1. No category

289
What is cognitive behavioural
therapy and does it work?
Commentary
Steven d Hollon
Addresses
Department
37240,
of Psychology,
USA;
Current
Vanderbilt
University,
Nashville,
Tennessee
e-mail: [email protected]
Opinion
in Neurobiology
1998,
8:289-292
http:/lbiomednet.com/elecref/O959438800800289
0 Current
Biology
Ltd ISSN
and observing
the consequences,
neither
die nor go crazy. In both
Cognitive
behavioural
therapy is an approach to treatment
based on the notion that the way an individual
thinks
about an event determines
in part how he or she responds
to that event,
both in terms
of affect and behaviour
[l]. According
to cognitive
theory, dysfunctional
beliefs
and maladaptive
information
processing
lie at the core
of many psychiatric
disorders.
In cognitive
behavioural
therapy,
the therapist
helps the patient
learn to identify
and correct erroneous
beliefs and systematic
distortions
in
information
processing
in the service of reducing
distress
and enhancing
efforts to cope.
Although
there
are several
different
variations
of the
approach,
they all share the same basic characteristic
[Z].
In essence, patients are encouraged
to treat their beliefs as
hypotheses
to be tested and are guided to do so in ways
that protect against the biases and distortions
that preserve
the idiosyncratic
misconceptions
inherent
in each disorder.
The approach
is closely
tied to experimental
cognitive
science, which suggests that information
processes
tend to
be dominated
by strategies
and heuristics
that are unduly
conservative
in nature and structured
to maintain existing
beliefs, even in the absence
of motivation
[3]. What this
means
is that patients
often
suffer
as a consequence
of their misperceptions
without
having any underlying
motivation
for doing so or for maintaining
those beliefs,
than
that they
dire possibility
leads to a state of panic, which patients
then take as confirmation
of their initial belief.
Rather
than avoiding
situations
in which
this process
patients
are encouraged
to test these catastrophic
by engaging
in activities
that exacerbate
their
0959-4388
Introduction
other
Similarly, patients with panic disorder tend to misinterpret
normal arousal as an indication
that they are about to
have a heart attack
or go crazy. Entertaining
such a
fear they
might
be true.
overwhelmed
by their
magnitude)
and to test their
negative
beliefs by engaging
in the requisite
behaviours,
carefully
monitoring
the outcome
of each step and its
impact on their mood.
which
is that they
instances,
the role of
the therapist
is to encourage
patients
to identify
and
test their own beliefs,
subjecting
them to a process of
empirical
scrutiny, much the same way that scientists
test
hypotheses.
Just as science
has had to rely on empirical
observation
and controlled
experimentation
to overcome
existing
prejudices
and preconceived
notions,
so too can
patients
make observations
in a structured
fashion
and
engage in behaviours
that are inconsistent
with existing
notions
to overcome
the conservatism
inherent
in any
existing
belief
In general,
system.
cognitive
behavioural
therapy
has
typically
been found to be at least as effective
as more traditional
psychotherapies
or drugs for most nonpsychotic
disorders
and quite
often
longer
lasting.
For many
of these
disorders,
it has emerged
as the treatment
of choice,
and there are clear indications
that its effects
transcend
the nonspecific
benefits
provided
by more traditional
interventions.
Medications
remain the treatment
of choice
for psychotic
disorders,
but there are growing indications
that cognitive
behavioural
interventions
may have an
important
role to play.
Specific disorders
Unipolar depression
Few disorders have
searchers
For example,
depressed
patients
tend to magnify
the
magnitude
of the difficulties
they face and typically
believe
that
they
are not competent
to accomplish
cherished
goals or enjoy the fruits of their labours if they
do. As a consequence,
they fail to initiate
goal-directed
behaviours
(not because
they do not want to succeed
but
because
they believe
they will not) and then interpret
their subsequent
lack of success as evidence
of their own
incompetence.
In essence,
they fall prey to self-fulfilling
prophecies.
Such patients
are encouraged
to break larger
tasks into their specific
components
(to forestall
being
occurs,
beliefs
arousal
interested
received
in cognitive
more attention
from rebehavioural
therapy than
depression,
with Beck’s cognitive
therapy [l] the modality
most often studied.
Beck has long argued that depression
can be viewed as a consequence
of negative
beliefs about
the self, the personal world, and the future (the negative
cognitive
triad). The sadness
and behavioural
passivity
that are the hallmarks
of the disorder
are seen as the
direct consequences
of the expectation
that one will not
get what one wants out of life, which itself is seen as
the logical consequence
of the tendency
to see oneself as
unlovable
or incompetent.
Thinking
is viewed
as being
schematic
in nature;
that is, beliefs
are organized
into
meaning systems that govern information
processing
under
conditions
of uncertainty.
These meaning systems range in
depth from specific beliefs in specific situations
(automatic
thoughts)
through
more general
probabilistic
statements
290
Commentary
of relationship
(dysfunctional
attitudes
and conditional
assumptions)
to rigid and absolutistic
trait theories
about
the self and others (core beliefs). These schemas operate
as latent diatheses
that are only activated under conditions
of stress in more episodic disorders,
but can also represent
hypervalent
constructs
that are always in operation
in more
chronic disorders.
Cognitive
therapy has been found to be at least as effective
as drugs in the treatment
of unipolar
depression
and is
possibly longer lasting [4]. Beginning
with the classic study
of Rush etal: [S], cognitive
therapy has either matched
or
bettered
drugs with respect to the relief of acute distress
in a series of direct comparisons
in a number
of different
studies [68]. Moreover,
in most of these studies, patients
treated
to remission
with cognitive
therapy
were about
half as likely to relapse following
treatment
termination
as patients
treated to remission
pharmacologically
[9-121.
However,
few of these studies
were placebo-controlled
and the adequacy
of the medication
treatment
provided
has been called into question.
The recent National
Institute of Mental Health (NIMH)
Treatment
of Depression
Collaborative
Research
Program
(TDCRP)
did provide
such a pill-placebo
control
and
cognitive
therapy was less effective
found
than
evidence
that
drugs for more
severely
depressed
outpatients
[13,14]. Nonetheless,
this
finding was not robust across the multiple
sites in the
TDCRP
[l&16]. Several studies are currently
under way
to compare the efficacy of drugs and cognitive
therapy in
more severely depressed
groups of patients.
Panic disorder
Recent
studies
also suggest
that cognitive
behavioural
therapy may be particularly
effective
and have an enduring
effect in the treatment
of panic disorder. As previously
described, cognitive theory suggests that it is the catastrophic
misinterpretation
of relatively
benign
bodily sensations
that triggers
the firing of the locus coeruleus
in the
brain stem and gives rise to the experience
of panic
[17,18]. That is, panic attacks occur when the individual
misconstrues
some transient
physiological
sensation
as a
sign of an impending
heart attack (or stroke) or psychotic
decompensation.
Clark and colleagues
(see [l&19]) at Oxford have done
some of the seminal
work in this area. In a carefully
controlled
trial, cognitive
therapy was found to be superior
to either
applied
relaxation
or drugs in the treatment
of panic disorder,
which
were, in turn, superior
to a
minimum-treatment
control [19]. Moreover,
as has been
the case for depression,
patients
treated
with cognitive
therapy were far less likely to relapse following treatment
termination
than those patients
treated with drugs alone.
Similarly, Beck et al. [ZO] found cognitive
therapy superior
to a nonspecific
control, and Barlow and colleagues
[Zl-231
have impressive
results with a closely related
cognitive
behavioural
intervention
called panic control therapy.
Generalized anxiety disorder
Generalized
anxiety
disorder
is yet another
disorder
in
which cognitive
therapy
appears to be particularly
effective. In generalized
anxiety disorder,
patients
experience
high levels of persistent
and pervasive
distress
across a
variety of situations.
This disorder
has always presented
something
of a problem
to more conventional
behavioural
therapy
(based
on exposure
or counter
conditioning)
because
there is often no clear external
precipitant
to
which anxiety can be extinguished.
Butler et al. [24] at
Oxford found an approach modelled
after Beck’s cognitive
therapy
both superior
to and more enduring
than either
behaviour
therapy or a wait-list
control. Similarly, Power
et a/. [25,26]
intervention
have
both
found a related cognitive
superior
to and longer
behavioural
lasting
than
minor tranquilizers.
These
studies suggest that cognitive
behavioural
therapy
is both more effective
and longer
lasting
than either
behaviour
therapy
or drugs in the
treatment
of generalized
anxiety disorder.
Social phobia
The picture is not so clear with respect to social phobia,
but still quite promising.
Social phobia involves persistent
fears of being embarrassed
in front of others and leads
patients
to avoid
normal
social
interactions
such as
speaking
or eating in public. Some of the best work in
this regard has been done by Heimberg
and colleagues
(see [27-29]), who have adapted
a cognitive
behavioural
intervention
to deal with unrealistic
concerns
about being
negatively
evaluated
by others in a group context
[27].
In a series
of studies,
cognitive
behavioural
therapy
was found to be more effective
than supportive
therapy
[Z&29] and as effective
as, and quite possibly
longer
lasting than, phenelzine
in the treatment
of social phobia
(RG Heimberg,
personal communication).
Recently, Clark
(DM Clark, personal communication)
and colleagues
have
begun to turn their attention
to adapting
Beck’s cognitive
therapy to the treatment
of social phobia. Just how fruitful
these efforts will prove remains
to be seen,
success with panic disorder is any indication,
prove quite interesting.
but if their
they should
Bulimia nervosa and the eating disorders
Bulimia nervosa is yet another area in which cognitive
behavioural therapy has emerged
as the treatment
of choice
[30]. In this disorder,
patients
engage
in periodic
binge
eating, often followed
by purge by vomiting
or laxative
abuse.
There
is a growing
consensus
that overvalued
beliefs about weight and shape lead to restrictive
dieting,
which, in turn, leads to loss-of-control
binge eating when
those overly strict rules are violated.
Fairburn etal. [31,32]
at Oxford found cognitive
behavioural
therapy somewhat
more effective
and at least as long-lasting
as interpersonal
psychotherapy
and no less effective
and longer lasting than
behaviour
therapy in the treatment
of bulimia. Similarly,
Agras and colleagues
[30,33] at Stanford
have found
cognitive
behavioural
therapy
at least as effective
and
longer lasting than drugs in a series of studies.
These
findings suggest that no other intervention
is as effective as
What is cognitive behavioural therapy and does it work? Hollon
cognitive
behavioural
and freedom
Personality
Patients
therapy
from relapse
and impulse
with
borderline
when
are taken
control
both
initial
response
disorders
personality
disorder
are
noto-
riously
difficult
to treat.
They
frequently
engage
in
parasuicidal
behaviours
and self-mutilation
and tend to
have stormy
relationships
with others,
including
their
therapists.
Linehan
[34] has developed
an approach
to treatment
called dialectic
behaviour
therapy
that is
based on the premise
that an inability
to tolerate
strong
states
of negative
affect is central
to the disorder.
In
dialectic
behaviour
therapy,
the patient
is taught to use
behavioural
and cognitive
skills to deal with this distress
without
engaging
in self-destructive
behaviours.
In the
only controlled
trial to date in this population,
Linehan
et
(I/. [35] found that patients treated with dialectic behaviour
therapy
engaged
in fewer
suicidal
or self-destructive
behaviours
and required
fewer days of hospitalization
than patients
who received
treatment-as-usual
in the
community.
Given how difficult these patients are to treat,
this study has generated
tremendous
interest in the larger
treatment
community,
even prior to replication.
Virtually
nothing
is known about the ocher personality
disorders.
However,
Beck and Freeman
[36] have recently extended
cognitive
therapy for just this purpose,
noting that those
pervasive
pathological
behaviours
that typically
define
the respective
disorders
can be viewed as compensatory
strategies
designed
to protect
the individual
from the
interpersonal
consequences
of his or her erroneous
beliefs.
While it is still too early to know whether
these theoretical
extensions
will be of use clinically, they do appear to make
better sense out of a particularly
vexing and refractory set
of disorders.
Similar work under way with other impulse
control disorders,
such as substance
abuse, also appears
promising.
Schizophrenia
and the psychotic
Conclusions
There is considerable
therapy
is effective
disorders.
The body
into account.
disorders
lore holds
that the delusions
found
among
schizophrenic
and other
psychotic
patients
are largely
impervious
to empirical
disconfirmation.
However,
recent
studies have suggested
that cognitive
interventions
aimed
at reducing
the conviction
with which these beliefs are
respect
viewed
effect
patient
[37,38].
directly
Care
with
the treatment
of choice for a number
of nonpsychotic
disorders,
often proving
more effective
than alternative
interventions
and typically longer lasting. That a relatively
brief intervention
can produce
lasting
change
in such
long-standing
and severe
emotional
disorders
is truly
remarkable
and suggest-s
that it may directly
address
underlying
etiological
processes.
Indications
are not so
clear with the personality
disorders
and problems
with
impulse
control
such as substance
abuse,
but initial
findings are promising.
Finally, there are indications
that
it may be of use in the treatment
of schizophrenia
and
the other psychotic
disorders,
albeit largely as an adjunct
to medications.
Cognitive
theorists
have long looked
to the emerging
principles
of cognitive
neurobiology
to
understand
the etiologies
of the disorders
they treat and
to shape the clinical strategies
they try to apply. It appears
that these interventions
represent
a valuable
addition
to
the clinical armamentarium.
Acknowledgements
‘I‘he author expresses his appreciation to David M Clark for his helpful
comments on an earlier draft of this manuscript. Preparation of this article
was supported by a National Institute of Mental Health grant (MH-55875)
tO the author.
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