Introduction

The hallmark features of cognitive–behavioral therapy (CBT) are short term, problem-focused cognitive and behavioral intervention strategies that are derived from the science and theory of learning and cognition. Also, the CBT approach to treatment implementation and evaluation is guided by principles of empirical science. The behavioral interventions aim to decrease maladaptive behaviors and increase adaptive ones by modifying their antecedents and consequences and by behavioral practices that result in new learning. Examples of behavioral interventions include behavioral activation for depression, problem solving for stress management, behavioral rehearsal for social skills deficits, and relaxation training and systematic exposure to anxiety-producing situations for anxiety disorders. The cognitive interventions aim to modify maladaptive cognitions, self-statements, or beliefs. The cognitive methods include identification of situational misappraisals and underlying distorted beliefs; rational disputation or logical consideration of the evidence to refute such misappraisals and core beliefs; behavioral practices designed to collect further data to disconfirm such misappraisals; and the generation of alternative, more evidence-based appraisals and core beliefs. Together, these cognitive and behavioral interventions have been shown to be effective for a number of different psychological disorders and conditions, including anxiety disorders, depression, personality disorders, substance use related disorders, eating disorders, pain management, couples distress, and aspects of psychosis. Indeed, CBT is considered to have the most evidence base of all psychosocial therapies (Roth & Fonagy, 1996).

The origins of CBT are in the science and theory of classical and instrumental conditioning, or learning theory. Within these theories, emphasis was given to the role of the reinforcing and punishing consequences that guide voluntary behaviors (e.g., positively reinforcing effects of euphoria upon continued drug consumption) as well as responses that become conditional due to associations with innately evocative events (e.g., development of fears of driving following a car accident). Originally, little consideration was given to the role of appraisals or thoughts as determinants of behaviors or emotions, although thoughts could be viewed as “another behavior” and therefore subject to the same rules of reinforcement and conditional responding.

Dissatisfaction with a strictly behavioral set of principles coincided with a rise in interest in cognitive principles that was spurred by social learning theory. This led to the content of judgments and underlying belief systems about the self and the world being given credence as determinants of emotion and action. Furthermore, the cognitive movement was fostered by advances in instrumental and classical conditioning theories that led to recognition of cognition as a potential mediator of learning. Thus, behavioral therapy became cognitive–behavioral therapy, all the while maintaining a science-based approach to the implementation of treatment, but now extending from behaviors to judgments and beliefs as targets of intervention. The science of cognition and information processing developed separately from the rise of cognitive therapy, and as described throughout this book, the former has raised significant questions regarding the purported mechanisms of the latter. Partly as a consequence of this questioning, recent “third wave” developments are reemphasizing behavioral principles and de-emphasizing the content of cognition.

In practice, individual clinicians vary in the degree to which they embrace behavioral as compared to cognitive principles and interventions. Some clinicians remain more behaviorally focused, and treat cognitions within a behavioral framework, such as by giving more emphasis to the function rather than the content of judgments and stated beliefs. The latter is particularly characteristic of the third wave therapies, such as acceptance and commitment therapy, which may be more appropriately termed behavior therapy rather than CBT. Other clinicians take an integrative approach, combining behavioral principles and interventions with cognitive principles and methods designed to modify the content of cognition. Still others are more cognitively focused and view the content of cognition as the driving factor behind all behaviors and emotions and as the primary focus of all therapeutic effort. The latter approach generally is referred to as cognitive therapy. However, cognitive therapists rely on behavioral methodologies to obtain evidence for disconfirmation or disputation of maladaptive cognitions. Hence, it is hard, if not impossible, to distinguish between cognitive therapy and CBT. Behavioral therapies that de-emphasize the content of cognition can be more readily distinguished from CBT, yet even here the distinction is sometimes hard to draw. For example, within behavioral interventions based on instrumental learning theory, thoughts can be regarded as antecedents to behaviors. Hence, if a set of verbal statements is an antecedent that elicits maladaptive behavior, then treatment aims to replace those statements with “alternative antecedent statements” that elicit more adaptive behavior. Clearly, such behavioral strategies overlap with cognitive strategies.

Thus, whereas more behaviorally versus more cognitively oriented clinicians rely on somewhat different principles for treatment formulation and understanding therapeutic change, they may use the same procedures for intervention. Conversely, both behavioral theory and cognitive theory principles can be evoked to explain therapeutic change with the same intervention strategy. As an example, behavioral theory attributes the effects of repeated exposure to feared situations to extinction of conditional fear responses; in accordance with cognitive theory, the same method of exposure serves to gather information that disconfirms mistaken judgments about danger.

Despite these variations in emphasis on behavioral and cognitive principles and methodologies, the CBT approach is unified by its empirical foundation, its reliance on the theory and science of behavior and cognition, and its problem-focused orientation. Whatever the emphasis given to behavioral or cognitive principles, the CBT therapist aims to replace maladaptive behaviors, emotions, and cognitions with more adaptive ones. Also, the CBT therapist accomplishes that aim within the context of ongoing evaluation of the effectiveness of intervention strategies and their modification, when necessary, to achieve optimal effects.

CBT is used widely by clinicians. For example, of 591 APA members who were randomly surveyed, 45.4% regarded themselves as CBT in theoretical orientation (Stewart & Chambless, 2007). This rate exceeded the rates for all other theoretical orientations, including psychodynamic (21.9%), eclectic (19.8%), humanistic/experiential (4.4%), family systems (3.9%), and other (4.6%). That being said, a number of clinicians who regard themselves as delivering CBT may overrate their competency in this approach to therapy (Brosan, Reynolds, & Moore, 2007, 2008) and, from patient report, often do not deliver the key elements of CBT (Stobie, Taylor, Quigley, Ewing, & Salkovskis, 2007). These deficiencies may be due to inadequate training in CBT. Programs in psychiatry, psychology, and social work across the United States were surveyed to establish the adequacy of training in empirically based psychotherapies, the latter being comprised mostly of CBT (Weissman et al., 2006). Only 17.8% of training programs provided both didactic and clinical supervision training in empirically based treatments. Interestingly, the highest rates of adequate training were in psychiatry, possibly because of the inclusion of CBT in accreditation criteria for psychiatry residency programs. Such requirements do not exist for psychology or social work programs. Lack of CBT competency, even among self-described CBT clinicians, may be additionally attributed to the overemphasis on training in CBT procedures at the cost of training in CBT principles. This imbalance may stem in part from the manualization of CBT interventions for various problems. Whereas manualization is a positive feature that facilitates empirical evaluation of CBT and enhances CBT dissemination, it may have inadvertently encouraged too much focus on procedure over principle. A good understanding of the principles underlying CBT, an exposition of which is a primary goal of this book, is necessary for optimal tailoring of CBT procedures to each presenting problem.

Nevertheless, even in the hands of less experienced therapists, CBT is a highly effective approach, in addition to being noted for the best evidence of all psychotherapeutic treatments (Roth & Fonagy, 1996). As such, CBT is entirely consistent with the evidence-based practice movement being encouraged by the American Psychological Association (APA; 2005). Evidence-based practice principles encourage clinicians to combine their clinical expertise with available research evidence for treatment planning. To facilitate the dissemination of evidence-based principles, the Division 12 (APA) Task Force on Promotion and Dissemination of Psychological Procedures (1995), updated by Chambless and Ollendick in 2001, and the Task Force on Effective Psychosocial Interventions: A Lifespan Perspective (Spirito, 1999) have published information about treatments that work for particular problems. The majority of empirically supported treatments that are cited in these documents are cognitive therapies, behavioral therapies, and cognitive and behavioral therapies, jointly termed CBT herein.

History

The history of cognitive–behavioral therapy (CBT) began with a heavily behavioral orientation throughout the 1950s to 1970s. The growth in cognitive therapy in the 1960s was followed by the integration of cognitive and behavioral approaches in the 1980s and onward. A third wave of behavioral therapies is now emerging, one which de-emphasizes the content approach to cognition and instead emphasizes the function of cognition.

ORIGINS

As a backlash to the prevailing “non-scientific” psychoanalytical approaches to treatment in the first half of the 20th century, the principles of learning theory guided a new, science-based approach to the conceptualization, assessment, and treatment of mental disorders. This new approach was behavior therapy. As noted by Levis (1999),

the behavioral therapy movement identified itself with the experimental field of learning, which already had an existing data base, a common language structure, and a guiding philosophy of science. By stressing the importance of defining terms and procedures operationally, coupled with a strong commitment to assessment and research, those involved hoped to reduce the existing chaos in the mental health field by developing new treatment techniques and assessment procedures based on established and documented principles of learning and behavior. (p. 157)

Two sets of learning theory principles guided the behavior therapy movement in its original form: classical (or respondent) conditioning and instrumental (or operant) conditioning. Briefly, classical conditioning (most associated with Pavlov, 1927) is based on environmental stimuli that produce reflexive responses, such as when a physical threat from another person produces a reflexive fear response. Hence, an innately evocative stimulus (or an unconditional stimulus, US) produces an unconditional, reflexive response (UR). Furthermore, if repeatedly paired with the US, a previously neutral stimulus can become a conditional stimulus (CS) that evokes a conditional response (CR) similar to the original UR. For example, as a result of the aversive experience of a motor vehicle accident (US) and the fear and pain it produced (UR), motor vehicles (CS) may become a signal for potential future accidents and therefore evoke a conditional anxiety response. Consequently, anxiety becomes conditioned to motor vehicles and may even be evoked automatically, or without conscious appraisal of perceived danger. In classical conditioning theory, the history of learned associations between neutral and innately evocative stimuli is presumed to explain current emotional–behavioral responses. Classical conditioning was and continues to be evoked as an explanatory process in the psychopathology and treatment of emotional disorders (e.g., anxiety disorders) as well as substance use related disorders and certain sexual disorders, among others.

Instrumental conditioning, originated by Thorndike (1898) and extended by Skinner (1938), refers to the modification of the occurrence or form of behavior by its consequences. As such, it is relevant to voluntary rather than reflexive behaviors. That is, a response is “selected”—and is thus voluntary—based on the consequences likely to be received; operant behavior “operates” on the environment and is maintained by its consequences. An example is the increased frequency of drug consumption due to the reinforcing, albeit temporary, euphoria produced by a substance and/or by the relief a substance provides from other negative emotions. The reinforcement provided by the euphoria and/or the escape from unpleasant emotions increases the likelihood of engaging in drug consumption in the future. In instrumental conditioning, behavioral responses are selected and shaped by the entire array of positive and negative consequences that the behavior produces. Operant conditioning has been applied to a wide range of disordered behavior, such as substance use related disorders, externalizing behaviors, pain management, and aspects of psychosis.

The course by which these two learning theories were translated into treatments differed. Pavlov and colleagues did not consider the treatment implications of classical conditioning. In fact, the first applications were made by Watson and Rayner (1920), who demonstrated the conditioning of a fear reaction in young “Albert,” and by Mary Cover Jones (1924), who developed fear reduction techniques for children based on learning theory. However, neither their work nor the work of Pavlov and his colleagues had any impact on clinical practice at the time, possibly because therapy was the domain of psychiatry that was dominated by psychoanalytic theory (Eelen & Vervliet, 2006). However, following World War II (i.e., 1945), there was an increased demand for therapeutic interventions and therapists, and the time was ripe for psychologists to receive training in new methods of intervention. This cause was met by the work of Joseph Wolpe, in South Africa, who had become dissatisfied with psychoanalytical approaches. Wolpe was interested in the experimental foundations of learning and their application to neuroses, out of which he developed systematic desensitization for treating fears and anxiety disorders (Wolpe, 1958).

Wolpe began by reviewing Pavlov’s research (1927) and Hull’s (1943) learning theory (which stated that behavior is influenced by drives and incentives, and conditioning only occurs if a reinforcement satisfies a need). Then he investigated the principles of aversive classical conditioning in cats. Once he established that cats became fearful of their cages by shocking the floor of the cage, Wolpe next established that he could eventually extinguish their aversively conditioned fears by a procedure of counterconditioning. In this procedure, the drive for hunger and food became a means for reciprocally inhibiting the fear response. That is, the cats were mildly food deprived, and then food was placed at progressively closer distances to the cage. The hunger and drive for food overcame the anxiety, and the cats eventually reentered the cages. Next, he extended his investigation to human fears and phobias. In an extensive series of case studies, Wolpe (1958) demonstrated the positive effects of graduated imaginal exposure to fear-producing situations, using the relaxation response (via progressive muscle relaxation, developed by Jacobson, 1938), as a counterconditioner of the anxiety associated with each image. This method was named systematic desensitization, and hence was born the first tested, standardized, and replicable method of behavioral intervention for emotional disorders.

In contrast to Pavlov’s lack of involvement in treatment application, Skinner directly contributed to the translation of instrumental conditioning principles to treatment interventions. He spearheaded the development of behavioral interventions in the United States in the 1950s and 1960s (e.g., Lindsley, Skinner, & Solomon, 1953), a development that also was spurred by the needs following World War II. Skinner believed that the solid body of scientific knowledge regarding the behavior of organisms provided alternative solutions to psychoanalytic approaches to treatment. He described the new form of treatment in his book Science and Human Behavior (1953). For him, treatment involved introducing observable variables to compensate for and correct a history that had produced “unfavorable” behaviors. That is, treatments based on instrumental learning, later coined behavior modification, involved basic principles of extinction of undesirable behaviors and reshaping by reinforcement of newly emitted and desirable behaviors, on varying schedules of reinforcement. Skinner and Lindsley first implemented instrumental principles for the management of problem behaviors (e.g., self-injurious) in patients with psychosis at the Metropolitan State Hospital, Massachusetts. Then, these behavioral modification procedures were extended to aspects of autism and other problem behaviors associated with mental retardation. “Simply stated, hospital wards were regarded and treated as huge Skinner boxes, in which the environmental events surrounding the emission of behavior by clients were controlled so as to extinguish or shape desired responses” (Goldfried & Davison, 1994, p. 5).

Although differing in principles, classical and instrumental behavioral approaches shared several features in common. Specifically, both approaches viewed “disorders” as the result of faulty learning. They held that because abnormal behavior is governed by the same principles that govern normal behavior, most abnormal behavior can be modified by behavioral procedures (Rachman & Wilson, 1980). Another shared feature was the reliance on empirical methods and principles and the motivation to move the field forward by not relying on nonmeasurable (i.e., psychoanalytic) constructs. The commitment to an applied science approach meant reliance on an explicit testable conceptual framework; therapeutic techniques that could be described with sufficient precision to be measured and replicated; experimental evaluation of treatment methods and concepts to determine their effects; and emphasis on rigorous evaluation of specific methods applied to particular problems rather than global assessments of ill-defined procedures applied to heterogeneous problems (Rachman & Wilson, 1980).

In the 1950s, the acceptance of behavioral theories and therapies was greatly influenced by Hans Eysenck, who was given the task of constructing a training program for clinical psychologists at the Maudsley Institute in London, the leading center for training in the United Kingdom. Eysenck himself was strongly influenced by the view that psychoanalysis was unfalsifiable and therefore nonscientific. He began by reviewing the efficacy of existing psychotherapy methods and, in an influential paper (Eysenck, 1952), concluded that traditional (psychoanalytical) therapies were no more effective than the passage of time or placebo. In 1960, he published the book Behavior Therapy and the Neuroses, in which he concluded that the only effective therapy was one based on modern learning theory, such as systematic desensitization and instrumental procedures, including aversion therapy. Thus, Eysenck instituted a model of clinical training at the Maudsley Institute that was guided by scientific behavioral psychology, a model that was subsequently reinforced by Stanley Rachman and Isaac Marks and thereafter continued to influence clinical psychology training in the United Kingdom. Furthermore, in 1963, Eysenck founded the journal Behaviour Research and Therapy, which provided an outlet for the results of ongoing investigations of behavioral therapies and thereby contributed significantly to their dissemination worldwide.

There was a burgeoning of efficacy studies of behavioral treatments in the 1970s and 1980s. Simultaneously, a set of standards for evaluating therapeutic outcomes, such as treatment credibility, treatment integrity, and rigorous control comparisons, was developed. However, as interest in efficacy outcomes and the technology of behavioral treatments increased, interest in the “theory” underlying those treatments and the “theoretical cohesion” of classical and operant conditioning principles waned. According to Levis (1999), “the term behavioral therapist, which formerly signified an individual committed to a behavioral philosophy of science, soon lost any meaningful operational specificity” (p. 159). Others similarly noted that behavioral therapy became divorced from behavioral theory (e.g., Eifert, Forsyth, & Schauss, 1993).

Independently, concern began to be expressed about the adequacy of learning theory accounts of psychopathology (e.g., Bandura, 1978). For example, the classical conditioning model of fears and phobias was criticized for its inability to explain why not all individuals who undergo an aversive experience develop a phobia. At the same time, operant principles began to be viewed as overly simplistic and mechanistic, to the point that “clinicians were frustrated with radical behaviorists’ failure to account for language and thought processes in terms useful for clinicians” (Eifert et al., 1993, p. 108). Furthermore, clinicians were dissatisfied with the results of behavioral treatment for depression and were in search of another model, something they found in cognitive therapy.

The pioneers of cognitive therapy were Albert Ellis (1957), who developed a cognitive therapy coined rational–emotive behavior therapy; Aaron Beck (1963), whose approach is called cognitive therapy; and Donald Meichenbaum (1977), who developed self-instruction training. In brief, Ellis viewed irrational thinking as the source of problem behaviors and emotions and emphasized direct disputation of irrational thinking and the development of rational thinking as the mode of treatment. Beck’s approach emphasizes surface level distortions in information processing and their relationships with underlying or core maladaptive belief systems; instead of disputation as a therapeutic technique, this approach uses Socratic questioning to help individuals see the errors in their thinking and generate alternative, more evidence-based appraisals. Meichenbaum’s approach teaches a method of self-instruction for facing challenging situations. Despite the differences in their cognitive approaches, all three viewed disorders as arising from faulty thinking; they agreed that dysfunctional thinking generates and maintains symptoms of psychopathology and that the content of cognition is the primary determinant of behavior and emotions. In marked contrast to the strictly behavioral approach, the cognitive approach addressed “nonmeasurable” cognitive concepts. However, the cognitive approach differed from inferential psychoanalytical approaches by focusing on present problems and present thinking and by regarding verbalizations as valid data points rather than as symbols of unconscious processes.

Paradigmatic shifts simultaneously were occurring in classical and instrumental conditioning theories. In the newer models, cognition was accommodated within learning theory models not just as a response but as a factor possessing causal significance or as a mediator of conditioning (e.g., Rescorla, 1968). Debate over the role of implicit or nonconscious expectancies versus explicit conscious appraisals in instrumental and classical conditioning continues. Nonetheless, the molding of cognition into conditioning was yet another factor that facilitated the uptake of cognitive theories and their blending into behavioral theories and therapies.

Bandura’s (1973) social learning theory, in which cognitive processes were assigned a role as critical determinants of behavior, was another positive influence on the acceptance of cognitions as a target for therapy. Bandura established that learning is not solely dependent on direct experience but occurs through judgments as well (although direct experience was still regarded as a critical determinant in its own right). Hence, in his model of reciprocal determinism, behaviors, cognitions, and environmental factors are viewed as continuously reinforcing each other. Subsequently, Bandura (1977) emphasized a particular cognitive construct, coined self-efficacy, as a primary determinant of behavioral change and as the primary mechanism underlying therapeutic interventions. Bandura posited that self-efficacy was more effectively raised through performance accomplishment rather than by verbal persuasion. This may be one of several reasons why his model was never fully incorporated into cognitive theories and therapies, although it was incorporated as a mediator of behavioral treatments.

Yet one more factor that facilitated the transition from behaviorism to cognitive–behaviorism was the value given by the cognitive approach to behavioral techniques, albeit as a means for changing maladaptive thinking styles. Thus, behaviorists did not have to relinquish their behavioral technology as they extended their targets beyond overt behavior to the domain of cognition. By the early 1980s, the cognitive revolution was fully underway. The establishment of centers, such as Ellis’s Centers for Rational Emotive Behavior Therapy, and the publication of treatment manuals, such as the Cognitive Therapy of Depression (1979) by Beck and colleagues, paved the way for clinical efficacy studies and dissemination of cognitive therapy procedures to clinicians at large.

The development of behavior therapy and cognitive therapy followed very different pathways. Behavior therapy developed out of experimental principles of learning theory and experimentation that were first tested in laboratory studies in animals, followed by laboratory studies in humans, and finally therapy outcome studies with clinical samples. Wolpe epitomized this approach in his studies of classical conditioning and reciprocal inhibition. In contrast, cognitive therapy derived from astute clinical observation by Ellis, Beck, and Meichenbaum of the role patients’ self-statements and beliefs played in their emotional and behavioral responding. Curiously, a science of cognitive psychology was growing at around the same time as cognitive therapy, but the two cognitive fields developed almost in isolation of each other. It was not until the mid to late 1990s that integrationist efforts were made, wherein theoretical principles and therapeutic procedures of cognitive therapy began to be judged in light of the principles and empirical findings from the science of cognitive psychology.

CONTEMPORARY APPROACH AND EVOLUTION TO PRESENT

The merging of behavioral and cognitive therapies resulted in therapists paying more attention to clients’ expectations and understandings as valid data points in their own right, therefore “supplying the content to behavior therapy” (Rachman, 1997, p. 18). The focus on cognitive content is achieved within the context of helping clients to become aware of maladaptive cognitive–affective–behavioral chains and to create learning experiences and acquire coping skills for interrupting those maladaptive sequences and for producing more adaptive responses.

More specifically, contemporary CBT typically begins with an individually based functional analysis of problem behaviors, cognitions, and emotions and the reciprocal interactions among them that serve to trigger and maintain maladaptive responding (i.e., causal modeling). In contrast to functional analysis as originally specified in instrumentally based behavioral modification procedures, contemporary CBT takes a broader view by considering the antecedents and consequences of behaviors, identification of which stimuli are eliciting which CRs, and the cognitions that are influencing behaviors and emotions. A functional analysis also evaluates the role of cultural factors in the expression and causal modeling of problem behaviors, cognitions, and emotions. The method of functional analysis is first implemented through the therapist’s questioning and observations, sometimes extending to behavioral observations of clients in their natural environment. It is then transferred to clients who are taught to adopt a personal scientist perspective, in which they become observers of their own patterns of behavioral, cognitive, and emotional responding in given environmental and cultural contexts. The functional analysis then guides the treatment plan.

Next, a set of change-oriented strategies are implemented. These may include the identification of idiosyncratic errors in conscious appraisals and their links with underlying core beliefs. A set of skills, often termed cognitive restructuring, is taught for modifying distorted appraisals and core beliefs, through disputation and logical empiricism. Behavioral methodologies are incorporated through behavioral experimentation, also called hypothesis testing, designed to collect evidence that disconfirms distorted thinking. Another set of intervention strategies address classically conditioned responses. An example would be systematic and repeated exposure to irrationally feared objects to extinguish CRs. Combining the cognitive and behavioral principles and procedures, changes in implicit cognitions as a result of the exposure experience are accompanied by explicit reappraisals that aversive outcomes do not occur and/or are not as aversive as anticipated.

Yet another set of strategies replaces maladaptive behaviors with adaptive behaviors through shaping and scheduled reinforcers and punishers. An example would be engaging in positively reinforcing activities as a means for correcting the low rate of positive reinforcement that characterizes depression. Again, these activities may be accompanied by explicit reappraisals of the value of the positive reinforcement, to offset cognitive biases that devalue positive reinforcers. The relative emphasis given to the principles and skills of cognitive restructuring versus operant and respondent learning varies according to each clinician’s leaning toward more cognitive versus more behavioral approaches to cognitive–behavioral change and, of course, the nature of the presenting problem. However, the truly integrated cognitive–behavioral clinician gives credence to both. The treatment plan is continuously revised in accordance with ongoing evaluation of the target emotions, behaviors, and cognitions. The final step of treatment is a relapse prevention plan, designed to maintain the skills that have been acquired over time.

As noted previously, CBT is widely used and is the most commonly cited therapy orientation among randomly surveyed clinicians from the American Psychological Association (Stewart & Chambless, 2007). Part of its popularity is attributable to the empirical support that CBT has achieved, showing positive results for a large array of psychosocial problems. As the most commonly cited empirically supported treatment, the scope and demonstrated utility of CBT are attractive to training programs and practitioners in general practice. The level of empirical support is a function of the empirical philosophy that is the essence of CBT.

The popularity of CBT is enhanced by a feature of empirical methodology, which is manualization of intervention procedures. Manualization was a necessary step for empirical evaluation, since manualization allows for replicability of CBT in independently conducted studies. While there may be some downsides to strict manualization, such as failures to tailor CBT to the presenting problem and perhaps failure to fully learn and appreciate the principles underlying CBT, manualization has played a major role in the dissemination of CBT in training programs and clinical practice in general. Furthermore, the popularity of CBT is consistent with the current emphasis upon evidence-based medicine. Finally, the time-limited nature of CBT and its suitability for delivery in group formats adds more to its cache by virtue of cost effectiveness, which of course is of high importance in the world of managed care.

FUTURE DIRECTIONS

We are now on the verge of yet another turning of the tides in the trajectory of CBT. As cognitive theories and therapies developed, cognitive processes began to be conceptualized much like processes of a computer. In this model, cognition is comprised of a number of processes, such as encoding, retrieval, attributional and appraisal. This type of theorizing placed cognitive therapy in line, to a certain degree, with the science of cognitive psychology (i.e., the science of ways in which information is attended to, stored, and retrieved). Hence, from the 1990s onward, attention has been given to the ways in which the science of cognitive psychology informs cognitive and behavioral therapies. Indeed, advances in our scientific understanding of the cognition–emotion interface for emotional disorders support some of the premises of cognitive therapies. However, at its core, cognitive therapy remains a therapy that targets the conscious content of cognition. The science of cognitive psychology has brought to light certain limitations of a content-based cognitive model of psychopathology and therapy. For example, it is now well recognized that the majority of information processing occurs at subconscious levels, without conscious appraisal. The adequacy of attempts to change subconscious cognition through conscious reappraisals has been questioned (e.g., Teasdale & Barnard, 1993). Alternative methods for shifting styles of information processing that do not depend on conscious appraisals are now being tested as complements to or replacements for cognitive therapy. These include mindfulness and acceptance-based approaches, which have been coined the third wave of behavioral therapies (Hayes, 2008). In some of these newer treatment models, such as mindfulness-based cognitive therapy (e.g., Williams et al., 2008), direct attempts to change the content of conscious appraisals is accompanied by skills of mindfulness. In other models, such as acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999), the role of conscious appraisal is not ignored, but instead of directly addressing the content of those appraisals, attention is given to their function and ways of disrupting that function.

Another recent development that is proving a challenge for more purely cognitive approaches is the evidence pertaining to newer behavioral treatments for depression. Dissatisfaction with behavioral approaches for depression was a major impetus for the development of cognitive therapies. However, in a complete “reversal of fortune,” the effectiveness of behavioral activation treatment for depression has been gaining support. This treatment is based on principles of operant conditioning and reinforcement (Jacobson, Martell, & Dimidjian, 2001). Moreover, behavioral activation maybe superior to cognitive therapies for severe depression (Dimidjian et al., 2006). Along with this upsurge in operant learning behavioral principles of therapy is a reinvigorated interest in classical conditioning principles of exposure therapy for anxiety disorders, spurred by advances in the basic science of learning and memory (e.g., Craske et al., 2008). In sum, the third wave of CBT is both shifting back to behavioral principles and extending forward to mindfulness and acceptance.

Theory

The principles and theories that underlie cognitive–behavioral therapy (CBT) derive from several different sources that have become interweaved with each other as CBT has developed from its initial behavioral routes to the contemporary cognitive–behavioral integration. After presenting the overarching goals of CBT, this chapter outlines the ways in which each set of theoretical principles conceptualizes maladaptive behaviors, emotions, and cognitions and their modification. First is learning theory, including classical conditioning and instrumental conditioning principles. Next is social learning theory, which provides a cognitive theory for behavioral change. Finally, cognitive appraisal theory is presented. Ways in which these theories overlap and accommodate each other are described. As previously noted, the more behaviorally oriented clinician will draw mainly from learning theory in conceptualizing a presenting problem and formulating a treatment plan, whereas the more cognitively oriented clinician will favor the theory and principles of cognitive appraisal. The cognitive–behavioral clinician can comfortably draw from both learning theories (including social learning theory) and cognitive appraisal theory to conceptualize a problem and formulate a treatment plan.

GOALS

Broadly speaking, the goal of CBT is to achieve symptom reduction and improvement in quality of life through the replacement of maladaptive emotional, behavioral, and cognitive response chains with more adaptive responses. Underlying this goal is the notion that problem behaviors, cognitions, and emotions have been acquired at least in part through experience and learning and therefore are open to modification through new experience and learning.¹ The target of CBT is to teach new ways of responding and to develop new learning experiences that together promote more adaptive patterns of behavioral, affective, and cognitive responding. Also, these changes are attempted within relatively brief periods of time; in other words, CBT aims to be not only problem-focused but also time limited.

Another goal of CBT is for long-term positive effects that are self-maintaining. Thus, learning experiences are repeated, and new ways of responding are practiced over a sufficient number of occasions and contexts that they become the major determinants and preferred methods of responding in the long term, independent of the therapy context. In this way, CBT aims to tool clients with their own repertoire of skills for dealing with problematic situations and thereby become less and less dependent on, and eventually autonomous from, the therapist.

These two overarching goals are achieved within the framework of a set of guiding principles of behavioral theory and science and cognitive theory (and more recently, cognitive science) for conceptualizing presenting problems and formulating intervention strategies. These principles drive another goal, which is to use an individually based functional analysis of the causal relations among cognitions, behaviors, emotions, and environmental and cultural contexts for tailoring intervention strategies specifically to the needs of a given problem. Thus, rather than assuming that one standard treatment fits all, CBT is based on careful observation and understanding of each individual’s presenting problem. Functional analysis refers to an analysis of not only the instrumental antecedents and consequences, but also which stimuli are producing which conditional responses (CRs), which cognitions are contributing to behaviors and emotions, and within which environmental and cultural contexts these occur. The therapist and client then make an informed choice about which methods for behavioral and cognitive change to use from a variety of different intervention strategies.

Another goal is to have a flexible approach to implementation, which is facilitated by ongoing evaluation and modification of intervention strategies as appropriate. Linked with this is the aim of engaging the client in the process of experimentation and ongoing evaluation of the effectiveness of the chosen interventions. Evaluation not only permits revision to the intervention strategies where necessary but provides an assessment of overall progress. Overall progress is measured by agreed-upon markers between the client and the therapist, and when the evidence indicates lack of progress, consideration is given to alternative treatment methods. Clearly, this entails therapist–client collaboration in formulating and implementing a treatment plan and a highly active orientation on the part of the client.

KEY CONCEPTS

This section is divided into key concepts of learning theory (classical and instrumental conditioning), social learning theory, and cognitive appraisal theory. The ways in which these theories overlap and accommodate each other are described as well.