Where does CBT stand today, nearly 60 years after its inception?
Since its development in the 1960s and 1970s, cognitive behavior therapy (CBT) has been extensively studied and found to be effective for a range of mental health conditions, medical conditions, and quality of life concerns. Recent studies show that it is the most extensively researched and widely practiced form of psychotherapy in the world.1,2
Where does CBT stand now, nearly 60 years after its inception? How has it evolved and how will it continue to evolve to meet the changing needs of individuals around the world?
The Development of CBT
Aaron T. Beck, MD, was a scientifically oriented psychiatrist who did a series of research studies in the 1950s that he predicted would validate psychoanalytic precepts of depression. When the results turned out to be opposite to his expectations, he sought other ways to explain this condition. In the early 1960s, he published a landmark article describing the cognitive model, which was to become the foundation of a new treatment, which he originally termed “cognitive therapy.”
The cognitive model proposes that it is not situations that directly impact one’s reaction (emotional, behavioral, physiological), but rather one’s perception of the situation, as expressed by the automatic thoughts that seem to spontaneously arise in one’s mind. And the consistent themes in automatic thoughts are influenced by the basic way individuals see themselves, other individuals and the world, and the future—their core beliefs.
One important part of the treatment he proposed was helping patients identify maladaptive thoughts when they notice negative emotion, maladaptive behavior, or a change in their physiological response. Throughout his long career, along with colleagues from around the world, Beck continually conducted research studies to assess the validity of his theories and the efficacy of the treatments he devised for a wide range of psychiatric disorders, psychological problems, and medical conditions with psychological components.
Recovery-Oriented Cognitive Therapy
In 2007, Beck received a request from the Commissioner of Philadelphia’s Department of Behavioral Health and Intellectual Disability Services to develop a more effective treatment for individuals diagnosed with serious mental health conditions, particularly those who had been chronically institutionalized, and those from low resource areas. Beck and his research team surmised that they needed to do more than merely adapt CBT for this population. Over time, they developed recovery-oriented cognitive therapy (CT-R).
CT-R does not focus on reducing patients’ psychopathology—their maladaptive cognitions and behavioral coping strategies. It instead focuses on increasing the strength of patients’ positive beliefs and adaptive coping strategies. As individuals build connections with others, engage in meaningful activities, and draw positive conclusions about themselves and their abilities, they become energized and motivated to engage in the work of therapy.
CT-R is a holistic, strength-based approach that helps individuals identify their values and aspirations, draw meaning from positive experiences, and take steps toward living the life of their choosing. As a result of CT-R’s influence, traditional CBT is becoming more strength- and values-based.
“TK” was a 52-year-old woman who had been severely depressed for several decades when she presented for treatment. Over many years, she had tried a number of psychiatric medications and psychotherapy modalities, including standard CBT, with little effect. Although she was quite hopeless about her ability to recover, she agreed to try a recovery-oriented approach. Her therapist elicited her key values: connecting with others and expressing her creativity. Initially, TK was operating in a maladaptive mode at the beginning of each therapy session. She moved slowly, failed to make eye contact, showed little affect, and reported feeling very depressed.
To help her get into an adaptive mode, characterized by more positive cognition, emotion, and behavior, her therapist suggested that they begin each session by examining different art books from the library. The therapist asked her questions designed to activate the artistic part of her mind (eg, “Why do you think the artist chose this subject/this medium/these colors/this background?” “If you had chosen this subject, what might you have done the same? Differently?” “What emotions or what message do you think the artist was trying to express?”). Engaging TK in conversation this way lifted her mood; she became more animated and significantly more communicative. She concluded that she could feel better by focusing on something that she really cared about instead of focusing on how badly she was feeling.
After 3 weeks, they agreed to examine books that demonstrated how to draw, and the patient made a number of quick drawings in the session. TK found that her cognitions around her inability to produce art were inaccurate. She was then willing to try drawing at home each day. By asking questions, her therapist fortified her positive beliefs: that she was a creative person, that she still had artistic talent, and that she could produce work that showed her talent.
TK agreed with the suggestion that she visit her aunt who resided in a nursing home, taking her pictures she had drawn. Soon she began giving her pictures to other residents and conducting informal art lessons with some of them. TK’s mood continued to improve as she and her therapist continued to work toward values and aspirations that were important to TK and to fortify her positive beliefs.
Expanding the Applications of CBT
CBT has expanded well beyond the traditional therapy office. Researchers have established that it can be effectively delivered in a wide range of settings to individuals in community-based agencies and residences, forensic settings, hospitals, and other medical facilities, and more. CBT is now routinely adapted for individuals from different backgrounds, cultures, and lived experiences. Research has also established that teachers, corrections officers, paraprofessionals, peers, and others in helping roles can be taught to deliver CBT efficaciously.
A tremendous amount of research is being done into new and creative ways to provide CBT interventions to individuals who have traditionally been unable to access evidence-based mental health care due to cost, lack of trained clinicians, or stigma surrounding seeking mental health care. Researchers have had success in implementing CBT with individuals in low-resourced areas by training nonprofessionals and peers to deliver CBT in a range of novel settings.
In India and Pakistan, the Thinking Healthy Programme teaches mothers to administer interventions for perinatal depression.3 In Indonesia, lay counselors are trained to deliver trauma-focused CBT and other interventions to children impacted by violence in their communities.4
Another notable program is the Friendship Bench in Zimbabwe.5 This program teaches health workers problem-solving and other brief CBT interventions, which the health workers then administer to individuals with mild to moderate depression and anxiety while sitting on outdoor community benches. Individuals are also invited to join special peer-led group support sessions so they can connect with other individuals.
Sometimes the groups complete projects, like making bags or mats out of recycled materials. This serves as behavioral activation, an important component of CBT for depression. Those seeking help have embraced the non-traditional settings, which feel less stigmatizing than being treated in a medical office.
Here in the United States, efforts are being made to provide services that address barriers to care and meet vulnerable individuals where they are. This includes the delivery of CBT interventions through community health centers, primary care settings, religious settings such as community churches, prison reentry programs, and within the public school system. These efforts also include home visits by social workers, outreach teams, nurses, and other care providers.
CBT as the Integrative Psychotherapy
Some forms of psychotherapy prohibit or discourage integration. From CBT’s inception, Beck defined CBT not by its techniques but instead by its reliance on the cognitive model. Effective CBT practitioners often incorporate strategies from a wide variety of evidence-based therapeutic modalities. Here are a few examples: acceptance techniques from acceptance and commitment therapy, emotion regulation techniques from dialectical behavior therapy, motivational techniques from motivational interviewing, experiential techniques from gestalt therapy, deriving the meaning of early traumatic experiences from psychodynamic psychotherapy, and many more.
These techniques are always selected and implemented in the context of a sound cognitive conceptualization. They are not presented as standalone interventions. For example, when patients have a maladaptive thought process such as persistent worry, the clinician helps them identify and modify their dysfunctional positive and negative beliefs about worrying before presenting mindfulness as a behavioral experiment to discover the effect of refocusing one’s attention away from worry thoughts in a non-judgmental way.
This kind of integration has led to a spirit of cooperation, rather than competition, between approaches, with the goal of delivering the best possible therapy.
The Future of CBT
I believe CBT will continue to be influenced by the recovery movement, placing an emphasis on individuals’ strengths and values. As more research is conducted, we will better understand the role of strengths and values in treatment, as well as the mechanisms of change involved in recovery-oriented interventions.
In addition, I believe there will be a continued emphasis on understanding and removing barriers to treatment, making CBT more accessible and affordable. Part of this effort will include the integration of CBT into national health systems around the world, building on the success of the Improving Access to Psychological Therapies (IAPT) program in the United Kingdom.6
In the United States, this will include the integration of CBT into state and local health systems and other population health environments. As part of this effort, we will continue to see opportunities to train professionals in non-traditional roles to administer CBT interventions.
I also think there will be an increased focus on the use of new technology to deliver and augment CBT treatment. There has already been a great deal of promising research conducted on computer-assisted CBT, which includes computer lessons that help patients build basic CBT skills and monitor progress.7 Clinicians provide support through brief phone calls or emails, reducing their overall contact with the patient and allowing them to treat more patients in a more cost-effective manner.
I believe telehealth is here to stay. Research shows that there is no difference in outcomes for a wide range of disorders between in-person psychotherapy and therapy delivered via telehealth.
Finally, I believe there are 2 areas that show great promise but require much more research: CBT-related smartphone apps and the use of artificial intelligence to deliver and augment therapy. We are just beginning to understand how these new technologies can help make evidence-based therapies more effective, accessible, and affordable for all.
Dr Beck is president of Beck Institute for Cognitive Behavior Therapy in Bala Cynwyd, Pennsylvania, and a clinical professor of psychology in psychiatry at the University of Pennsylvania in Philadelphia.
1. David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy Is the current gold standard of psychotherapy. Front Psychiatry. 2018;9:4.
2. Knapp P, Kieling C, Beck AT. What do psychotherapists do? a systematic review and meta-regression of surveys. Psychother Psychosom. 2015;84(6):377-378.
3. Atif N, Krishna RN, Sikander S, et al. Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme. BMC Psychiatry. 2017;17(1):79.
4. Dawson K, Joscelyne A, Meijer C, et al. A controlled trial of trauma-focused therapy versus problem-solving in Islamic children affected by civil conflict and disaster in Aceh, Indonesia. Aust N Z J Psychiatry. 2018;52(3):253-261.
5. Chibanda D, Bowers T, Verhey R, et al. The Friendship Bench programme: a cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. Int J Ment Health Syst. 2015;9:21.
6. Clark DM. Realizing the mass public benefit of evidence-based psychological therapies: the IAPT Program. Annu Rev Clin Psychol. 2018;14:159-183.
7. Eells TD, Barrett MS, Wright JH, Thase M. Computer-assisted cognitive-behavior therapy for depression. Psychotherapy (Chic). 2014;51(2):191-197.