Modifying Beliefs and Altering Behaviors: The Development of Cognitive-Behavioral Therapy
Michael A. Stier
There are over 240 psychotherapy and counseling techniques currently in use within the United States but questions concerning which therapy style is the most helpful have risen. Evidence-based practice was implemented to structure therapy sessions based on techniques that have been empirically researched for effectiveness. Due to the enforcement of evidence-based practice, cognitive-behavioral therapy is growing in popularity because of its cost efficiency, immediate results, and prominent client success. The following research will compare the results of cognitive-behavioral therapy to other commonly used therapy styles to assess effectiveness and time efficacy. Although a vast majority of therapy models help clients in psychological distress, it is important for insurance companies, clinicians, and clients to recognize the notable difference between cognitive-behavioral therapy and other commonly used therapy styles.
While therapy can be seen in forms such as medicine or occupation, psychotherapy is commonly practiced by psychologists or psychiatrists with clients who are normally in emotional or behavioral distress. Although more than 44 million people suffer from mental health disorders (APA, 2005), two thirds of that population do not seek proper treatment for their mental illnesses (APA, 2005). Trouble with insurance companies and difficulty with money is the number one reason that individuals do not seek the proper help; however, the second reason is commonly associated with the stigma of seeing a mental help professional (APA, 2005). A stigma, as explained by Heathline in 1999, is a Greek word that originates from a tattoo or mark that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or a morally polluted person. Typically people would not identify a person who is in psychotherapy as a "blemished or morally polluted person," which leads to the notion that the process of psychotherapy is unfamiliar to most of the population. In other words, it seems that psychotherapy is thought as demeaning to the client due to the unfamiliar process that occurs. For instance, on a less significant level, a person may constantly explain that he or she does not like a certain food such as sushi even though he or she has never tried the food. Even though individuals have no personal experience with sushi, they describe it as against their tastes because it is unfamiliar to them.
According to Thombs (2006), psychotherapy can be described as "professional services aimed at helping individuals or groups overcome emotional, behavioral, or relationship problems" (p. 120). The process of psychotherapy can be easily confused and misrepresented due to the multiple forms of psychotherapy currently in practice. Some of these comparative and conflictive forms of psychotherapy include psychoanalysis, cognitive-behavioral therapy, Adlerian therapy, and existential therapy. The typical perception of psychotherapy is usually visualized as a middle aged, white haired man listening to the problems and concerns of a distraught client lying on an oversized brown couch. This type of therapy, which is commonly mistaken for the process of psychotherapy, is psychoanalysis. This type of therapy is based on having the client tell stories from his or her past experiences that seemed to have troubled him or her as well as any current issues that may be distracting him or her. The therapist's duty is to listen to and interpret these past stories into current problems that clients may be experiencing. This form of psychotherapy was introduced and reinforced by well known psychologist Sigmund Freud, who devoted his practice to focus on the concept that unconscious factors motivate behavior. Another type of psychotherapy is cognitive-behavioral therapy, founded by Albert Ellis. Cognitive-behavioral therapy stresses the importance of thinking and belief systems as the root of personal problems (Corey, G., 2009). This therapy is not concerned with the client telling stories of his or her past to the therapist, but is concerned with the therapist seeking to use both cognitive and behavioral principles and methods to modify the client's maladaptive patterns. In other words, the therapist's goal is to give the clients healthier and more effective coping strategies to deal with problems he or she may face throughout life as well as changing their belief system towards the destructive qualities which the individual is attempting to overcome.
Some psychotherapy models, such as cognitive-behavioral therapy, have gained an edge in practice through outpatient clinics as well as with insurance companies due to support from empirical evidence in regards to effectiveness of treatment and time efficiency. Furthermore, evidence-based practice mandates the types of treatments that therapists can offer which will be covered under the client's insurance policy. These treatments have been selected by the American Psychological Association and insurance companies from the combination of testing treatment effectiveness. It seems intuitive that treatments should be mandated as working models before being used on clients. However, this type of practice has caused problems within groups of therapists. For example, a general model of treatment may be an excellent idea for some cases, but the argument arises in relation to the generalization of treatment plans and accommodations for specific characteristics of an individual client.
Psychotherapy methods can be as diverse as the therapist being told a story to implementing cognition changes to the client's life. However, psychotherapy is not a place for advice or unconditional positive reinforcement. The world is full of advice and, most of the time, the client's problem is deciding which advice to follow. The goal of psychotherapy is to give the client's own voice and opinions an opportunity to regain confidence and take control of his or her life. The answer to the problems should not come from the therapist, but from the client; the therapist must unlock those answers for the client to use effectively. Therapy is not a massage and certainly not an easy task for the client to endure as most times it can be uncomfortable and hurtful to access certain periods in his or her life. However, if there is not a small amount of discomfort within the therapy session, the client may not be making any improvements in his or her current condition (Pologe, B., 2006).
The process of psychotherapy succeeds due to the increased awareness of other agendas; consequently, the less aware of these patterns of motives, feelings, thoughts, actions, and perceptions, the more they control people's behavior. The coping strategies for these adverse feelings become outdated and are no longer effective with the individual (Pologe, B., 2006). Although there are varying degrees of psychotherapy, a general definition can usually be accepted: any treatment of mental, behavioral, or a relationship problem that aids a client in recognizing his or her own maladaptive coping strategies to produce a greater quality of life.
The differences between the varying therapy styles have been adequately researched and analyzed to increase knowledge of treatment success rates and improvement in time management. Zaretsky, Lancee, Miller, Harris, and Parikh (2008) used a sample of 79 consenting adult men and women with Bipolar Disorder on stable medication regimens to investigate the difference between psychoeducation and cognitive-behavioral therapy. The sample was randomized so the participants would either receive seven sessions of individual psychoeducation, which is comparable to psychoanalysis, or seven sessions of psychoeducation followed by 13 additional sessions of cognitive-behavioral therapy. The client's progress was reported by a combination of weekly mood and medication reports as well as monthly assessments for psychosocial functioning and mental health. They found that participants who received cognitive-behavioral therapy in addition to psychoeducation experienced 50% fewer days of depressed mood over the course of a year than participants that received psychoeducation alone. Furthermore, participants in psychoeducation were found to be prescribed more antidepressants throughout the year compared to the participants that received both treatments (Zaretsky et al., 2008).
Olmstead, Sindelar, Easton, and Carroll (2007) examined the differences among different treatment options including cognitive-behavioral therapy, contingency management, and drug counseling in relation to the cost-effectiveness. They found that cognitive-behavioral therapy with the addition of contingency management was the most cost-effective while drug counseling was found to be the least cost-effective. Although contingency management worked well with cognitive-behavioral therapy in the previous study, Carroll, Nich, and Ball (2005) examined the role of homework assignments in clients with dependency. A one-year follow up assessment of the clients demonstrated that participants who had completed more homework assignments significantly increased the quantity and quality of their coping strategies in addition to using less cocaine throughout their treatment.
Cognitive-behavioral therapy is not only effective in treating cases of substance abuse or dependency as exemplified by Petry, Litt, Kadden, and Ledgerwood (2007), which examined the effects of cognitive-behavioral therapy and support groups such as Gamblers Anonymous. Participants were either referred to Gamblers Anonymous in addition to sessions of cognitive-behavioral therapy or exclusively to Gamblers Anonymous. They found that both treatment options decreased the client's condition with gambling, however, the use of Gamblers Anonymous and cognitive-behavioral therapy produced larger success rates of lowering gambling addiction than the support group alone. Results from this study seem sensible because although support groups are helpful to individuals with problems of addiction, it cannot be considered professional treatment.
Furthermore, Safren, O'Cleirigh, Tan, Raminani, Reilly, Otto, and Mayer (2009) evaluated the impact that cognitive-behavioral therapy had on medication adherence and reduction of depression in individuals with HIV. Individuals who were receiving cognitive-behavioral therapy significantly improved adherence to medication regiments and depression in comparison to the control group. Moreover, individuals who were originally in the comparison group chose to cross over to treatment with cognitive-behavioral therapy and experienced similar results as the original experimental group. Additionally, Rosell, Bernal, River-Medina (2008) assessed the differences between cognitive-behavioral therapy and interpersonal psychotherapy in a sample of clients with depression symptoms. They concluded that both cognitive-behavioral therapy and interpersonal psychotherapy are effective treatment models for depression, but cognitive-behavioral therapy significantly reduced the depressive symptoms and improved self concept much better than interpersonal psychotherapy.
However, Litt, Kadden, Cooney, and Kabela (2003) administered 26 weeks of either cognitive-behavioral therapy or interactional therapy to 128 alcohol dependent men and women to assess coping skills and drinking habits. Both of the therapy types used displayed very successful drinking coping skills among the individuals. Neither treatment differed from the other in terms of a greater increase of coping strategies, which questions the advantages of cognitive-behavioral therapy over interactional therapy in use with alcohol dependents.
Psychotherapy can appear in many diverse forms including psychoanalysis, Gestalt therapy, and cognitive-behavioral therapy. These therapy techniques are commonly used within outpatient clinics and hospitals in addition to many years of successful application in private practice. All of these methods have been found successful in treating mental illness and reorganizing an individual's life. However, it is apparent in current research that therapy methods have been evolving, becoming progressively more time efficient and impactful. For instance, according to Linehan, Armstrong, Suarez, Allmon, and Heard (1991) in a study comparing cognitive-behavioral therapy to other "common therapy methods," they found that patients who received cognitive-behavioral therapy had much lower rates of inpatient days per year (M=8.46) than patients that received the common therapy methods (M=38.86). In addition, cognitive-behavioral therapy significantly held patients in treatment more effectively than with the other common therapy styles. Even though both of the therapy methods described in the study successfully helped the patients, it was apparent that cognitive-behavioral therapy was more valuable in respects to time efficiency and patient return.
Austrian psychologist Sigmund Freud and his followers developed an explanation of human behavior and psychological functioning that was named psychoanalysis. Freud encouraged free association which means that when patients arrive to therapy, they may speak about any subjects they would like. This freedom of speech generates a relaxed atmosphere between the therapist and patient in addition to lowering resistance experienced by the patient. Freud posited that if a patient is relaxed, unconscious notions will slowly drift towards the topic at hand, where the problem usually exists. This type of therapy provides no aim or specific goals to accomplish within a set time frame, making accomplishments in therapy directly associated to the pace the patient provides. Furthermore, emphasis is placed in the patient's past experiences and the impact that remains in his or her current state (Boeree, 2006).
Arguments have been composed against psychoanalysis because of the lenient timeline that provides only slight foundation of therapeutic progression. In addition, many critics of psychoanalytical therapy assert that it is not a science since it cannot be measured in a specific form of succession. According to Popper (1986), psychoanalysis cannot be considered a science because it is not falsifiable and predictions of psychoanalysis are not calculations of evident behavior but of discrete psychological states. Moreover, Colby (1960) explained that psychoanalysis is not a science because it lacks the ability to predict future or past experiences. For instance, psychoanalytical therapists claim that child molestation or abuse will cause neurosis later in life. However, if this statement could be considered valid, it would imply that any individual that has been molested or abused as a child would acquire these specific neurotic traits. On the other hand, if an individual possessed the specific neurotic traits, it would imply that he or she was abused or molested during childhood. Neither of these claims can be proven valid with any accuracy (Colby, 1960).
One of the theories that moved away from psychoanalytic thought was Gestalt psychology founded by Max Wetheimer. However, Gestalt therapy was founded by Fritz Perls in the 1960s to incorporate a more global perspective. For instance, people and objects are not viewed separately, but in conjunction with their surrounding atmosphere and cannot be separated from that environment. Gestalt therapy focuses mostly on perception of instinctive mental laws that govern how objects are perceived and brings all therapeutic focus to the present moment. Concurrently, it is accepted by Gestalt therapists that "the whole is different than the sum of its parts," which is critical in considering the client and environment (Corey, 2009).
Criticisms have been made against Gestalt therapy that includes accusations to its confrontational approach. The therapy style that Perls used includes provoking and confronting any current problems the client may be experiencing. However, some argue that Perls and his followers can be considered too confrontational with clients (Shepard, 1975). Equally important, Gestalt theory lacks a distinct, clear, and fully elaborate theory of development which hinders the understanding of theory compared to human behavior in various stages of life. Developmental processes could be crucial in understanding and interpreting current problems or situations a client may be experiencing. Furthermore, the most criticized aspect of Gestalt therapy includes the therapist's role as a medium for change. If the therapist does not have a strong personal commitment to the client and to following the Gestalt principles, the therapeutic process will be significantly diminished (Lobb & Salonia, 1993).
Although psychoanalytical and Gestalt therapy models work to help clients progress to a greater quality of life, cognitive-behavioral therapy is growing in popularity since the 1960s due to Aaron Beck and Albert Ellis. Beck worked in conjunction with Ellis, founder of Rational Emotive Behavioral Therapy, which focuses on an individual's experiences, beliefs, and finally consequences (Corey, 2009). Cognitive-behavioral therapy is a short term therapy model that focuses on practical solutions and using hands-on techniques to modify patterns of thinking or behavior that reside behind the client's difficulties. Cognitive-behavior therapy works by changing an individual's attitudes and behaviors by focusing on thoughts, images, beliefs and attitudes that he or she holds. How an individual attains this information relates to the way he or she behaves and deals with emotional problems (Martin, 2007).
While psychotherapy and Gestalt therapy models take years to complete, cognitive-behavioral therapy normally lasts four to seven months for most emotional problems. Clients normally attend one session per week and sessions normally last 50 minutes. Within the session, the therapist and client work collectively to identify the problems and develop new coping strategies to help with any future encounters. However, to many professionals, cognitive-behavioral therapy is considered to be a combination of psychoanalysis and behavioral therapy. Both aspects are needed for cognitive-behavioral to be successful because psychoanalytical theory establishes meaning within the conversation between the client and therapist while behavioral therapy modifies meaning to produce a positive outcome (Martin, 2007).
According to Martin (2007), studies have shown that cognitive-behavioral therapy can dramatically reduce the symptoms of many emotional disorders. In addition, many studies have shown that individuals with as little as 12 sessions of cognitive-behavioral therapy have found to be more effective than being prescribed medication for a period of two years. This suggests that cognitive-behavioral is not an immediate adjustment to emotional problems, but a learning experience that encourages real change rather than feeling better only when in session with the therapist (Martin, 2007). A study conducted by DeRubeis, Gelfand, Tang, and Simons (1999) compared the progress of therapy for individuals who were using cognitive-behavioral therapy and individuals who were using medication to manage severely depressed clients. They found that cognitive-behavioral therapy produced better results than taking the medication alone. Moreover, Butler, Chapman, Forman & Beck (2006) found that cognitive-behavioral therapy was superior on parameters of treating depression, anxiety, anger, marital problems and was equally successful as the use of antidepressants.
Through the information described above, cognitive-behavioral is not a separate therapy style from psychoanalysis and Gestalt therapy. Similar to most therapy styles, adaptations from previous work and therapy are restructured to accommodate the therapist's ideas and evolving research. However, with the dramatic time efficacy and production of long term behavioral changes that can be applied to any facet of the client's life, it is clear to see why cognitive-behavioral therapy styles are becoming more popular with psychologists, psychiatrists, and insurance companies.
American Psychological Association. (2005). Facts & Statistics. Retrieved February 26, 2009, from http://www.apahelpcenter.org/articles/topic.php?id=6
Boeree, G. (2006). Sigmund Freud. Retrieved March 29, 2009, from Shippensburg University. Web site: http://webspace.ship.edu/cgboer/freud.html
Butler, A., Chapman, J., Forman, E. & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. [Electronic Version]. Clinical Psychology Review, 26(1), 17-31.
Colby, K. M. (1960). An introduction to psychoanalytic research. New York: Basic.
Corey, G. (2009). Theory and Practice of Counseling and Psychotherapy (8th ed.). California: Thomson Higher Education
DeRubeis, R., Gelfand, L., Tang, T. & Simons, A. (1999). Medications versus cognitive behavior therapy for severely depressed outpatients: Mega-analysis of four randomized comparisons. [Electronic Version]. American Journal of Psychiatry, 156, 1007-1013.
Frey, R. J. (2003). Stigma Definitions. Retrieved February 26, 2009, from
Linehan, M., Armstrong, H., Suarez, A., Allmon, D., & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. [Electronic Version]. Archives of General Psychiatry, 48, 1060-1064.
Litt, M., Kadden, R., Cooney, N., & Kabela, E. (2003). Coping skills and treatment outcomes in cognitive-behavioral and interactional group therapy for alcoholism. [Electronic Version]. Journal of Consulting and Clinical Psychology, 71(1) 118-128.
Lobb, S. & Salonia, G. (1993). What is the future in Gestalt therapy? [Electronic Version]. Studies in Gestalt Therapy, 2, (26-34).
Martin, B. (2007). In Depth: Cognitive behavioral therapy. In PsychCentral. Retrieved April 2, 2009, from http://psychcentral.com/lib/2007/in-depth-cognitive-behavioral-therapy/.
Olmstead,T., Sindelar, J., Easton, C., & Carroll, K. (2007). The cost-effectiveness of four treatments for marijuana dependence. [Electronic Version]. Addiction, 102, 1443-1453.
Petry, N., Litt, M., Kadden, R., & Ledgerwood, D. (2007). Do coping skills mediate the relationship between cognitive-behavioral therapy and reductions in gambling in pathological gamblers? [Electronic Version]. Addiction, 102, 1280-1291.
Pologe, B. (2006). What Psychotherapy Isn't. Retrieved February 27, 2009, from http://www.aboutpsychotherapy.com/Twhatpsyisnt.htm
Popper, K. (1986). Predicting overt behavior versus predicting hidden states. [Electronic Version]. Behavioral and Brain Sciences, 9, 254-255.
Rossell, J., Bernal, G., & Rivera-Medina, C. (2008). Individualand group CBT and IPT for Puerto Rican adolescents with depressive symptoms. [Electronic Version]. Cultrual Diversity and Ethinic Minority Psychology, 14(3), 234-245.
Safren, S., O'Cleirigh, C., Tan, J., Raminani, S., Reilly, L., Otto, M., & Mayer, K. (2009). A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. [Electronic Version]. Health Psychology, 28(1), 1-10.
Shepard, M. (1975). Fritz. New York: E.P. Dutton.
Thombs, D. L. (2006). Introduction to Addictive Behaviors (3rd ed.). New York: The Guilford Press.
Zaretsky, A., Lancee, W., Miller, C., Harris, A., & Parikh, S. (2008). Is cognitive-behavioural therapy more effective than psychoeducation in bipolar disorder? [Electronic Version]. Canadian Journal of Psychiatry, 53(7), 441-448. Retrieved April 19, 2009 from EbscoHost Database.