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By: J. Arehart-Treichel

Cognitive-behavioral therapy will be more widely used during the next five to 10 years, predicts one of its developers. He bases his projections in part on what has occurred in Britain and Scandinavia.

Cognitive-behavioral therapy (CBT) is an amalgam of cognitive therapy and behavioral therapies able to help patients counter negative thoughts and behaviors underlying various mental illnesses. Science has demonstrated that it can pack quite a therapeutic wallop.

"There are more than 375 trials of cognitive-behavioral therapy in the research literature," Donna Sudak, M.D., director of psychotherapy training at Friends' Hospital in Philadelphia and a member of the APA Committee on Psychotherapy by Psychiatrists, told Psychiatric News. "There is very robust evidence of its efficacy in depression and in multiple anxiety disorders, particularly generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social phobia.

"The nice thing about CBT is that you can use it in a 15-minute appointment, a 60-minute appointment, or on an inpatient service."

In addition, she noted, there are data to support its use as "an effective adjunctive treatment for bipolar disorder and schizophrenia-not by any means as the sole line of treatment, but in terms of increasing medication adherence, decreasing hospital days, and increasing patients' responses to medication. There is also good evidence of its efficacy in bulimia and as an adjunct in the treatment of a number of medical conditions-for example, chronic pain, chronic headache, and irritable bowel syndrome."

In fact, of all the talk therapies, CBT is "the most widely studied in controlled, clinical trials," added Bernard Beitman, M.D., chair of psychiatry at the University of Missouri and a member of the APA Committee on Psychotherapy by Psychiatrists.

Anecdotal reports from psychiatrists also underscore the value of CBT.

For example, Angela Harper, M.D., a psychiatrist in private practice in Columbia, S.C., once had a medical student as a patient. "She had a lot of false beliefs about her ability to do the work," Harper recalled during an interview. "Yet with the help of a year's worth of weekly CBT, she went from being a C+ to B student to being a B+ to A student."

H. Blair Simpson, M.D., Ph.D., an assistant professor of clinical psychiatry at Columbia University, uses CBT to help patients with obsessive-compulsive disorder. She has seen patients make remarkable recoveries as a result. "It is a very moving thing when you see someone combat their disabling anxiety and gain their life back with CBT," Blair attested. "It can not only reduce their symptoms, but also increase their self-esteem in the process."

And aside from the direct benefits that CBT brings patients, psychotherapists see other advantages.

Progress Can Be Rapid

"Generally compared with longer-term psychotherapies, we see progress pretty rapidly, which is enormously rewarding for therapists and patients," said Judith Beck, Ph.D., director of the Beck Institute for Cognitive Therapy and Research in Philadelphia and the daughter of Aaron Beck, M.D., the father of CBT. "A lot of the therapy is really oriented toward `How can I help the patient have a better week?' So we are focusing on current problems.... We are also teaching the patients how to use the techniques, for example, breaking down larger problems into smaller parts. These are tools that they can use for the rest of their lives."

"The nice thing about CBT," said Harper, "is that you can use it in a 15-minute appointment, in a 60-minute appointment, or on an inpatient service. It has a lot of different utilities to it that other psychotherapies don't necessarily have."

For example, she noted, "patients tend to enjoy it because it is more interactive. They get some feedback from you as a therapist and also some helpful suggestions on what they can do when they get home and things to practice. And a lot of patients like homework for the simple reason that it gives them something to work on between appointments, and they feel like they are getting some therapeutic benefit between visits."

One of the most gratifying aspects of using CBT, Simpson pointed out, is that it provides people "with a set of skills that they can use on their own to master their own problems."

CBT Presents Several Challenges

Yet like any psychiatric treatment, CBT has its drawbacks.

"A major challenge with CBT," Beck explained, "is that the therapist has to learn the cognitive formulation for each of the specific psychiatric disorders that she'll be treating and has to learn how to vary treatment for those disorders. [For example,] treatment of panic disorder has some similarities with treatment of depression, but it is also different in important ways."

Simpson agreed: "This is one of the big research questions now, at least in anxiety disorders: Is there one generic CBT that one could teach therapists and that they could then apply to the different anxiety disorders?"

"Some of the patients don't like to do homework," said Harper. "In order to do CBT completely correctly, you really should be using homework in your therapy... .The other thing that may be a drawback is that some folks who are very intelligent and have a lot of insight have difficulty at first seeing the benefits of breaking things down to more simple ways of looking at things."

"One of the things that is really important early on with [CBT] is to educate the patient in this way of thinking, in this way of understanding problems," emphasized Jesse Wright, M.D., professor and chief of adult clinical psychiatry at the University of Louisville and a CBT proponent. "And for some patients that comes very easily,... whereas for other people, it takes a bit of effort to educate them so that they can understand how this therapy works."

Wright added that there are some patients who just won't cooperate with the approach CBT requires. The therapy "is not a panacea that works for every patient in every situation. Some people prefer other kinds of treatment. Some people would rather just take a medication and not have psychotherapy at all."

Future Appears Bright

Even with these constraints, it looks as if CBT is not only going to continue to flourish, but to evolve.

"One of the funny, but to me expectable, evolutions of CBT," Beitman observed, "is that those who practice it are starting to recognize resistance, transference, and countertransference in what goes on.... [In other words,] they are realizing that some of the aspects of psychodynamic therapy have relevance for doing CBT."

"CBT techniques will be modified to make them even more effective than they are today," said Simpson. "For example, virtual reality CBT treatments and computer-interactive CBT treatments are being developed. There is also interest in using medications that might enhance the effects of CBT itself. And what I anticipate, and what I hope, is that we'll know more and more about the brain mechanisms that underlie how CBT actually works."

"I think that what is going to happen," Beck said, "is that CBT is going to be applied more and more widely, for different diagnoses and for different populations. A huge amount of research in cognitive therapy is with medical patients who have a psychological component [to their illness].... I think there will be more of an application of cognitive therapy in the primary care office.... And I think it will also be used more broadly not only in individual therapy, but also in group therapy."

Founder Predicts Wider Use

Finally, as Aaron Beck, M.D., university professor of psychiatry at the University of Pennsylvania and father of cognitive therapy, told Psychiatric News, "I think that CBT has been refined and perfected enough that the next stage is going to be dissemination. What I foresee is that it will be much more widely used by psychiatrists, who will probably integrate it into treatment of the severely mentally ill, and then by other professional groups, including psychologists, social workers, and nurses."

He explained that his projections "are based on observations, not just on wish fulfillment. In Britain and the Scandinavian countries, CBT has become the dominant form of psychotherapy and has been endorsed by the national health services of those countries."


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