What Is Cognitive and Behavioral Therapy

Cognitive and Behavioral Therapy (CBT), a hybrid of Behavioral Therapy ( BT) and Cognitive Therapy (CT), focuses on modifying maladaptive thoughts and behaviors to achieve psychological change. Behavioral Therapy has it's origins in a cumulative body of work spanning 19th century classical conditioning to Systematic Desensitization developed in the mid 1950s. Behavioral Therapy views psychological disorders as learned or conditioned behaviors that can be unlearned and changed through behavioral modification.

Cognitive Therapy was developed in the 1960s by psychologists Albert Ellis and Aaron Beck. Both Ellis and Beck argued that BT’s hard rejection of the "unscientific" theories and practices of psychoanalysis erred in overlooking the role of cognition in psychological disturbances. Independently they emphasized the role of cognitive process in the development of psychological conditions where “maladaptive” beliefs give rise to distorted interpretations that in turn drive emotional distress. Cognitive therapy looks at how a situation or event is interpreted by the person. Click here. for see a graphic representation of automatic thoughts and core beliefs in Beck’s model.

Today CBT boasts over 30 years of research, validating it’s efficacy and status as the treatment of choice for for a range of conditions. This Dissemination has contributed to a dynamic evolution of CBT, as methods have been adapted to the unique characteristics of the conditions being treated. This, in turn, has attracted new generations of researchers with increasingly diverse clinical interests. Unfortunately, competing theoretical and clinical orientations have also emerged, and their co-existence has not always been harmonious. Consequently, modern CBT, in spite of having shared origins and a common foundation is not a unified method but a canvas of diverse approaches and practices.

My CBT Approach
As noted in the previous section, contemporary cognitive and behavioral therapy encompasses diverse theoretical orientations and clinical practices. My particular approach draws heavily from the cognitive therapy lineage, as I believe that it is essential to consider the complexity of human neurobiology that has sprung from evolution, when developing best practices for the of treatment of anxiety. At the same time, I put great emphasis on the “doing” or behavioral component of treatment. While it is true that changes in beliefs lead to changes in behavior; it has also been shown that exposure to feared situations is necessary for there to be changes in beliefs and interpretations. Thus, I believe it is important to integrate both cognitive and behavioral components when treating anxiety.

Within this integrative framework, however, the specific cognitive or behavioral points of emphasis, do vary depending on the anxiety disorder being treated, the individual and the stage of treatment. For, example, David Barlow’s blended cognitive and behavioral approach remains the gold standard for the treatment of
panic disorder, whereas, behaviorally-based systematic desensitization continues to be the treatment of choice for phobias and agoraphobia.

In terms of weight of influence,there is no doubt that my training in the treatment of Obsessive Compulsive Disorder, has had the most significant impact on my clinical evolution, leading me deeper into the cognitive, Beckian methods and subsequently taking me to a new generation of cognitive therapy, the Inferential Based Approach (IBA) developed by
Kieron O’Connor and colleagues in Montreal Canada.

My Approach To Exposures
Although, I strongly believe in establishing clear and measurable behavioral goals, in my approach the “C” in CBT, is the figure in the ground of treatment. In behavioral therapy this focus is inverted, as exposure methods are considered the centerpiece of change. In cognitive therapy, such exposures are framed as behavioral experiments. In IBA, exposure is termed “reality sensing”. I use all three methods, depending on the type of anxiety disorder and/or the specific requirements of that treatment moment.

When setting up “exposures”, the goals I establish with clients are, “naturalistic”. That is, I seek natural reset points toward the end of recovering and moving back into “normalcy”. Consequently, in my practice, exposure involves facing what is avoided or feared in the context of an individual’s personal values and within the bounds of what is reasonable and culturally acceptable. However, I do NOT believe that the “unnatural”-and in some cases extreme- exposures, many behavioral therapists in the US still use (ie. desensitizing to contamination obsessions by a touching a toilet seat and having to lick one’s fingers) are necessary or acceptable. Even more problematic, in my opinion, is
the way exposure and response prevention (ERP) is used to treat tormenting, repugnant obsessions. This method requires sufferers to write out and then record scripts of the unacceptable- or even horrific- acts they fear they might commit and then listen to these repeatedly until they “desensitize”. As I explain on the OCD page of this site, I believe that, in addition to increasing the risk of drop out, I consider these types of exposure methods not only misdirected and frankly irrelevant, but also counter-productive and, in some cases, potentially harmful. In the words of a former client when describing [these types of exposures, generally]: “it’s be like being asked to desensitize to heights by climbing on a unicorn.” In the case of tormenting obsessions, one could say this is like having to imagine being crushed in an elevator to overcome claustrophobia.
What Clients Can Expect
The first several sessions are dedicated to:
  • Review of symptoms
  • Diagnosis
  • Gathering of family/biological history.
Treatment Steps and Components
The exact nature of the treatment approach used, depends on the specific anxiety disorder being treated and the unique needs of each client. Examples of generic treatment components/stages include:
  • Psychoeducation regarding the anxiety condition(s) being treated and the specific CBT model(s) to be used.
  • Readings.
  • Establishing goals and treatment rationale
  • Reinforcing motivation and motivational momentum
  • Strategies, techniques, tools, and interventions to achieve change.
  • Exposures, Reality sensing or behavioral experiments.
  • Tracking of treatment progress though the use of daily symptoms logs and task monitoring sheet.
  • Strategies for treatment set backs and resistance
  • Review of knowledge and internalization of model
  • Preparing for extended intervals or termination
  • Relapse prevention
Termination or Extended Interval Maintenance
Once goals are satisfactorily met as reflected through ongoing symptom monitoring and measurement, treatment either ends or moves into a maintenance phase of extended interval sessions.