies (CTs). However, there remains skepti- cism regarding the relative contributions of CT strategies to BT strategies in promoting symptom change within the CBTs (Longmore & Worrell, 2007). Additionally, critics have asserted that changes in thinking are not mechanisms of change in CBTs (e.g., Kazdin, 2007), calling into question whether
Correspondence regarding this article should be addressed to Lorenzo Lorenzo-Luaces, University of Pennsylvania, Department of Psychology, 3720 Walnut Street D20, Philadelphia PA 19104; e-mail: [email protected].
0005-7894/© 2016 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
there is any kind of contribution of the “cognitive” in cognitive-behavioral therapy. Despite debate regarding their active treatment
components as well as working mechanisms, CBTs continue to be the most widely studied forms of therapy (Hofmann, Asmundson, & Beck, 2013). A uniquely appealing aspect of CBTs is that their theo- ries of therapeutic change comport well with most modern conceptualizations of psychopathology. In this review, we attempt to reconcile skepticism regarding the relative contribution of CT strategies to BT, aswell as themechanisms that account for their efficacy. First, we provide a very brief historical over- view of the origins of CBT and discuss the support for the cognitive vulnerability models to depression and anxiety disorders. We discuss methodological chal- lenges in psychotherapy research that have impeded a more thorough understanding of the relative con- tributions of cognitive to behavioral techniques. We then focus most of our discussion on research on the cognitive mechanisms of change in CT, BT, and CBTs for depression and anxiety disorders. We use the terms cognitive therapy (CT) and
cognitive techniques to refer to behaviors therapists engage in that are targeted towards changing the content or process of thoughts, inferences, inter- pretations, cognitive biases, and cognitive schemas.1
The terms “cognitive therapy” (CT) and “cognitive-behavioral therapy” (CBT) are often used interchangeably. We believe this is somewhat unfortunate in that it might be informative to reserve the term CT to a set of interventions within the broader family of CBTs that are more “purely” cognitive in nature. However, throughout the article, when we refer to findings in studies of CT or CBT, we are adhering to the label the study authors use. Additionally, we use CBTs, in plural, to refer to the family of cognitive-behavioral therapies.
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These interventions can include Socratic question- ing, examining the evidence for and against beliefs, cognitive restructuring, and adopting alternative core beliefs. We use the terms behavior therapy (BT) and behavioral techniques to refer to behav- iors therapists engage in that are targeted towards a change in observable behavior, including in vivo exposure, imaginal exposure, and activity sched- uling. We use cognitive-behavioral therapies in the plural (CBTs) to refer to the family of interventions to which CT and BT belong, and in the singular, CBT, to refer to a treatment package that combines cognitive and behavioral techniques. By cognitive change, we refer to changes in the content of thoughts, inferences, interpretations, and cognitive biases. By behavioral change, we refer to changes in behavior, such as increasing the frequency of selected behaviors (e.g., approaching feared stimuli, engaging with pleasurable activities) or decreasing the frequency of other behaviors (e.g., safety behaviors). We include in our paper a discussion of issues related to the conceptualization and measure- ment of cognitive vs. behavioral interventions as well as cognitive vs. behavioral mechanisms of change and conclude with a summary and with recommen- dations for future research.
