Cognitive Behavioral Therapy
- Addie Weaver, Addie WeaverCurtis Research Center, School of Social Work, University of Michigan
- Joseph Himle, Joseph HimleSchool of Social Work, University of Michigan
- Gail SteketeeGail SteketeeSchool of Social Work, Boston University
- and Jordana MuroffJordana MuroffSchool of Social Work, Boston University
This entry offers an overview of cognitive behavioral therapy (CBT). Cognitive behavioral therapy is introduced and its development as a psychosocial therapeutic approach is described. This entry outlines the central techniques and intervention strategies utilized in CBT and presents common disorder-specific applications of the treatment. The empirical evidence supporting CBT is summarized and reviewed. Finally, the impact of CBT on clinical social work practice and education is discussed, with attention to the treatment’s alignment with the profession’s values and mission.
Cognitive behavioral therapy (CBT) is a structured, time-limited approach to psychotherapy that aims to address clients’ current problems (Dobson & Dobson, 2009). CBT uses problem-focused cognitive and behavioral strategies guided by empirical science and derived from theories of learning and cognition (Craske, 2010). These interventions are delivered within a collaborative context where therapists and clients work together to identify problems, set goals, develop intervention strategies, and evaluate the effectiveness of those strategies.
CBT represents a broad approach to treatment that encompasses various theoretical models, including cognitive therapy (CT; Beck, 1976; Beck, Rush, Shaw, & Emery, 1979; Beck, 1995), rational-emotive behavioral therapy (REBT; Ellis, 1962, 1979; 1994; Ellis & Dryden, 1997), problem-solving therapy (D’Zurilla & Nezu, 2007; Haley, 1987), stress inoculation training (SIT; Meichenbaum, 1993; Meichenbaum & Deffenbacher, 1988), schema-focused therapy (Young, 1994; Young, Klosko, & Weishaar, 2003), and dialectical behavioral therapy (DBT; Linehan, 1987, 1993). Though individual cognitive behavioral treatment models may vary in their emphasis on behavioral and cognitive principles and methodologies, interventions under the CBT umbrella are unified by an empirical foundation, reliance on the theory and science of behavior and cognition, and a problem-focused orientation (Dobson & Dobson, 2009).
CBT can be defined by common features that cut across individual treatment models or variations.
Most notably, the cognitive behavioral approach emphasizes a person’s thinking as the prime determinant of emotional and behavioral responses to life events (Beck, 1976; Ellis, 1994; Meichenbaum, 1993). Dobson and Dozois (2001) offer three basic principles that are common to most CBT models:
The access hypothesis, which asserts that the content and process of our thinking is knowable and, with appropriate training and attention, persons can become aware of their own thinking
The mediation hypothesis, positing that there is cognitive mediation between events and persons’ typical responses to them. CBT maintains that the way people think about or interpret their experiences has a profound impact on how they feel about those experiences. Therefore, thoughts and beliefs strongly influence behavioral patterns. CBT suggests that thoughts and corresponding emotional and behavioral responses may become routine and automatic over time.
The change hypothesis asserts that, because cognitions are knowable and mediate the response to different situations, it is possible to intentionally modify how people respond to events. CBT maintains that an increased recognition and understanding of emotional and behavioral reactions, through the systematic use of cognitive strategies, leads to more functional and adaptive responses.
Additionally, CBT generally asserts that a more realistic, or accurate, appraisal of the world, and the ability to adapt to the real world, is one indication of good mental health. Conversely, maladaptive or dysfunctional assessments of reality lead to a distorted view of the world and more emotional and behavioral problems. As the mediation hypothesis suggests, CBT asserts that patterns of thinking, including general ideas, assumptions, and schemas (firmly held basic beliefs about the self, others, and the world), are derived over time based upon persons’ experiences interacting with their social environment (Dobson & Dobson, 2009). These assumptions and schemas affect how people view the world around them, potentially predisposing them to certain ways of thinking that become self-fulfilling prophesies (Beck, 1976). Once schemas became established, they not only affect memories of past experiences, but also influence future development by restricting the situations and activities people choose to engage in (Beck, 1976; Dobson & Dobson, 2009).
However, CBT contends that people do not just passively react to events and triggers in the world around them; rather, they have the potential to actively shape the course of their lives (i.e., change hypothesis). Therefore, CBT utilizes cognitive and behavioral strategies to help clients identify and replace maladaptive behaviors, emotions, and cognitions with more adaptive ones. Behavioral interventions, including behavioral activation, exposure, problem solving, social skills training, and relaxation training, focus on decreasing maladaptive behaviors and increasing adaptive ones by modifying their antecedents and consequences in ways that lead to new learning. Cognitive interventions, such as thought recording, reality testing, and reattribution or reappraisal, aim to restructure maladaptive or distorted thoughts and generate alternative, more evidence-based appraisals and beliefs.
Origins, Major Developers, and Contributors
CBT emerged as an approach to psychotherapy during the mid-20th century. The philosophical foundations of CBT were informed by Greek and Roman Stoicism, Buddhism, and Taoism, all of which emphasize reason, logic, and acceptance (Beck et al., 1979; Dryden, David, & Ellis, 2010). Influenced by the shift from psychodynamic theory to more scientific approaches to treatment (Beck, 1967; Ellis, 1979), CBT derived from advances in behavioral and cognitive theory and science (e.g., Eysenck, 1960; Lazarus, 1966). Behavioral approaches drew from the classical conditioning theory of Watson (Watson & Raynor, 1920; Watson, 1925) and Mowrer (1960) and the operant conditioning theory of Pavlov (1927) and B. F. Skinner (1938, 1963), both of which focus on antecedents and reinforcers of behavior and advocate an empirical approach to evaluating behavior. In the 1950s and 1960s, pioneers in behavior therapy developed these theories further into models for intervening in various mental health problems, such as mood (depression, anxiety) and behavioral problems in children and adults (for review, see Clark & Fairburn, 1997). A few of these models and methods are noted below.
Early exposure methods for treating anxiety were derived from the animal models of reciprocal inhibition of Wolpe (1958), which he adapted for use in humans, developing and testing systematic desensitization, or brief exposures to feared cues offset by carefully trained relaxation responses (or other fear inhibitors). His methods were supported by Lang’s (1968) studies documenting the fear reducing effects of desensitization and further outlining the nature of fear. The two-stage model of fear and avoidance of Mowrer (1960) proposed that human fear was conditioned through the pairing of ordinary cues with actual fear and that avoidance persisted because it was negatively reinforced. This model was used extensively to develop interventions for anxiety and obsessive-compulsive disorders. Skinner’s operant conditioning models were further developed for application of reinforcement and contingencies applied to a variety of child and adult behaviors. Examples include Azrin’s token economy, time out, and habit reversal procedures for motor disorders (see Hersen, 2005), as well as Kazdin’s (1978) work on skills training and parent management for child behavior problems.
The social learning theory of Albert Bandura (1977) and social cognitive theory (1986), which focused on observational or vicarious learning, promoted both behavioral and cognitive models for understanding mental health. Albert Ellis (1962) and Aaron Beck (1976) developed early models of cognitive behavioral therapy that established the philosophical, theoretical, and practice foundations of this approach. While Ellis (1962) and Beck (1976; Beck et al., 1979) developed their models independently, both focused on the relationship between cognition and emotional disturbance, concluding that distorted and dysfunctional thinking is the primary determinant of mood and behavior (Craske, 2010). These early cognitive behavioral approaches also shared an emphasis on the importance of eliciting clients’ reports of situations and events occurring in daily life and assigning common sense meanings to clients’ problems (Dobson & Dobson, 2009).
Ellis’s rational emotive behavior therapy (REBT; Ellis, 1962, 1979, 1994; Ellis & Dryden, 1997) was built upon the ancient Greek and Roman Stoic philosophers, such as Epictetus, Epicurus, and Marcus Aurelius, and Asian philosophers, such as Confucius, Lao-Tsu, and Gautama Buddha, all of whom maintained that people are not disturbed by things but by their view of things (Ellis & Dryden, 1997). Ellis asserted that people’s beliefs, or how they think, strongly affect their emotional functioning. The REBT model maintained that emotional reactions were mediated by “internal sentences” or thoughts, and that holding certain irrational beliefs (e.g., absolutism, demand for love and approval, and demand for comfort) resulted in internal self-statements that were maladaptive responses to situations (Ellis, 1962). Ellis suggested that irrational beliefs lead to mislabeling of situations that ultimately create psychological problems and emotional distress. Ellis (1962) developed the ABC model to guide this process, wherein an activating event (A) happens in the environment around you; you hold a belief (B) about that event; and your belief elicits an emotional response or consequence (C). As a result, Ellis maintained that rational beliefs elicit appropriate emotional and behavioral response while irrational beliefs lead to inappropriate and dysfunctional response (Ellis & Dryden, 1997). Therefore, a goal of REBT is to help clients identify, challenge, and alter their irrational beliefs and negative thinking patterns to be more rational and realistic. REBT also focuses on targeting emotional responses that accompany irrational thoughts and encourages clients to change unwanted behaviors through meditation, journaling, and guided imagery.
Similarly, Beck based his cognitive therapy (CT) model (1976; Beck et al., 1979) on the idea that critical or negative automatic thoughts and unpleasant physical or emotional symptoms combine to form maladaptive cycles that maintain symptoms and result in emotional distress. Beck (1976) asserted that a person’s fundamental beliefs about themselves and the world predispose them to either psychological health or distress. CT suggests that a person’s way of organizing themselves and the world, or cognitive schema, results in automatic thoughts about situations and events (Dobson & Dobson, 2009). Beck identified common cognitive distortions (e.g., all-or-nothing thinking, overgeneralization, jumping to conclusions, should statements, labeling and mislabeling) that often operate as automatic thoughts (Beck, 1963, 1976; Beck et al., 1979). He argued that cognitive distortions lead to faulty assumptions and misconceptions that inform both emotional and behavioral responses to an event or situation (Beck, 1963). CT aims to help clients identify automatic thoughts, understand how cognitive distortion or negative thinking influence feelings and behavior, develop a more realistic appraisal of situations and events, and modify dysfunctional beliefs and assumptions that predispose cognitive distortions (Beck, 1976; Beck et al., 1979).
Other popular therapeutic approaches under the CBT umbrella include Meichenbaum’s (1993; Meichenbaum & Deffenbacher, 1988) stress inoculation training (SIT), and problem-solving therapy (PST; D’Zurilla & Nezu, 2007; Haley, 1987). SIT helps persons develop skills, such as self-instruction, relaxation, behavioral rehearsal, and in vivo exposure, to protect themselves against the effects of anxiety and trauma and against future stressors. PST focuses on training individuals to effectively use problem-solving skills, which encourages and increases healthy coping and the ability to adapt.
It is also important to note the more recent development of third wave behavioral therapies. Since the 1990s a number of new interventions, referred to as the third wave of behavioral therapy, have emerged. Though rooted in CBT, third wave behavioral therapies emphasize the role of mindfulness and acceptance in the healing process. Dialectical behavior therapy (DBT; Linehan, 1987, 1993), acceptance and commitment therapy (ACT; Hayes, 2004; Hayes et al., 2006), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002), and mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) are commonly considered part of the third wave. While still acknowledging the mediation between thoughts, behavior, and emotions, third wave interventions focus less on challenging clients’ irrational or negative thoughts and more on changing clients’ relationship to thoughts and feelings (Hayes, 2004; Singh, Lancioni, Wahler, Winton, & Singh, 2008). To this end, third wave behavioral therapies incorporate contextual and experiential change strategies such as mindfulness, acceptance, and cognitive defusion, and encourages a focus on relationships, values, emotional deepening, and contact with the present moment (Hayes, 2004), While proponents of third wave behavioral therapies assert that they maintain CBT’s commitment to an empirical, scientific approach to treatment (Hayes, 2004; Hayes, Masuda, Bissett, Luoma & Guerrero, 2004), some scholars have argued that third wave behavioral therapies may be getting ahead of the data (Corrigan, 2001) and do not yet meet established criteria to be considered empirically supported treatments (EST; Ost, 2008).
Cognitive behavioral therapists utilize a combination of cognitive and behavioral intervention strategies to address clients’ presenting problems. Clinicians select appropriate intervention strategies after conducting a thorough initial assessment to clarify how thoughts, emotions, and behaviors are interrelated. The intervention strategies employed may vary based upon clients’ presenting problem and skill level, as well as the treatment model. Behavioral interventions are often employed earlier in treatment as they are likely to address symptoms quickly, leaving clients better equipped to start focusing on cognitive aspects of problems (Dobson & Dobson, 2009); however, some approaches reverse this order. All CBT techniques are implemented within the context of therapist and client collaboration. Cognitive behavioral therapists emphasize and reward the clients’ effort when implementing intervention strategies, regardless of their outcome.
The central techniques and intervention strategies used in CBT are described below in the order they are generally implemented in treatment, beginning with psychoeducation, followed by behavioral interventions, and then cognitive restructuring. Finally, homework, a key aspect of CBT that is implemented across intervention strategies, is discussed.
Psychoeducation is defined as teaching relevant psychological principles and knowledge to clients (Anderson, Hogarty, & Reiss, 1980). Helpful materials include information about the diagnosis, the treatment rationale, and research findings (Anderson et al., 1980), which can be presented in a variety of ways, depending on clients’ learning needs. Cognitive behavioral therapists often recommend a combination of didactic materials, including pamphlets, books, videos, and websites, that are tailored to a client’s education, language, literacy, skills, interests, resources, privacy needs, distress level, concentration ability, and quality of materials (Dobson & Dobson, 2009). Psychoeducation lets clients know that they are not alone and that their problems have been widely identified, researched, and discussed (Anderson et al., 1980). This can lead to feelings of support, hope, and validation, as well as a sense of control over problems that may begin to shift beliefs.
Behavioral Interventions: Reinforcement and response contingencies.
A variety of behavioral techniques are subsumed within this broad category of interventions that derive from operant (Skinnerian) models of human behavior. Following a careful behavioral analysis of the stimulus and responses in the problem context, therapists may apply direct reinforcements (rewards) for positive behaviors and costs (e.g., time out, loss of a privilege) for performance of problematic behaviors. In the case of child behaviors within a family context, parents are typically trained to observe the child’s behavior and apply appropriate positive and negative reinforcements.
Behavioral activation encourages clients to engage in pleasurable or mastery (e.g., self-care, chores, paying bills) activities in a scheduled, monitored way. Originally developed by Ferster (1973) and Lewinsohn, Sullivan, & Grosscup (1980) as a depression treatment, behavioral activation has been implemented widely with clients experiencing decreased activity and reduced reinforcement across a range of diagnostic categories. Behavioral activation is used to help clients increase the quantity and quality of positively reinforced behavior and improve coping behaviors to deal more adaptively with negative life situations (Dobson & Dobson, 2009). Implementing behavioral activation early in therapy is likely to result in improved mood and higher levels of energy.
The first step in behavioral activation involves having clients create a simple, concrete list of their current activities, or, if they don’t engage in any current activities, a list of activities they enjoyed in the past or imagine would be helpful (Dobson & Dobson, 2009). Clients then identify an activity that they would like to increase (e.g., spending time with friends, cleaning the house) and choose small, incremental steps in support of their goal (e.g., call a friend; invite a friend to lunch). Throughout the intervention, clients are asked to complete an Activity Schedule, where activities are systematically recorded until they become more habitual. Clients’ efforts, rather than outcomes, are verbally reinforced, and clients are asked to make positive statements about their efforts as well (Dobson & Dobson, 2009).
Social skills training.
Social skills training, also referred to as communication skills training and assertiveness training, is a core component of behavior therapy and is used in CBT as needed (Dobson & Dobson, 2009). Social skills training includes the teaching and practice of basic communication and verbal skills (e.g., how to start conversations; how to make and respond to requests; pacing, rate of speech; loudness of voice; extraneous or habitual voice patterns, tone of voice), and nonverbal communication skills such as appropriate body language (e.g., physical proximity, facial expressiveness, hand gestures). More advanced skills such as assertive communication, dealing with conflict, and communicating in intimate relationships may also be addressed through social skills training (Dobson & Dobson, 2009). When providing this training, therapists must consider the variability in social expression (e.g., across culture and age groups) to ensure clients are able to communicate their needs and desires in an appropriate, acceptable manner (Dobson & Dobson, 2009).
Problem solving training.
CBT uses a general problem-solving format that is distinct from problem solving as a stand-alone treatment. In the problem-solving behavioral intervention strategy, clients identify a specific problem, generate strategies for addressing the problem, implement the strategy, and evaluate its effectiveness for addressing the identified problem (D’Zurilla & Goldfried, 1971).
The problem solving process begins with identifying and naming a specific problem (e.g., symptom of psychological disorder, psychosocial stressor) (D’Zurilla & Goldfried, 1971). The therapist and client determine the parameters of the problem, such as frequency, duration, triggers, and resolution, and develop an assessment strategy (Dobson & Dobson, 2009). During this process clients are encouraged to consider the idea of change and how to promote change. The therapist and client collectively generate a variety of possible strategies without initial evaluation of the approaches in order to think broadly and creatively about potential solutions. Then, they conduct cost-benefit analyses to evaluate each alternative and its likelihood of solving the original problem (D’Zurilla & Goldfried, 1971). The optimal strategy is selected and its implementation is discussed in detail (e.g., when it will begin, how it will be conducted, for how long) (Dobson & Dobson, 2009). The client then implements the selected strategy as homework. Finally, the client and therapist evaluate the outcome of the problem-solving strategy. If the problem was solved, they move to the next issue. If the problem was not solved, only partially solved, or changed, then the therapist and client circle back to reevaluate the problem and consider other alternative strategies (Dobson & Dobson, 2009).
CBT utilizes relaxation training to provide a personal self-care activity for clients, either as a strategy to decrease physical tension, calm down when agitated, or regulate internal sensations (Dobson & Dobson, 2009). Therapists can teach clients to use several different types of relaxation training, including progressive muscle relaxation, breathing retraining, autogenic relaxation, and visualization exercises (Jacobson, 1938, 1970; Wolpe, 1969). It is often helpful to create personalized audio files for clients that include collaboratively planned relaxation strategies (Dobson & Dobson, 2009). CBT encourages frequent practice of relaxation strategies, and strategies are often tied to visual reminders or paired with regular daily activities to facilitate clients’ ability to call on these skills when needed.
Exposure-based interventions are among the most empirically tested and effective components of CBT (Barlow, 2002; Farmer & Chapman, 2008; Richard & Lauterbach, 2007). Exposure encourages clients to confront a feared stimulus (e.g., thoughts, emotional responses, activities, situations) in order to manage physiological anxiety and decrease fears. As exposure requires clients to take risks, cognitive behavioral therapists must ensure a good therapeutic alliance and communicate a solid rationale for the intervention strategy prior to its implementation (Dobson & Dobson, 2009).
The ultimate goal of exposure is to help clients recognize that a feared stimulus is not as scary, unpredictable, or out of control as they imagined and let them know that they can cope with previously avoided situations (Dobson & Dobson, 2009). Exposure-based interventions increase clients’ self-efficacy. Gradual and systematic exposure over time has been shown to diminish avoidance patterns, which indicates new learning (D’Zurrilla, Wilson, & Nelson, 1973; Watson, Gaind, & Marks, 1971). More recent, Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury, and Baker (2008), noting that fear levels at the time of exposure have not been shown to be reliable indicators of learning, have posited the evocation of inhibitory learning and fear toleration as shown at episodes of reexposure.
Exposure targets should be hierarchical, starting with a stimulus expected to trigger low levels of anxiety and gradually moving to stimuli likely to result in higher levels of anxiety (Dobson & Dobson, 2009). Effective exposure typically produces feelings of moderate anxiety intensity and should not produce extreme or overwhelming anxiety. Exposure is most effective when used frequently and continuously until anxiety is reduced; accordingly, exposure-based interventions may require longer and/or more frequent sessions (Foa, Jameson, Turner, & Payne, 1980). Though exposure interventions can occur in vivo or in imagery, in vivo exposure leads to greater benefits (Emmelkamp & Wessels, 1975). Clients are encouraged to practice exposure in a variety of situations and settings to promote generalization, with clients keeping a record of exposures and outcomes (Dobson & Dobson, 2009). Practice should occur both in-session and outside of sessions as part of homework.
CBT clinicians use cognitive restructuring to help clients become aware of the connection between their thoughts, emotions, and behaviors. Cognitive restructuring consists of intervention strategies to help clients recognize, evaluate, and effectively respond to dysfunctional, negative, or distorted thoughts. The intervention strategies commonly employed during cognitive restructuring are described below.
Identification of problematic thoughts: Thought recording. Cognitive behavioral therapists must help clients develop an awareness of their dysfunctional or negative thoughts before they can employ interventions to change these thoughts. Thought recording helps increase clients’ awareness of dysfunctional or negative thoughts, while also providing a way for them to share and communicate experiences with their therapist (Dobson & Dobson, 2009). A daily dysfunctional thought record (DTR; Beck et al., 1979; Beck, 1995) is often used for this purpose. The DTR includes columns in which clients can record situations (e.g., date, time, event), as well as the automatic thoughts, emotions (e.g., type and intensity), and behaviors (e.g., actions and tendencies) the situations elicit. Later in treatment, clients are often given another version of the DTR that includes columns in which alternative (more adaptive) thoughts and behavioral outcomes are recorded as well.
Because identifying and recording dysfunctional and negative thoughts can be challenging for clients, their abilities and skill levels must be considered. Further, some clients may respond negatively to the term “dysfunctional” thought, so clinicians may need to modify their language to ensure that it is acceptable to clients (Dobson & Dobson, 2009). Therapists must be sure that clients clearly understand the linkage between their thoughts and responses before encouraging them to engage in thought recording.
Labeling cognitive distortions.
Once clients have identified and recorded their negative thoughts, clinicians can help clients identify cognitive distortions and discuss them. Driven by core beliefs, assumptions, or schemas, cognitive distortions interact with situational facts or circumstances, leading to automatic thoughts and situation-specific thinking (Beck, 1963). Cognitive behavioral therapists must recognize clients’ distorted thinking in order to plan effective intervention strategies (Dobson & Dobson, 2009). It is common for therapists and clients to review a list of cognitive distortions together. The dysfunctional thought record (DTR), described above, can be modified to include an additional column where clients name the cognitive distortions underlying their negative and dysfunctional thoughts.
Evaluating problematic thoughts: Reality testing and Socratic questioning. To counter cognitive distortions and negative or dysfunctional thoughts, CBT encourages clients to evaluate their thoughts through empirical hypothesis testing. Thoughts are viewed as hypotheses, rather than facts, and therefore can be questioned and challenged. Reality testing refers to intervention strategies that offer opportunities for clients to compare their thoughts to the actual evidence.
One of the most straightforward strategies for countering negative thoughts and distortions is simply asking clients to examine the evidence (e.g., type, quality, amount) that supports and refutes their original thought (Dobson & Dobson, 2009). Therapists use Socratic questioning (Beck et al., 1979) to help clients make guided discoveries and question their thoughts (Craske, 2010). Socratic questioning simply follows the client’s own logic, as if their assumption were true and corollaries to their reasoning would follow: “If what you say is true, then it seems like X would also be true. Do you think that’s correct?” This process often leads clients to realize that they do not have all of the information necessary to draw conclusions. It introduces data that does not fully support or is inconsistent with the original thought, and it may inform an alternative explanation for events (Beck et al., 1979). In addition to helping clients change their beliefs and assumptions, reality testing and Socratic questioning support clients’ ability to confront, rather than avoid, problem situations (Dobson & Dobson, 2009).
Clients who have cognitive distortions or negative, dysfunctional thoughts often falsely attribute the cause of certain events or situations. It is common for clients to relate events and situations to themselves and to blame themselves for perceived negative outcomes associated with events or situations. Three well-recognized dimensions of attributions are locus (internal v. external), stability (single occurrence/unstable v. permanent/stable), and specificity (specific to one situation v. global) (Dobson & Dobson, 2009). For example, someone with depression may have the tendency to make internal, stable, and global attributions for failure (e.g., I am a failure), but external, unstable, and specific attributions for success (e.g., I was lucky that time) (Alloy, Abramson, Whitehouse, Hogan, Panzarella, & Rose, 2006).
CBT seeks to assist clients in recognizing and addressing attributional biases. Once clients are able to recognize attributional biases, they can compare their thoughts to factual evidence. Reattributional pie charts may be used to address attribution biases. First, the clinician and client construct a pie chart reflecting the factors that the client believes contributed to an event or situation (usually a negative one). Next, other potential causes of the event or situation are identified. The clinician asks the client whether any other factors may help to explain the situation or if any additional information may be important to consider. Finally, the pie chart is modified to reflect this reattribution. The exercise can be completed without pie charts using a percentage metaphor to attribute causes or by simply naming various causes of an outcome without determining the proportions for each causal factor (Dobson & Dobson, 2009).
De-catastrophizing/Identifying unrealistic expectations.
Clients with cognitive distortions and negative or dysfunctional thoughts may predict negative futures and create self-fulfilling prophecies. This is particularly common among clients with anxiety. CBT utilizes an evaluation process to facilitate clients’ ability to identify self-fulfilling prophecies and examine evidence related to their predictions (Dobson & Dobson, 2009). Results of the evaluation are used to challenge negative or unrealistic expectations.
The evaluation process involves hypothesis testing implemented through homework. Clients are first asked to clearly identify their predictions. Then clients establish what evidence will be necessary to either confirm or reject their prediction and develop a procedure for collecting relevant evidence (Dobson & Dobson, 2009). Next clients collect evidence as part of homework. At the next session, clients’ predictions are compared to the evidence and evidence-based outcomes. This evaluation-based cognitive intervention strategy may help clients realize that engaging in situations, rather than avoiding them, results in more accurate information and, therefore, may encourage them to collect and evaluate evidence when making predictions in the future (Dobson & Dobson, 2009).
The downward arrow is a common CBT strategy used to address implications of specific negative thoughts to help identify strongly held beliefs or catastrophic fears (Beck et al., 1979; Beck, 1995; Burns, 1989). The downward arrow technique helps clients think of their thoughts as hypotheses that can be evaluated rather than facts (Dobson & Dobson, 2009). Clinicians ask a series of questions about the meaning that clients attach to their thought until the client has no additional responses: “So if that happened, what would it mean?”; “What’s the worst part about that?”; “What would that mean about you?” The Downward Arrow method can serve as an initial assessment tool to identify problematic beliefs, and later in treatment as a way to examine and change intermediate and/or core beliefs when they occur during sessions.
Generating alternative thoughts.
Once clients have identified and evaluated dysfunctional, negative, or distorted thoughts, CBT employs cognitive strategies to generate, evaluate, and ultimately routinize more adaptive, alternative thoughts (Dobson & Dobson, 2009). Alternative thoughts can be introduced by the client, the therapist, or collaboratively. Clients may be asked to generate alternative thoughts after evaluating and reviewing evidence related to their original problematic thoughts. If clients have difficulty coming up with alternatives, therapists can offer suggestions for the client to consider. During this process, therapists must respect clients’ original problematic thoughts and acknowledge that generating alternative thoughts can be difficult.
After an alternative thought has been identified, the advantages of both the original and the alternative thought are evaluated. The evaluation process often includes an assessment of the negative thought and the alternative response (e.g., how useful, how helpful they are to clients), as well as cost-benefit analyses of the original thought and the alternative. Clinicians may also ask clients to consider how they would advise a friend with this type of thinking. Once acceptable alternative thoughts have been identified and evaluated, several strategies can be utilized to help clients respond to their original problematic thoughts with the more adaptive, alternative thoughts.
A point-counterpoint approach is used to help clients respond to negative thoughts. This technique utilizes cue cards with the original thought on one side and the alternative thought on the other side. Therapists then state or read the original thought while clients practice saying the alternative.
Rational role play.
Rational role play can be used to reinforce clients’ use of alternative thoughts and to increase clients’ confidence and ease in responding to negative, dysfunctional, or distorted thinking. This strategy calls for therapists and clients to engage in a role play between negative and more adaptive thinking, with the therapist articulating the problematic thoughts and the client verbalizing the alternative responses.
Task-interfering cognitions—task-orienting cognitions (TIC-TOC).
Another strategy used in CBT to encourage clients’ use of alternative thoughts is the task-interfering cognitions—task-orienting cognitions, or TIC-TOC intervention. The TIC-TOC approach, which refers to the sound of a clock’s pendulum, focuses on going back and forth between task-interfering cognitions (e.g., “I will never get this done”) and task-orienting cognitions (e.g., “If I just get started, it will likely get easier”). TIC-TOC helps clients develop an automatic, alternative response to negative thoughts. The TIC-TOC strategy is most appropriate for clients who experience repetitive thoughts that interfere with specific tasks (Dobson & Dobson, 2009).
Homework is an essential part of CBT. Goals for homework include learning and generalizing change beyond therapy sessions (Beck & Tompkins, 2007; Lambert, Harmon, & Slade, 2007). Homework assignments may consist of reading educational materials, completing activity schedules and dysfunctional thought records, conducting behavioral experiments, practicing communication skills, or evaluating problematic thoughts (Dobson & Dobson, 2009). Homework assignments are collaboratively developed by therapists and clients, increasing the likelihood of compliance and success. The meta-analytic review of Kazantzis, Whittington, and Dattilio (2010) suggests that extra-therapy assignments enhance treatment outcomes, although homework compliance has not been positively associated with outcome in all studies (Kazantzis & Dattilio, 2007).
Various models of CBT have been applied to a wide range of mental health problems, substance abuse disorders, and other problems. The most common, empirically supported applications of CBT are identified and described below.
Adult Disorders: Depression
CBT treatments for depression have typically employed behavioral activation to increase natural reinforcers in the environment and cognitive restructuring to reduce negative automatic thoughts and increase positive ones, which in turn improve mood and behavior. Meta-analytic studies on treatment outcomes of such CBT methods for depression concluded that most studies show CBT to be superior to waitlist control and placebo treatments (e.g., Beltman, Oude Voshaar, & Speckens, 2010; Butler, Chapman, Forman, and Beck, 2006). When compared to pharmacological approaches, CBT and pharmacotherapy independently produced similar benefits for depression symptoms within the moderate to large range (Vos et al., 2004). Research also demonstrates that medications combined with CBT are associated with better outcomes than CBT as a standalone treatment (Chan, 2006), however, Butler, Chapman, Forman, and Beck (2006) concluded that CBT was moderately superior to medication treatment. Additionally, Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) suggest that CBT is as effective as other psychological treatments, such as psychodynamic psychotherapy, problem-solving therapy, and interpersonal psychotherapy, although CBT did not appear to improve upon behavioral treatments that lacked cognitive components. Similarly, findings for adolescents showed much larger effects for CBT than waitlist and other forms of treatment, including relaxation and supportive therapy. Hundt, Mignogna, Underhill, and Cully (2013) examined skill use as a component of CBT and found evidence that CBT skill practice has a mediating effect on depression.
CBT for bipolar disorder commonly includes psychoeducation of patients and families, monitoring manic and depressive symptoms, encouraging medication adherence, stress management strategies (e.g., control of the circadian rhythm, daily thought records, social skills training, problem solving), and reduction of stigma. CBT methods produced only moderate benefits for manic and depressive symptoms in meta-analyses of pre-post outcomes, and these effects tended to diminish during the follow-up period (Hofmann et al., 2012). While evidence that CBT works well as a stand-alone treatment unaccompanied by medications is limited (as psychopharmacotherapy is the most common form of treatment), CBT did appear to help delay or prevent relapse when compared to medications (Beynon, Soares-Weiser, Woolacott, Duffy, & Geddes, 2008). The analysis of da Costa et al. (2010) found that the majority of studies indicated better outcomes when CBT was combined with medication compared with medication alone. However, they caution that more studies are needed.
Adult Disorders: Anxiety Disorders
CBT methods have been especially well studied for anxiety disorders. Reviews on meta-analytic studies of psychotherapies for a range of anxiety disorders conclude that behavioral and cognitive treatments are efficacious whether delivered separately or combined (Deacon & Abramowitz, 2004; Hofmann et al., 2012). Hofmann and Smits (2008) conducted a meta-analysis of CBT versus placebo-controlled studies and found that CBT was effective for adult anxiety disorders, with the strongest effect among those with OCD and acute stress disorder. Norton and Price (2007) found similar results in another meta-analysis of CBT across the anxiety disorders.
Panic and agoraphobia.
Effective treatments for panic, with or without agoraphobia, have included the following elements: education about the nature and physiology of anxiety and panic, correction of misinterpretations of body sensations (for example, bodily signals of catastrophic outcomes like heart attack or suffocation), exposure to feared body sensations that trigger these misinterpretations, as well as coping skills to manage discomfort. These CBT methods show substantial advantages over waitlist and pill-form or psychological placebo conditions (Deacon & Abramowitz; 2004; Hofmann et al., 2012). In some studies, combined CBT showed advantages over behavioral methods alone (Gould, Otto, & Pollack, 1995), although Deacon and Abramowitz (2004) noted that cognitive and behavioral methods could not always be differentiated from each other.
CBT for social anxiety typically includes exposure, cognitive restructuring, and social skills training that are delivered in either group or individual formats, or both. Meta-analytic findings indicated that CBT produced better outcomes than waitlist or placebo/attention control comparisons with evidence from follow-up measures demonstrating that medium-to-large effects were maintained or increased (Gould, Buckminster, Pollack, Otto, & Yap, 1997; Hofmann et al., 2012). Behavioral treatments using exposure were quite effective, and the addition of cognitive restructuring produced slightly higher effect sizes, but not significantly so; CT alone was less beneficial (Taylor, 1996). In reviewing the meta-analyses for CBT for social phobia, Deacon and Abramowitz (2004) concluded that behavioral elements were essential to effective treatment. In general, CBT methods showed more benefits over time than medication treatments (Hofmann et al., 2012).
Similarly, early studies on OCD showed clear efficacy of behavioral treatments that included exposure to feared cues plus response prevention of rituals and avoidance behaviors, commonly abbreviated as ERP (e.g., Abramowitz, 1997; van Balkom et al., 1994). More recently, cognitive therapy models have applied cognitive restructuring to misinterpretations of intrusive thoughts, images, or impulses. A meta-analysis by Abramowitz, Foa, and Franklin (2002) indicated a stronger overall effect size from ERP versus CT, though the difference between these two methods was not significant. Practitioners often combine both methods for clients with OCD, especially in the form of behavior experiments that contain elements of both cognitive therapy and behavior therapy. Deacon and Abramowitz (2004) concluded that for both OCD and social phobia, behavioral methods without cognitive elements appeared to be the critical factor in therapy outcomes.
Generalized anxiety disorder.
Specific external triggers for GAD are more difficult to identify, and so it is challenging to apply standard exposure therapy used for other anxiety disorders. Thus, a wider variety of CBT methods have been studied. These include progressive muscle relaxation, self-monitoring and early cue detection, applied relaxation, self-control desensitization, and cognitive restructuring (Borkovec & Costello, 1993). Overall, meta-analyses strongly support the effectiveness of combined cognitive-behavioral interventions for GAD (Deacon & Abramowitz, 2004; Gould, Otto, Pollack, & Yap, 1997). A meta-analysis by Covin, Ouimet, Seeds, and Dozois (2008) found that combined cognitive and behavioral interventions were effective in treating pathological worry, a core component of GAD. Too few studies provide an adequate test of the benefits of strictly cognitive or strictly behavioral methods to indicate clearly that these are as effective as combined treatments.
Post-traumatic stress disorder.
Post-traumatic stress disorder (PTSD) is usually treated with a combination of behavioral and cognitive methods, including exposure to fear evoking memories and situational cues, cognitive restructuring, and anxiety-management skills. Other interventions include education, relaxation, and cognitive interventions to help manage anxiety symptoms and modify maladaptive beliefs. Eye-movement desensitization and reprocessing (EMDR; Shapiro, 1991) includes imagined exposure to traumatic memories plus coping statements during trauma recall, accompanied by therapist-guided saccadic eye movements. The review of Butler et al., (2006) indicated strong benefits of CBT over waitlist, EMDR, as well as stress management and other therapies. Other studies suggest that CBT methods produce similar effects to EMDR (Bisson et al., 2007), but agree that the actual benefit of the eye movement element is highly questionable. Deacon and Abramowitz (2004) concluded that the effectiveness of behavioral versus cognitive strategies could not be determined from meta-analyses, as most interventions for PTSD involved combinations of these two methods.
A number of meta-analyses have examined the efficacy of CBT for psychosis, also known as CBTp. CBTp includes cognitive and behavioral methods such as skills training, problem solving, Socratic questioning, exposure, and coping strategy enhancements (Lincoln et al., 2012). The largest of these meta-analyses reviewed 34 studies (Wykes, Steel, Everitt, & Tarrier, 2008). CBT showed a larger effect size for pre-post-treatment than treatment as usual (i.e., pharmacotherapy using anti-psychotic drugs) (Butler et al., 2006; Hofmann, Asmundson, & Beck, 2013; Hofmann et al., 2012). Beneficial effects were found for both positive and negative symptoms of schizophrenia, although the effects were larger overall for positive symptoms (Kingdon & Dimech, 2008). Wykes et al. (2008) meta-analytic review also showed improvement in functioning, mood, and social anxiety for CBTp interventions compared to medications. A recent community-based clinical study by Lincoln et al. (2012) found that CBTp for positive symptoms was effective for a variety of clients, treatment settings, and providers. Gould, Mueser, Bolton, Mays, & Goff (2001) reviewed studies in which cognitive therapy for psychotic symptoms in schizophrenia targeted recognition of, and distorted thinking about, positive symptoms of hallucinations and delusions. Five of seven studies showed a significant decrease in these symptoms and two showed non-significant decreases. Butler et al. (2006) noted that other methods of treatment, such as befriending clients and supportive therapy, had an intermediate degree of effect, falling between CBT and routine care. Interestingly, Hofmann et al. (2012) reported that early intervention services and family treatment had a greater impact in reducing hospital admission and relapse than did CBT.
CBT for substance abuse integrates principles of harm reduction, motivation, and relapse prevention by applying a combination of skills training and operant conditioning, to manage cues and control urges, with cognitive therapy and motivational interviewing. CBT has been shown to be an effective intervention for alcohol and other drug use disorders (Dutra et al., 2008; Magill & Ray, 2009). A CBT study of substance abuse found that the quality of skills was more important than quantity, and that having even a few coping skills can often produce positive outcomes (Kiluk, Nich, Babuscio, & Carroll, 2010). Hofmann et al. (2012) summarized evidence that multiple sessions of CBT worked only moderately well for cannabis dependence and noted that other psychosocial interventions that are also associated with behavioral (i.e., contingency management) and cognitive strategies (i.e., relapse prevention, motivational interviewing) as well as medication treatments showed more benefit for dependence on opioids and alcohol (see Powers, Vedel, & Emmelkamp, 2008).
CBT methods for treating eating disorders typically include developing a shared formulation of the problem, self-monitoring, weekly weighing, establishing regular eating patterns, involving others, and cognitive therapy to resolve the overvaluing of shape and weight and to reduce perfectionism and rigid dietary rules. Summaries of meta-analytic studies indicated that CBT showed strong effects for bulimia nervosa in pre-post trials (Butler et al., 2006) and medium effects compared to control therapies, such as interpersonal psychotherapy, dialectical behavioral therapy, hypno-behavioral therapy, supportive psychotherapy, weight loss strategies, and self-monitoring (Hay, Bacaltchuk, Stefano, & Kashyap, 2009; Hofmann et al., 2012). Behavioral treatments appeared to show more benefit than combined cognitive and behavioral methods (Thompson-Brenner, 2003). Binge eating disorder responded well to psychotherapy that typically included CBT methods as well as structured self-help with larger effect sizes than medications (Vocks et al., 2010). Combining these treatments did not improve binge eating specifically but appeared to increase weight loss somewhat (Reas & Grilo, 2008).
Cognitive behavioral interventions for chronic pain and/or fibromyalgia typically involve a number of CBT-based interventions including but not limited to: progressive muscle or imagery-based relaxation, sleep hygiene techniques (e.g., consistent times in/out of bed; evening wind-down activities); cognitive interventions aimed at negative automatic thoughts related to sleep (e.g., “I will be a mess tomorrow if I don’t get to sleep”); pleasant activity scheduling; and activity pacing (e.g., limiting activities on days when feeling well and continuing some level of activity on higher pain days) (Williams, 2003). A recent meta-analysis of psychological treatment studies for fibromyalgia found modest effect sizes on short-term pain for a range of psychological interventions but found that CBT-based interventions were associated with the largest treatment effect sizes compared to other psychological approaches (Glombiewski et al., 2010).
Intimate Partner Violence (IPV) Perpetrators and Survivors.
Cognitive behavioral interventions for IPV perpetrators typically include cognitive approaches aimed at modifying attitudes and beliefs related to women, problem solving strategies, social skills training (e.g., assertiveness training) and anger management (e.g., timeout from anger-inducing situations, relaxation) approaches (Eckhardt et al., 2013). A single meta-analytic review involving psychosocial treatment for batterers found relatively small effects on a range of outcomes, including continued perpetration (Babcock, Green, & Robie, 2004). CBT-based approaches for batterers are typically delivered in small groups.
Studies of CBT-based approaches for IPV survivors are more limited in number but generally find positive impact on a range of targets including PTSD-related and depressive symptoms. In the largest of these studies, Kubany and colleagues (Kubany et al., 2004) compared immediate versus delayed cognitive trauma therapy for battered women (an approach that includes but is not limited to PTSD-related psychoeducation, prolonged exposure to abuse-related stimuli, cognitive approaches, assertiveness training and perpetrator identification training, and trauma history exploration) and found robust positive effects on PTSD symptoms, depression, guilt, and self-esteem in the immediate versus the delayed treatment group.
Smoking Cessation and Weight Loss.
CBT for smoking cessation often combines principles of motivational interviewing to address early stage ambivalence/barriers related to quitting with a range of CBT-informed interventions (Perkins, Conklin, & Levine, 2008). Core CBT strategies typically include analysis of smoking triggers, stimulus control-related strategies for avoiding smoking triggers, responding to smoking-related cognitions, and learning coping strategies for craving (e.g., observe craving changes, relaxation). A meta-analysis of the best-designed randomized controlled intervention trials for smoking cessation indicated that intensive behavioral interventions are associated with substantial increases in smoking abstinence compared to control (Mottillo et al., 2009). Finally, augmenting behavioral interventions with pharmacological interventions is likely more effective than behavioral interventions alone and sustained abstinence from smoking remains challenging even with best-practice treatment (Hall et al., 2002).
CBT-based strategies also dominate the literature on the psychosocial treatment of obesity. CBT techniques for weight control are in many ways similar to those used for smoking cessation and other addictive behaviors and include increasing motivation to control eating, increasing awareness of over-eating triggers, increasing active behaviors and exercise, identifying and challenging maladaptive cognitions related to eating, and self-monitoring (Cooper, Fairburn, & Hawker, 2003). A recent meta-analysis of randomized, controlled trials of psychosocial interventions (all but one involving either BT or CBT) found large and significant effect sizes for eating behavior and modest weight reductions post-treatment (Moldovan & David, 2011). Follow-up effect sizes are reduced for both eating and weight loss but remain significant.
Cognitive behavioral couples therapy (CBCT) employs guided behavior change, social skills training emphasizing constructive communication, and cognitive restructuring interventions (e.g., guided discovery; reattribution, downward arrow) to address dysfunctional or distorted thoughts (Baucom, Epstein, Kirby, & LaTaillade, 2010). Socratic questioning should be used cautiously in CBCT, as the therapists’ questioning of one partner’s thoughts in the presence of the other partner may further contribute to negative outcomes (Baucom et al., 2010). Recent enhancements to CBCT, influenced by systems and ecological models of relationship functioning (e.g., Brofenbrenner, 1989) and a strengths-based perspective, place increased attention to macro-level interaction patterns as well as to personality, motives, and more stable individual characteristics (Epstein & Baucom, 2002). The meta-analytic review of Butler et al. (2006) found that cognitive behavioral marital therapy had a moderate effect on marital distress; however, their review included only one meta-analysis (Dunn & Schwebel, 1995) on cognitive behavioral therapy for couples.
Child Behavioral Management
The meta-analytic review of Hofmann et al. (2012) concluded that CBT was associated with large effects in treating internalizing symptoms in children and adolescents with anxiety disorders. This was especially true for children with OCD, as CBT improved these symptoms more than other forms of psychotherapy and serotonergic medications. Improvements in depressive symptoms were evident but not as strong, with medium effects. In the case of depression, CBT was as effective as interpersonal and family systems therapies but more effective than selective serotonin and other reuptake medications.
With regard to externalizing behaviors (e.g., disruptive classroom behaviors, aggressive/antisocial behaviors), CBT was as effective as other forms of psychosocial treatments and showed more benefit compared to treatment as usual, but not compared to pharmacotherapy. Very similar findings were also evident in meta-analyses of CBT for attention deficit hyperactivity disorder. Behavioral techniques such as motivational enhancement and application of contingencies showed modest benefits for adolescent smoking and substance use behaviors compared to no treatment, but not compared to other forms of psychotherapy.
Given its scientific approach to treatment, it is not surprising that CBT is one of the most thoroughly researched forms of psychotherapy. The results of 120 clinical trials examining the effect of CBT were published between 1986 and 1993 (Hollon & Beck, 1994), by 2004 Butler et al. (2006) identified more than 325 published outcome studies on CBT’s efficacy (Butler et al., 2006), and Hofmann et al. (2012) found 269 meta-analytic studies of CBT published since 2000.
The extensive research suggests a strong empirical basis for CBT across a wide range of disorders (Butler et al., 2006; Hofmann et al., 2012). A review of 16 meta-analyses by Butler et al. (2006) found CBT effective for treating adult unipolar depression, generalized anxiety disorder, panic disorder with and without agoraphobia, social phobia, obsessive-compulsive disorder, PTSD, schizophrenia, marital distress, anger, bulimia nervosa, sexual offending, and chronic pain as well as adolescent unipolar depression, childhood depressive and anxiety disorders, and childhood somatic disorders. The meta-analytic review of Hofmann et al. (2012) suggests CBT has the strongest support for treating anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Results suggest that treatment gains are generally maintained over follow-up intervals ranging from 6 to 24 months (Butler et al., 2006; Norton & Price, 2007). It should be noted that comparisons were usually with control conditions receiving no treatment or nondirective supportive counseling as a placebo. Limited research has compared CBT to other active psychotherapies (Butler et al., 2006; Hofmann et al., 2012).
Evidence also suggests the versatility of CBT. CBT is effective when delivered in both individual and group formats (e.g., Butler et al., 2006; Hofmann et al., 2012) and findings indicate that frequency and duration of sessions are not related to outcomes (Norton & Price, 2007). Research demonstrates that CBT is effective among diverse populations, including participants of different racial and ethnic backgrounds, ages, and socioeconomic status (e.g., Ayers, Sorrell, Thorp, & Wetherell, 2007; Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrinton, 2004; Compton et al., 2004; Hays, 2009; Horrell, 2008; Schraufnagel, Wagner, Miranda, & Roy-Bryne, 2006; Scogin, Welsh, Hanson, Stump, & Coates, 2005; Wilson & Cottone, 2013). Additionally, literature suggests that CBT is effective when implemented in non-mental health settings, such as primary care offices, schools, and vocational rehabilitation centers (e.g., Brown & Schulberg, 1995; Hoagwood & Erwin, 1997; Rose & Perz, 2005; Roy-Byrne et al., 2005). Further, evidence is growing indicating that CBT can be effectively delivered with technology, with computerized CBT (cCBT) and CBT delivered via videoconferencing garnering empirical support (e.g., Andrews et al., 2010; Antonacci, Bloch, Saeed, Yildirim, & Talley, 2008; Kaltenthaler et al., 2006; Simpson, 2009).
CBT and Social Work
Enhancing human well-being and helping to meet basic human needs of all people, with particular attention to vulnerable populations, is the primary mission of the social work profession (NASW, 1996). Additionally, the NASW Code of Ethics (1996) states that social workers should advance the professional mission by working toward the maintenance and promotion of high standards of practice. Therefore, it is not surprising that social work has long emphasized the need for a scientific foundation to inform and guide practice (Cheney, 1926; Reynolds, 1942). The movement toward evidence-based practice (EBP), or “the integration of best research evidence with clinical expertise and client values” has further influenced the social work profession (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000, p.1).
Eileen Gambrill, one of the earliest most influential scholars to introduce and advocate the use of EBP within the social work profession (Thyer, 2002), was also instrumental in studying and encouraging the implementation of behavioral approaches in social work (e.g., Gambrill, 1977; Gambrill, Thomas, & Carter, 1971). In the late 1960s and early 1970s, scholars at the University of Michigan School of Social Work, including Edwin Thomas, Richard Stuart, and Gambrill, began applying behavioral approaches to social work practice (Gambrill, 1995). Gambrill (1995) notes the expansion of behavioral methods, including CBT, within social work, and she attributes this to their compatibility with professional interests as well as their commitment to a scientific approach, including the use of empirical research, to guide practice.
CBT has arguably the best evidence for effectiveness of mental and behavioral health problems among all psychotherapies (Hollon & Beck, 1994; Dobson, 2010; Butler et al., 2006; Hofmann et al., 2012), and has become one of the most frequently used psychosocial interventions. Given the increasing emphasis on EBP, CBT has had a distinct impact on social work practice. Social workers make up the largest group of behavioral health providers in the United States (NASW, 2005) and deliver more than 60% of mental health treatment (NASW, 2006). An increasing number of social workers report using CBT as their preferred model of practice (Granvold, 2011; Thyer & Myers, 2011). Between 1987 and 2007, the percentage of social workers practicing from a CBT-perspective more than tripled (Bike, Norcross, & Schatz, 2009; Norcross, Garofalo, & Koocher, 2006). Evidence suggests that between 30% and 43% of social workers practicing in the United States report using CBT (Pignotti & Thyer, 2009; Prochaska & Norcross, 2010). The need for clinical social workers in the fields of mental health and substance abuse is expected to rise by 20% between 2008 and 2018 (Bureau of Labor Statistics, 2010), and expert forecasts indicate that CBT will be increasingly in demand and used among social workers (Prochaska & Norcross, 2010). However, an acute shortage of qualified CBT therapists exists in many countries relative to demand and the treatment’s potential value to society (Chambless & Ollendick, 2001).
Though social workers indicate CBT is a preferred method of practice, a large gap remains between the availability of EBPs and their use in clinical practice (Weissman & Sanderson, 2002; New Freedom Commission, 2003). One proposed reason for this persistent gap is mental health professionals’ lack of training in EBPs, such as CBT. While the combination of didactic content and supervised clinical work is considered the gold standard for learning a new treatment, a survey of randomly selected CSWE-accredited MSW programs suggests that 62% did not require both didactic training and clinical supervision for any EBP (Weissman et al., 2006). Didactic content related to CBT was offered and required at substantially higher rates than other evidence-based psychotherapies (e.g., interpersonal psychotherapy, multisystemic therapy), with 93% of MSW programs offering didactic training in CBT and 80% requiring didactic training in CBT. Though 66% of MSW programs reported offering clinical supervision for CBT, only 21% of programs required it (Weissman et al., 2006). Restructuring the organizational framework of social work curriculum to provide students with intensive training seminars and practicum devoted to EBPs and the systematic monitoring of clinical outcomes may help to address this gap within social work education (Thyer & Myers, 2011).
The widespread use of CBT among social workers and its inclusion in social work curriculum has led to attention to the fit between CBT as a therapeutic approach and social work’s professional mission and values. The critical analysis of CBT and social work values undertaken by Gonzalez-Prendes and Brisebois (2012) suggests that CBT promotes equality within the therapeutic relationship, aims to understand the context that has shaped a person’s reality, and promotes a healthy level of social interest (e.g., protecting the rights of others and addressing unfair or unjust treatment that diminishes the quality of a person’s social environment). Therefore, the analysis concludes that CBT, grounded in a non-judgmental, strength-based, empowering philosophy and focused on promoting unconditional acceptance and respect of self and others, aligns with the social work profession’s mission of social justice (Gonzalez-Prendes & Brisebois, 2012).
CBT refers to a family of short-term, problem-focused interventions rooted in behavioral and cognitive traditions that acknowledge the primary role thoughts have in shaping behaviors and emotions. CBT employs behavioral and cognitive intervention strategies aimed at identifying and challenging maladaptive or dysfunctional thoughts, behaviors, and emotions with more adaptive alternatives. Evidence supporting the effectiveness of CBT has grown substantially since the 1980s and, as such, the treatment has been increasingly used by mental health professionals, including social workers. Social workers provide a large proportion of mental health services and most commonly endorse CBT as their preferred model of practice. However, a documented shortage of providers qualified to deliver CBT has been registered, and social workers could be better prepared to provide CBT if more schools of social work offered both didactic and supervised clinical training. CBT aligns with social work’s guiding values and mission, and it has been found to effectively treat mental disorders across diverse populations and settings, further supporting its relevance to the social work profession.
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