Introduction to Cognitive Behavioral Therapy
CBT is a psychotherapeutic model that includes a process of engaging an individual in a collaborative manner in order to examine the way the individual constructs and understands the world around him or her (cognitions). The cognitive behavioral therapist evaluates processes by which the individual acts on those cognitions (behaviors). The targeted behaviors and cognitions are challenged through a series of behavioral or cognitive experiments aimed to gradually change one's way of thinking, behaving, and interacting within the environment.
The therapist uses a process of guided discovery to help the individual uncover belief systems or conclusions that are unconsciously influencing current feelings, behaviors, or thoughts. Once the belief systems, called schema, are uncovered, the therapist helps the patient to experiment with alternative explanations and responses in order to evaluate the evidence of this faulty reasoning.
Advanced practice psychiatric nurses (APPNs) are in a unique position to coordinate physical, psychiatric, and social theory into true holistic care for the individual using the highest standards of empirically supported treatment. Given the evidence supporting CBT, it makes sense that APPNs become adept in the use of this psychotherapeutic method.
Overview of Cognitive Behavioral Therapy
CBT is based on treatment plans that are clearly conceptualized and based on tested theories that guide the clinician through each action, session, and overall plan of care. It is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems.[3-9]
Efficacy of Cognitive Behavioral Therapy
Cognitive therapy and, by extension, CBT have demonstrated empirical efficacy in a wide range of medical disorders such as tinnitus, chronic pain disorders, [11-16] premenstrual dysphoric disorder,[17,18] sexual disorders, and sleep disturbances. In addition, CBT has been proven to have superior efficacy as a psychotherapeutic method for mood disorders such as depression,[5,20-22] anxiety, and panic disorders.[23-31]
CBT, as opposed to other psychotherapeutic models, has proven efficacy for disorders such as eating disorders,[32-34] personality disorders, substance misuse disorders,[35,36] marital problems,[37-39] posttraumatic stress disorder,[9,40-42] self-injurious behaviors, obsessive compulsive disorder,[7,43-46] schizophrenic symptom reduction,[47-49] hypochondriasis  and somatoform disorder, antisocial behaviors, and sexual offense spectrum disorders.
Guiding Principles of Cognitive Behavioral Therapy
Cognitive Set. Each individual responds in an idiosyncratic manner to their environment. Each situation encountered requires the individual to process incoming data, analyze the content and meaning, and then respond in a way that makes sense to that person. The interpretation of the data and meaning assigned to it results in that person's emotional reaction to the situation and behavioral response based upon the interpretation and emotion.
CBT posits that thoughts, behaviors, and feelings interact to form a cognitive "set." If there are adaptations or changes to one area of the "set," the remaining components will also become altered. The therapist and the individual investigate the "set," determine if change is warranted, and establish outcome goals that are reasonable, attainable, and measurable.
The therapist's role is to act as a coach, mentor, or guide through the process; to provide necessary skill training; and to help design, in collaboration with the patient, appropriate experiments with high likelihood for success. The therapist uses techniques that include collaborative empiricism and guided discovery (Socratic method of questioning) to assist the individual in challenging mistaken assumptions and other cognitive errors that may be affecting that person's response to a given situation.
Cognitive Shift. If an individual is under duress, as in anxiety or depressive states, that person's unique coding system becomes more primitive or reactionary, resulting in a skewing of the information processing. The result of this skewing is a "cognitive shift" that introduces bias into the interpretations, inferences, and coding mechanisms, resulting in distorted thoughts or cognitions.
The process of skewing based on the individual's coding system results in a pattern of unique idiosyncratic vulnerabilities that predispose one to psychological distress. Epictetus said thousands of years ago that "everyone must deal with each thing according to the view which he forms about it." The idiosyncratic view is a manifestation of individual cognitive processing patterns.
Development of Cognitive Behavioral Therapy
Cognitive therapy differs significantly from other models of psychotherapy in that it "is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient." It is generally agreed that CBT evolved primarily from the work of Aaron T. Beck, who conducted systematic studies on depression and suicidal thinking using structured cognitive therapy with clear guidelines to follow and specific procedures. 
During the 1970s, researchers began to apply behavioral techniques to cognitive theories and strategies. Prior to this, traditional behavioral experiments were used to shape measurable behaviors, with little attention paid to the cognitive processes involved in the behavioral and emotional changes. Fearful responses were extinguished with exposure protocols, for example.
With the addition of cognitive therapy to behavioral experimentation, extensive research has demonstrated significant efficacy in the combined approach, using cognitive techniques (to modify fearful cognitions, for example) along with behavioral techniques (such as exposure therapy and relaxation training). It is imperative that interventions target all 3 foci (cognition, behavior, and emotion) in order to effect sustainable changes, cognition being the pivotal point.
Cognitive Behavioral Therapy Techniques and Targets
CBT is based on the assumption that each individual behaves, thinks, and feels about a certain situation based upon their interpretation of that situation. CBT uses specific techniques to help people learn to recognize the way that their thoughts, feelings, and subsequent behaviors interact.
Table 1 and Table 2 provide an overview of some of the most commonly used CBT techniques. The techniques are chosen based upon the target feeling or behavior. In order to begin the change process in the CBT approach, the therapist works with the individual to uncover their unique automatic thoughts.
Dysfunctional or maladaptive thoughts are perceived by the individual as "automatic," with little personal control over the cognition. In fact, these automatic thoughts (ATs) are the target for CBT techniques. Dysfunctional ATs are upsetting or not helpful to an individual and usually contain distorted conclusions or premises. This is what makes cognitive distortions excellent targets for change: the individual is trained to evaluate the distorted thought pattern and alter it in a more adaptive fashion.
The therapist often focuses on the most common type of distortion that an individual uses, points out the process to the individual, and then assists him or her in exploring the factual basis of the cognitive style. See Table 3 for examples of cognitive distortions.
Modifications or Alternative Approaches Within Cognitive Behavioral Therapy
Dr. Jeffrey Young developed schema therapy (ST) as an expansion, extension, and revision of classic CBT. Young stated that, "in comparison with standard cognitive therapy, ST probes more deeply into the childhood origins of distorted thinking, relies more on imagery and emotion-focused techniques." Individuals are guided by belief systems, or schema, generated by every experience, action, reaction, and interaction and based on our own personal, religious, familial, cultural, gender, and age-related contacts that we have had over the years.[1,2,53,59]
Fundamental core beliefs or assumptions are a unique component of the perceptual filter people use to view their world. Cognitive behavioral therapists seek to change schemas that are no longer useful or are maladaptive. Schemas may be selected by an individual for recall, suppressed in memory, or they may be used for interpretation of information, generation of affect, motivation, or action and/or control. [1,2] ST is, and has been, a critical component of classical CBT since its inception. Understanding an individual's schemas, belief systems, and underlying attitudes is essential in understanding the individual.
Schemas are in a constant state of adaptation and become increasingly complex as an individual ages. Thus, the process of adaptation may serve to help or hinder the individual as they apply their schema to new situations. Young proposed that early schemas are more resistant to change than schemas that develop later in life. He identified these schemas as early maladaptive schema.
Young identified 5 domains that correspond with the basic needs in children. The domains are: disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and overvigilance and inhibition.  When one's needs are not met, early maladaptive schema develops, which is explored and modified in ST treatment.
Young further postulated that there are 3 processes regulating the functioning of activated schema. These processes are schema maintenance, schema avoidance, and schema compensation. Basically, these coping styles or processes correspond with the basic stance an individual takes when a schema is triggered: surrender to it (maintenance), avoid it, or fight back (compensation). For additional information on ST, refer to Dr. Young's Web site: http://www.schematherapy.com.
Rational Emotive Behavior Therapy
Rational emotive behavioral therapy (REBT) began as rational therapy (RT) in the early 1950s and was based on the combined principles of Greek and Roman stoicism.  The name was changed, first to include emotional and later behavioral components, even though Ellis had always incorporated both of these techniques into RT.
REBT is a form of CBT and is practiced by therapists around the world. The model is based on the premise that all humans learn both self-preserving and self-destructive thoughts, feelings, and behaviors. Illogical behaviors and thoughts are considered self-defeating while logical, flexible, and empirically validated thinking generates self-enhancing emotion.
The basis of REBT is to teach individuals strategies to control dysfunctional emotions using an "ABC" model with a structured format. The individual is educated on the relationship between their B (beliefs) and C (emotional/behavioral consequences) and the A (activating events). Therapy is directed at: (1) acknowledging that emotions/behaviors are dysfunctional; (2) identifying irrational beliefs; (3) recognizing that these beliefs are illogical and maladaptive; and (4) replacing the irrational beliefs with ones that are logical and adaptive.
Dialectical Behavioral Therapy
Another approach to CBT is dialectical behavior therapy (DBT), which was developed by Dr. Marsha Linehan in her work with parasuicidal patients. Significant empirical support has been shown for the efficacy of treatment with DBT in parasuicidal individuals with cluster B personality disorders. This treatment is a combination of behavior therapy and acceptance approaches blended together by a set biosocial theory and multiple modes of treatment (eg, individual therapy, group skills training, pharmacotherapy).
Mindfulness skills target improvements in awareness of internal experiences without judgment. Mindfulness is the cognitive therapy technique that is otherwise known as, "OK, tell me what you are thinking/feeling right here, right now." Emotion regulation skills are designed to reduce vulnerability to emotions, increase positive emotions, accept emotions, and change specific emotional states using behavioral and cognitive skills. Distress tolerance skills assist patients in tolerating ordinary life pain without engaging in behavior that is self punishing.[63-65]
Case Example: Treatment of Depression With CBT
Kathy is a 42-year-old married woman who has been diagnosed with breast cancer. Kathy has completed 1 series of chemotherapy treatments following a mastectomy with reconstruction. Kathy makes an appointment with her nurse practitioner, Karen, for evaluation of depression. She is reporting difficulty falling asleep, early morning awakening at 4:00 am, tearfulness, anergia, low motivation, hopelessness, and helplessness.
Kathy also has negative views of herself ("I am so ugly now") and her future ("I don't believe I will ever have a normal life again"). Karen evaluates her for medical explanations for her symptoms such as anemia, which is common in individuals treated with chemotherapy, and finds that all serum levels are normal. Karen decides to call Kathy in for an appointment to talk about her symptoms and options for therapy.
Karen structures her session with Kathy in the following way:
1. Assess Kathy's mood and review her view of recent events.
2. Collaboratively set an agenda for the meeting, making sure that discussion of psychotherapy and medication options are a component.
3. Review results of Kathy's medical evaluation.
4. Discuss Kathy's issues and views as identified on the agenda.
5. Introduce or review specific skills to address her cognitions and behaviors.
6. Formulate a homework task and identify any factors that may interfere with homework completion.
7. Help Kathy summarize the main points of today's meeting and conclusion.
8. Discuss her thoughts and feelings about the session.
Karen uses a Socratic dialogue technique to talk with Kathy. The goal of her questions is to understand the meaning Kathy is attaching to her experiences and the way she understands herself as an individual. Karen does this by gently and persistently evaluating experiences and Kathy's interpretations that support her beliefs and attitudes as well as examining the advantages and disadvantages of maintaining those views.
Specific questions Karen might ask include:
Examining Kathy's thoughts and allowing her to develop an alternative plan gives her control over her behavioral choices. This increases the possibility that Kathy will "own" the plan and act upon it in between sessions. Karen and Kathy evaluate progress on the plan (homework) in the following session. Depending upon the results of the homework, Karen and Kathy will modify the plan or move on to the next issue.
Karen uses this same method of questioning to evaluate Kathy's negative thought processes and faulty conclusions.
Karen: "You said that your life will never be normal again. What do you mean by normal?" (evaluating idiosyncratic meaning)
Kathy: "I am so deformed and I don't have any energy and I don't care about anything anymore!"
Karen: "Which is more troubling to you — feeling deformed, no energy, or not caring about anything?" (Note: Karen is helping Kathy focus on one problem/issue at a time, making change more reasonable than a "scattergun" approach).
Kathy: "If I have to choose, I would say feeling deformed."
Karen: "Okay. Let's start with that feeling. Tell me more about feeling deformed."
Kathy: "My right breast is rebuilt — but I don't have a nipple and I have this huge scar across my chest! It is so ugly!"
Karen: "What choices have you discussed with your surgeon about replacing your nipple?" (Examining alternatives)
Kathy: "He said there were more surgeries I could have to build one, or I could have a tattoo of a nipple put on it."
Karen: "Which of these options is more appealing to you?" (Note: Karen did not ask if one option was more appealing. She is giving Kathy limited choices in a positive direction.)
Kathy: "I think a tattoo — the other surgery really sounds painful."
Karen: "Would the tattoo make you feel more or less deformed?" (Note: the answer seems obvious; however, it is important for Kathy to move from an all-or-nothing mindset to one that includes a spectrum of possibilities.)
Karen: "What have you investigated about this possibility?"
Kathy: "I haven't started that yet."
Karen: "Where will you start investigating this possibility?" (Note: Karen does not ask a question that allows for a nonstart reply.) (homework)
Kathy: "Well, my daughter got a tattoo last month — I can ask her where she went. She is going to laugh when I ask her about a tattoo parlor!" (Kathy is now smiling and even laughing, which indicates forward movement and a shift from negative to positive mindset.)
Karen: "You'll have to let me know how that goes!" (Note: Again, Karen states her response in the affirmative expectationthat Kathy will follow through as opposed to asking her if she will ask her daughter, which would allow for a negative response.)
Then end result of the session with Kathy is that Kathy now has a homework assignment that will shift her image of "deformed" toward a more positive possibility.
CBT is a process of engaging an individual in a collaborative manner in order to examine the way the individual constructs and understands the world around them (cognitions), and to evaluate the processes by which the individual acts on those cognitions (behaviors). The role of the APN is to act as a coach, mentor, or guide through the process, provide the necessary skills training, and design appropriate experiments with high likelihood for success in collaboration with the patient.
There has been a rapid increase in the numbers of psychiatric nurses who obtain advanced degrees and develop independent practices. The APN specializes in holistic assessment, prevention, and treatment approaches in a variety of settings. The approaches become more complicated as psychiatric medication, physical complications, and psychological conditions collide.
APNs need specialized and empirically tested evidence to guide their practices. CBT has been proven to integrate well in nursing practice and meets the scientific standard for effective techniques and interventions that are empirically based. As a result, CBT is the ideal vehicle for the APN to use to guide counseling and education interactions with individuals.
Table 1. Cognitive Techniques
The individual is helped to uncover underlying assumptions in logic and sequence through careful questioning by the therapist, who asks, "If this is true, then what happens?"
The therapist assists the client to clarify statements and terms used so that both the therapist and the patient have a clear understanding of perceived reality.
Labeling of Distortions
The individual is helped to identify automatic thoughts that are "dysfunctional or irrational." For example, the therapist might stop the individual during the session and have them repeat a portion of their sentence, saying, "did you mean you were 'starving to death' or you were really hungry?" to help the person evaluate internal dialogue and the images they evoke as a way to help them self-monitor for more accurate description.
Questioning the Evidence
The individual is helped to question the facts related to their cognitions and conclusions. This procedure investigates whether information is based on facts or assumptions.
Examining Options and Alternatives
This technique involves the development of all possible alternative explanations in order to learn the skills in generating options rather than "only one way" thinking.
In individuals with the habit of accepting all or most of the blame for outcomes, this is an excellent technique for redistribution of responsibility. This is also helpful for individuals with personality disorders that place the blame squarely on the shoulders of others for most outcomes.
Catastrophic thinking is one of the hallmarks of anxious individuals. These individuals tend to focus on the most negative possible outcome of any given situation. Decatastrophizing allows for balance and realistic focusing by examining the "worst possible outcome" and developing a plan of action.
Advantages and Disadvantages
For individuals who appear to be stuck between 2 options, examination of the advantages and disadvantages of certain situations helps them to develop alternative perspectives. This breaks the "all-or-nothing" mindset and permits a more balanced view of the situation.
Paradox or Exaggeration
This type of technique should only be used by the very skilled therapist; otherwise, the patient may view this technique as sarcasm or belittling. When used appropriately, the therapist takes an issue to the extreme to help the person see the absurdity of their sometimes overinflated viewpoints.
Turning Adversity to Advantage
This technique is akin to "making lemonade out of lemons." The individual is helped to identify how they can use what appears to be a negative situation to their advantage. For example, being turned down for a job may open the individual up for more attractive possibilities that they had not investigated.
Prior to making a behavioral change, it is sometimes less threatening to "practice" the new behavior through visualization and discussion. For example, this would include practicing assertiveness in a mirror or "talking through" a confrontation out loud prior to actually following through with the conversation.
Automatic Thought Records
The automatic thought record (ATR) is a key component of CBT. The ATR is used as homework after introducing the process within the therapy session. The individual completes the columns identifying a troubling situation, resulting emotion, and thoughts associated with both. The therapist and patient work on clarification and development of "rational" responses in order to debate or challenge the original reaction.
Table 2. Behavioral Techniques
Assertiveness training involves a combination of cognitive and behavioral practice. The therapist may model assertive behavior, assist the patient within the session with role-play, and finally develop in vivo experiments that increase in complexity over time until the new behavior is internalized.
The behavioral component usually follows the cognitive training component and again includes behavioral experiments to gather more evidence or to develop more effective responses and styles.
Graded Task Assignments
This technique is used in a series of steps that become increasingly more complex or difficult as a means of overcoming fears or anxiety-producing threats.
Bibliotherapy: The cognitive behavioral therapist will often prescribe specific readings related to the individual's difficulties.
Guided Relaxation and Meditation
Therapists often employ behavioral techniques aimed at reduction of autonomic nervous system responses to anxiety such as measured breathing, relaxation training, meditation, and other techniques.
Social Skills Training
These skills are often taken for granted by many individuals. It is important for the therapist to review and instruct on behaviors that will improve the potential for successful social interactions.
This technique was first introduced by Albert Ellis as a rational emotive therapy technique. Rational emotive therapists have the patient engage in behavioral experiments that emphasize their concern for what others think of them. The individual develops an experiment testing their hypothesis (people think I smile funny when I walk and look at me weird) and collects data between sessions. (Have a neutral observer collect the actual data. This helps them differentiate between "feeling" and "fact" to move past shame-based behaviors [see homework below].
The hallmark behavioral technique in CBT is the use of homework assignments. Activities are designed within the therapy session to be carried outside and practiced between sessions.
Table 3. Examples of Cognitive Distortions
All-or-nothing (dichotomous thinking)
He either loves me or he doesn't.
Mind reading (this is not thought insertion which is psychotic and in the opposite direction)
I am sure they all think I am stupid.