Introduction to CBT summary
Week 1
Chapter 1: Overview (Farmer)
Cognitive behavior therapy (CBT) is a widely used and efficacious treatment approach for a variety of
psychological conditions, including depression, anxiety disorders, personality disorders, substance
abuse disorders, eating disorders, and couple’s distress. CBT is a heterogeneous concept that
represents a variety of therapeutic approaches that emphasize, to varying degrees, cognitive,
behavioral, emotional, psychological, and environmental factors in relation to psychological
disorders. One of these is the cognitive approach to understanding and treating psychological
disorders (Aaron Beck & Judith Beck). A primary assumption of their model is that distorted and
dysfunctional thinking influences mood and behavior and that such biased forms of thinking are
common to all psychological disorders. Each psychological disorder is associated with a unique set of
thought distortions and underlying core beliefs unique to that condition. Therapeutic activities
should promote realistic, accurate and balanced thinking and the modification of thinking will
produce changes in mood and behavior. The modification of underlying beliefs, or schemas is
required for a lasting therapeutic change.
Cognitive perspectives vary in the degree to which the environment is viewed as a determinant of
thinking, emotion, and action. In contrast to models that emphasize the predisposing/causal
properties of cognitive constructs, behavior theory and therapy avoid ascribing mental concepts a
causal role in behavior and instead place emphasis on the physical environment. Thinking and
emotional responding are examples of behavior and are subject to many of the same influences as
more observable behaviors. The term cognitive behavior therapy incorporates several points of view
that can be contradictory, or even incompatible.
Behavioral interventions in CBT: underlying assumptions and common features
Within psychology and psychiatry, ‘deviant’ or ‘defect’ models of abnormality predominate.
Individuals who have psychological disorders or who display problematic behaviors are regarded as
deviant or abnormal, on the basis of what he/she presumably has (e.g., maladaptive schemas in
psychological disorder). The presumed internal defect that the person has is targeted for therapy;
the internal anomaly must be changed, removed, or altered if the person is to no longer be deviant
or disordered.
Behavior theory and therapy have a different view. The search for internal causes of behavior is
largely avoided, it is primarily concerned with what one does and the contexts within which behavior
occurs. Notions of what is normal/abnormal are found in cultural norms, values, and practices.
Culture provides the context for determining which behaviors are normal and deviant, which can also
change over time. From a behavioral perspective, the determinants of what is regarded as abnormal
behavior are no different from the determinants that shape and maintain normal behavior. It
assumes that there is nothing inherently defective or deviant about persons who report emotional or
behavioral problems.
Behavioral interventions within CBT: description and application
Behavioral perspectives are associated with a number of assumptions about the individual, the
context within which he/she lives, and the factors that influence his/her behavior. Psychological
disorders are defined by behavior, which can occur within the individual (covert behavior) and
observed by others (overt behavior). Behavioral perspectives are concerned with the functional
relationships that exist between the behavior of a person and the environment that establishes the
context for such behavior. When behavior therapists develop hypotheses about behavior, the three-
,term contingency framework is often used, which refers to the interaction of the person with his/her
environment and it includes three elements:
1. Antecedents of behavior: conditions or stimuli that set the occasion for behavior to occur
(specific persons, places, objects or events). The person’s learning history for behavior under
similar conditions influence whether a person will engage in a particular form of behavior in a
given setting.
2. Behavior: anything a person does (overt and covert).
3. Consequences: the effect that behavior produces. Behavior is reinforced if the consequences
that follow behavior increase the likelihood of that behavior again occurring on future
occasions. A behavior is punished if the consequences that follow decrease the likelihood of
that behavior again occurring in similar future situations.
The function of behavior is why people behave the what they do. Functionalism is based on
Darwinian evolutionary principles. In behavior theory, the behavior that is functional in particular
environmental contexts (i.e., produces reinforcing consequences) is selected or made more likely,
whereas behavior that is not functional is not selected, or becomes extinguished. Behavior is largely
determined. For selection to occur, there must be variation along some dimensions because the
absence of variation precludes the possibility of differential selection. Environmental determinism is
the overarching process associated with the selection of variations in an individual’s behavior during
his/her lifetime. Behavioral accounts are also associated with contextualism. Contextual approaches
emphasize how events and behaviors are organized and linked together in meaningful ways. It is
primarily concerned with the context within which behavior is embedded.
The focus of therapies vary in accordance with underlying theory and mechanisms of behavior
change. Each form of therapy targets the most central determinant or cause of problematic behavior.
Consequently, the types of interventions and means vary across therapies.
Contemporary behavior therapies are primarily concerned about the contexts within which a client’s
problematic behavior occurs. They place emphasis on potentially modifiable antecedents and
consequences associated with the maintenance of problematic behavior. They are also concerned
with the client’s behavioral repertoire (some clients display problematic behaviors because they
have not yet learned alternative and more adaptive forms of action). They also assess a client’s
motivation for change, which they view as a state or condition resulting from environmental events.
This means that motivation is modifiable and can be increased or decreased as a result of
environmental manipulations.
In the behavioral assessment of clients, several features associated with the functional context of
behavior are assessed and evaluated:
The antecedents of problematic behavior
The consequences of problematic behavior
The client’s learning history as it relates to current problematic behaviors.
The client’s current behavioral repertoire should cover 4 response domains:
1. Overt behaviors
2. Thoughts
3. Emotions
4. Physiological sensations
The client’s motivation for change
Decisions as to which behavioral interventions are appropriate are decided individually for each
client given the outcomes associated with assessments of these areas. Behavior theory and therapy
suggest that the factors that influence behavior vary across individuals.
There are general characteristics of behavioral interventions:
, An empirical orientation: its grounding in the basic behavioral sciences, use of empirically
supported intervention strategies, and use of ongoing assessments of the client’s behaviors
targeted for therapeutic change.
Therapist-client collaboration: the client is active and the therapist and client work together
to develop a formulation of the client’s problem areas and a plan for therapy.
An active orientation: clients are actively encouraged to do something about their problem
areas rather than only talk about them.
A flexible approach: hypotheses concerning the client’s problem areas undergo continuous
testing and evaluation, with the formulation and therapeutic activities modified and adjusted
by new information or observations.
An emphasis on environment-behavior relations: actions are conceptualized in the situational
contexts within which they occur.
A time-limited and present focus: the time allotted for therapy varies with the nature and
severity of the problem, with emphasis placed on one’s current situation rather than the
past.
A problem and learning focus: solutions to problematic behaviors are sought, often geared
toward teaching new or adaptive behaviors.
An emphasis on both change and acceptance processes: interventions encourage the
development of client self-validation and the adoption of a nonjudgmental approach to the
experience of thoughts, feelings, and bodily sensations.
An overview of the history of behavior therapy and behavioral interventions within CBT
Basic theories of learning
The theoretical roots of contemporary behavioral interventions are found in the foundations of
modern learning theories.
Late 1800s/ early 1900s:
Respondent or classical conditioning the basic idea is that some environmental stimuli,
when presented in a particular way, yield a reflexive, innate (or unlearned) response (S R).
- Generalization: conditioned responses (CRs) often occurred in the presence of stimuli that
resembled or were similar to the CS (conditioned stimulus) in some way.
- Extinction: if the CS was repeatedly presented without the UCS, the CR would eventually
disappear.
- Classical conditioning is also evident in PTSD and in the acquisition of some phobias.
Thordike’s theory law of effect: the learning process and associated behaviors are
influenced by the consequences that follow behavior.
Skinner further developed Thorndike’s theory of instrumental behavior, which resulted in the
operant theory of behavior (R C): selection of consequences is emphasized. Much of the
behavior that people display is selected and shaped over the course of a lifetime by the
consequences that such behavior produces.
Early applications of learning theories to behavior change
Early 1960s
Early therapeutic interventions based on behavioral principles began to have widespread
influence. There were some early efforts before 1960 that applied learning theory to
behavior change, but these did not result in an impact on clinical research and practice.
The emergence of behavior therapy
Wolpe (1958) published the first manualized treatment protocol, based on the behavior-
change principle (reciprocal inhibition).
Eysenck (1959): introduced the term behavior therapy
1960: publication of a book that described a number of treatment methods, such as
desensitization, negative practice, and aversion therapy.
, 1950-1960s: behavioral techniques based on Skinnerian principles of operant conditioning
were developed and evaluated.
Mid 1960s: the term behavior modification became widely applied to the practice of applying
learning principles to producing behavior change.
1970s: emergence of behavioral assessment technologies.
The emergence of CBT
In the 1970s and 1980s the contemporary CBT became firmly established and gained momentum.
The social learning theory (Bandura) was influenced by learning principles. Beginning around the late
1970s, interest in behavior therapies began to wane due to the cognitive revolution and the
publication of scholarly works that described new and innovative therapies largely consisting of
cognitive restructuring interventions. A defining feature of cognitive therapies is the strong emphasis
on the cognitive mediation of behavior – specifically, how individuals interpret their world, view
themselves, or think about the future. Therapeutic tasks involve assisting clients by identifying their
idiosyncratic way of thinking and modifying thought processes through rational examination and
logic.
Toward the next generation of cognitive and behavior therapies
In the past two decades there is an emergence of a new generation of cognitive and behavior
therapies, such as acceptance and commitment training (ACT), dialectical behavior therapy (DBT),
which focus on emotion and language. They incorporate mindfulness and acceptance principles,
techniques, and practices into the framework of therapy. Another key feature that distinguishes this
most recent generation of approaches from previous generations is their focus on the context, in
which behavior occurs. Comparatively less emphasis is placed on the modification of the physical
environment to alter behavior or on the modification of the content of particular behaviors,
thoughts, and emotions to promote therapeutic change. Rather, a greater emphasis is placed on the
modification of contexts in which the responses are experienced. It addresses principles and areas
not previously acknowledged in more traditional behavioral and cognitive therapies.
Summary
CBT is increasingly regarded as the treatment of choice for a wide variety of psychological conditions.
Theoretical elements that distinguish behavior therapy approaches from those of other schools of
therapy include:
Behavior theory and therapy place emphasis on the environment as the primary determinant
of behavior, instead of internal causes of behavior.
Behavior theory and therapy are based on principles of determinism and functionalism, in
which behavior that is functional is selected or becomes more probable over time, whereas
behavior that is not functional is not selected.
In behavior therapy, the three-term contingency often constitutes the basic level of analysis
and serves as a guide for intervention selection, application, and evaluation.
