Introductory Chapter: Definition of Cognitive Behavioral Therapy and Its Principal Applications

1. Story of modern cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a modern form of short-term psychotherapy based on the idea that the way an individual thinks and feels affects the way he behaves.

The core premise of this treatment approach was pioneered by Albert Ellis who in 1957 introduced the term “rational emotive therapy” (RET) to emphasize its focus on emotional outcomes. Successively, Aaron Beck in 1976 created “cognitive therapy” (CT), which served as the bases for the development of CBT.

According to Beck’s formulation, maladaptive cognitions, which consist in general beliefs or schemas about the self, the world and the future, contribute to the maintenance of emotional distress and behavioral problems. According to this model, specific therapeutic strategies that change maladaptive cognitions lead to change emotional distress and problematic behaviors.

In 1995, Ellis created the term “rational emotive behaviour therapy” (REBT) because behavioral factors constitute a fundamental component of this treatment approach [1].

More recently, practitioners and scholars started to call it rational emotive and “cognitive behaviour therapy” to emphasize its role in CBT paradigm.

REBT protocols were applied in domains of clinical psychology, rational emotive education, organizational setting or counseling [2].

Since the late 1980s and 1990s, REBT was investigated in a series of randomized control trials that demonstrated its efficacy in many psychological conditions such as social phobia [3], obsessive–compulsive disorders [4], depression [5], psychotic symptoms [6] and behavioral disorders.

In 2013, on the bases of meta-analysis studies, REBT was included in the category of CBT [7] since its protocols are similar in structure with CBT protocols, while the main difference is that REBT specifically focuses on evaluative beliefs and not descriptive or inferential ones [8].

Since these early models, CBT have developed appropriate protocols to treat subjects of almost every age such as children, adolescent, adults or elderly and for individual, families and couples.

2. Principal applications of CBT

Cognitive behavioral therapy is an empirical and evidence-based psychotherapy that integrates cognitive science and behavioral theories, combined with clinical psychology, to conclude that the way people perceive a situation determines their reaction more than the actual reality of the situation does [9].

CBT provides useful tools that can be used to induce or facilitate belief revision such as cognitive restructuring or exposure/response prevention; these protocols have been applied both in groups and in individuals, even if the individual format is used more frequently than the group format.

This treatment plan uses patients’ collaboration as a motivating factor, in order to generate changes in their behaviour, beliefs and habits that can be self-reinforced. In fact, CBT gets patients actively involved in their treatment so that they understand that the way to improve their lives is to adjust their thinking and their approach to everyday situations.

The overall goal of this treatment is symptom reduction, improvement in functioning and remission of the disorder. The initial sessions of CBT illustrate the close relationship between cognition and emotions. Each typical therapy session begins establishing an agenda of current problems, followed by cognitive restructuring of maladaptive cognitions. At the end of the session, the therapist assigns homework to help the patient to apply specific skills in his real life. Every step of CBT is reasoned and transparent. If the patient suffers from psychomotor retardation, behavioral strategies are implemented with cognitive interventions. The therapist can also use a series of questions to help the patients evaluate the utility and validity of their cognitions [10].

CBT consists in different protocols that are effective in the treatment of a vast variety of mental disorders, such as generalized anxiety disorders, panic disorders (in particular with agoraphobia or social phobia) and obsessive–compulsive disorders [11].

The session content varies for each specific disorder based on the empirically proven cognitive and behavioral model of each disorder. For example, cognitive themes concern about consequences of a panic attack (in phobia disorders), concern about social embarrassment (in social anxiety disorders), concern about dangers of worrying (in generalized anxiety disorders) and concern about consequences of intrusive thoughts (in obsessive–compulsive disorders).

CBT can be used to treat mood and emotional disorders such as depression or dysthymia [12]. With depressive disorders, the general therapeutic process of CBT is to split up into different steps, with an insistence on distinct therapeutic mechanisms, establishing a therapeutic relationship and managing maladaptive behaviors and cognitions.

CBT has been extensively tested for a wide range of neurotic and stress-related disorders such as general stress, post-traumatic stress disorders and somatoform disorders (such as hypochondriasis and body dysmorphic disorder) or medical problems with psychological components.

Several studies have demonstrated CBT utility in problematic gambling, substance use disorder (as nicotine, cannabis, opioid or alcohol dependence), eating disorders (as bulimia nervosa, binge eating disorders) [13] and sleep dysfunction (in particular insomnia) [14] or to approach fatigue, chronic pain conditions [15, 16] and inflammation pathologies [17], especially if associated with distress [18].

CBT is probably effective also for psychotic disorders associated with positive symptoms (i.e. delusions and/or hallucinations) in schizophrenia, personality disorders (including antisocial personality disorder) [19], anger expression (anger, verbal and physical aggression, driving anger, anger suppression and anger difficulties) and bipolar disorders. CBT is particularly promising for schizophrenia in patients who suffer from acute episode of psychosis rather than a more chronic condition [20].

Neurofunctional studies have demonstrated that CBT induces brain activation and functional changes in the amygdala, insula and anterior corticolimbic brain circuits that control cognitive, motivational and emotional aspects of physiology and behaviour [21].

CBT should be used by a health professional with experience and training in cognitive and behavioral therapies, especially when used for the treatment of anxiety and mood disorders.

This book, written by authors that are expertice in CBT, is useful both for clinicians and psychotherapists who wants to understand modern cognitive psychology and develop specific personalized treatment plans of cognitive behavioral therapy.