In order to overcome behavioral problems such as anxiety, depression or fear, individuals usually communicate their problems or anxieties with their trusted friends or family members. In case of somewhat complicated problem, a counselor is consulted. These are a relatively simple form of psychotherapies that individuals have been practicing for centuries. However, with the development of modern science and advancements in the field of Psychology, theorists have identified some more effective approaches for psychoanalysis. One of these approaches is cognitive behavioral treatment or therapy (CBT). CBT of depression is a psychotherapeutic treatment approach that involves the application of specific, empirically supported strategies focused on changing negative thinking patterns and altering behavior. Cognitive therapy teaches a client the connection between thought patterns, emotional state, and behavior. This therapy encourages the client to change irrational and negative thinking patterns in order to alleviate the emotional symptoms that are caused by the thoughts. These approaches were developed as a result of modern psychological research and are therefore based on scientific principles.
Cognitive Behavioral Therapy (CBT) represents a combination of behavioral and cognitive theories of human behavior, psychopathology, and a melding of emotional, familial, and peer influences. There are several subclasses of the psychotherapy CBT some of these include, Rational Emotional Behavior, Cognitive, Rational Living, and Dialectical Behavioral Therapy among others. CBT builds a set of skills that enables an individual to be aware of thoughts and emotions; identify how situations, thoughts, and behaviors influence emotions; and improve feelings by changing dysfunctional thoughts and behaviors (Cully,J., Teten, A.,2008). This topic/theory is chosen because it targets multiple areas of potential vulnerability (e.g., cognitive, behavioral, affective) with developmentally-guided strategies and traverses multiple intervention pathways. The target group or populations in which this research will address include psychological disorders in youth and adolescents. This paper will discuss the framework and review why this practice is a staple for therapeutic practices. The application of CBT within the mental health field will be reviewed and rationalized as to why this particular theory is chosen for future practice.
History of CBT
True to its name, cognitive-behavioral therapy (CBT) emerged as a rational amalgam of behavioral and cognitive theories of human behavior, causal and maintaining forces in psychopathology, and targets for intervention (Kendall & Hollon, 1979). CBT was originally developed to treat depression, and has since been adapted to the treatment of anxiety disorders, substance use disorders, personality disorders, eating disorders, bipolar disorder, and schizophrenia (Wenzel, A., Brown, G. K., & Karlin, B. E. (2011). CBT was developed by Aaron Beck in the 1960's, this began with development that blended the elements of behavioral therapy with cognitive therapy. Thus, although behavioral therapies and cognitive approaches seemed to develop in parallel paths, over time the two approaches merged into what is now called cognitive-behavioral therapy ( Milkman,H., Wanberg,K.(2007). It stems from the initial approach of Rational Emotive Therapy (RET). Assumptions of cognitive behavioral therapy were initially developed by Albert Ellis in Rational-Emotive Behavior Therapy (REBT) and, then, later altered by Aaron Beck with Cognitive Therapy (CT) and Donald Meichenbaum with Cognitive Behavioral Modification.(CBM) (Spicer, A.2005).Within REBT is a directive, persuasive, and confrontational form of therapy in which the therapist fulfills the role of a teacher. Clients have negative 'irrational' thoughts when faced with an activating event. When or if clients confront these thoughts and change them, the theory is wanted changes in behaviors/reactions will follow. Cognitive therapy incorporates open ended questions to allow reflection, to address and resolve a person's issues themselves.
The numerous strategies that comprise CBT reflect its complex and integrative history. Following from early respondent conditioning theories (Bandura, 1977), CBT incorporates concepts such as extinction and habituation. CBT went on to integrate modeling and cognitive restructuring strategies from social learning and cognitive theories. In addition, focus on self-talk and problem solving are each evident in CBT's general focus on fostering the development of personal coping strategies and mastery of emotional and cognitive processes. Consistent with a tripartite view (cognition, behavior, emotion) of psychopathology (Barlow, 2000), CBT targets these multiple areas of vulnerability and avenues of intervention.
Research provides a history of CBT as applied to youth psychopathology. This history can be traced back to the 1960's when the value and effectiveness of the prevailing psychodynamic perspective was questioned (Levitt, 1963) and found to be lacking. Behavior therapy consequently gained distinction but, in the 1960s, these therapies were initially controversial and primarily relegated to the treatment of behavior dysfunction in severely disordered children. It was not until the mid to late 1970's that the continuing expansion of behavioral therapies reached higher functioning clients, integrated the role of cognitive processing, and incorporated a focus on emotions. The transition did not happen at once. In the end, social cognitive processing, psychology of self-control, and emotion regulation were blended into behavioral interventions and,emerged as CBT of the present day.
Before there was CBT, there was behavioral therapy which initially was controversial and underestimated however ultimately paved the way for empirically-supported treatments for mental health disorders of youth. For example, the Mowrers' 'bell-and-pad' procedure for the treatment of enuresis is an often-cited example of an early behavioral intervention. Though clinical applications of behavioral strategies did not begin in seriousness until the 1960's,initial work set the stage by targeting and addressing observable behavior and by measuring outcomes for later child cognitive-behavioral interventions.
Respondent conditioning explanations of behavior influenced early behavior therapy, particularly for the treatment of anxiety. In respondent conditioning, a conditioned stimulus (CS) closely follows an unconditioned stimulus (UCS) that elicits an unconditioned response (UCR) of fear. After repeated pairings, the CS alone will elicit the conditioned response (CR) of fear. Respondent conditioning was historically important in birthing notions of exposure tasks for the treatment of anxiety, now a well-established example, if not hallmark, of modern CBT for child anxiety (Barrios, O'Dell, 1998). Children often try a number of behaviors and then learn from consequences. One example of this is smoking, if you try smoking and you are accepted within the crowd of peers this is a positive reinforcement and a child will likely repeat the behavior. If the same child is caught and disciplined the likelihood of continuing the behavior is minimized and less likely to be repeated (McLeod,S. 2007).These possibilities play a major role in the shaping of behavior over time. Environments low in predictable and preferred contingencies may lead to decreased self-efficacy and maladjustment.
Many behavioral processes continue to be used within CBT. Over time, behavioral therapy began to address the thought processes and cognitive skills that were seen as involved in the implementation and receipt of contingency management and came to be implemented among less severe populations. This change to higher-functioning youth and to an increased awareness of the role of cognition was an important part of the conversion to CBT. Many behavioral interventions, and cognitive-behavioral interventions, were initiated and researched with children in mind. They were not borrowed adult treatments, or downward extensions of adult treatments applied with children. To its credit, cognitive-behavioral therapies with youth were intentionally developmentally-sensitive and research-informed interventions.
With CBT the approach is rooted in fundamental principle that one's cognitions play a significant role in development and maintenance of emotional and behavioral response to life situations. Case in point Post Traumatic Stress Disorder (PTSD). PTSD is a type of anxiety disorder, this can occur after experiencing extreme emotional trauma with a perceived threat of death or serious injury. CBT approach to treatment typically incorporates two theoretical orientations as to why the fear is developed. The first of these is the Learning Theory. Learning Theory focuses on how the mechanisms of fear and avoidance of the trauma are conditioned, activated and reinforced. The second is Emotional-Processing Theory. This is the meaning attached to the memory prevents the individual from confronting the traumatic memory and then processing the information. The goal of CBT for PTSD patients is to teach cognitive-reframing techniques. These may include a form of exposure to the traumatic memory, such as repeated exposure to images or a written description of the trauma. This allows the patient to construct a detailed account of the event and discuss feelings and cognitions associated. Thought process strategy allows understanding patients to see how pushing the memory further away in the mind actually reinforces the impact of the memory. The memory instead is dealt with and accepted as a memory. In a study of 92 assault victims trauma focused cognitive behavioral treatments/therapy, using virtual reality, imagery, or written exposure are effective treatments for PTSD(Prendes,A., & Resko, S.). Rates of exposure to violence and traumatic events for children and adolescents are exceedingly high. In a nationally representative sample of children and adolescents in the United States, 60.4% reported exposure in the past year, with lifetime rates nearly a half to one-third higher, depending on exposure type (Finkelhor, Turner, Omrod, & Hamby, 2009). Clearly with these statistics CBT will be beneficial in the treatment of children and adolescents. Cognitive-behavioral therapy is also used widely in treatment of borderline personality within youth. CBT with borderline patients because of their explicit focus on self-regulation use of Meichenbaum's approach to teaching impulse control to impulsive children. Focus on the progressive internalization and reutilization of self-instructions to stop, look, listen, delay, plan, and implement an appropriate strategy. Cognitive techniques, directed against catastrophizing, black-and-white, or either-or thinking are appropriate for treating borderline patients. The therapist points out the way these cognitive patterns are activated under certain circumstances and helps the patient reality-test them when they emerge. Borderline patients are not easily 'argued out of' their distortions, and are seldom able when their emotions are aroused to engage in the kind of reality-oriented 'collaborative empiricism' of cognitive therapy(Westen,D.1991).
The shift forward
CBT is defined as a purposeful combination of the demonstrated efficiencies and methodological rigor of behavioral procedures with the cognitive-mediational processes that influence adjustment (Kendall, Hollon, 1979). In the 1970's, internal thought processes (e.g., self-talk began to be viewed as both targets and mechanisms of change, with an importance on improving cognitive skills rather than modifying behavior. Two early reports of CBT with children were combinations of self-instructional training, with coping modeling and a response cost contingency. As promise was seen in efforts to incorporate children's developing cognitive abilities into behavior modification to produce therapeutic change, cognitive processes became integrated with behavioral interventions. By integrating cognition, the behavioral model adopted a broader and effective behavior change strategies.
Meyers and Craighead (1984) identified several forces that led the shift toward interventions that were cognitive-behavioral in nature. One force, cognitive psychology, was a factor that impacted behavior therapy with children through (a) modeling, (b) self-instruction training, and (c) problem-solving. The cognitive information processing explanation of modeling, or observational learning, holds that even in the absence of respondent or operant contingencies, an individual can learn by viewing another person's behavior. Although modeling was historically identified with behavior therapy, Bandura's explanation of modeling effects highlighted attention and retention, which are cognitive processes drawn from an information-processing model of cognitive psychology, as among the major factors that influenced observational learning. Bandura's account of modeling, which ushered in a cognitive explanation for a portion of behavior therapy, and his discussion of the role of symbolic cognitive processes in behavior change, were springboards for the theoretical advance of CBT (Meyers, Craighead, 1984). Indeed, various behavior therapy interventions began to be understood from both an information-processing and a more general cognitive viewpoint (Mahoney, 1974).
Self-instruction training was another avenue through which cognitive psychology impacted behavior therapy. Self-instruction emerged to teach impulsive children how to control their behavior. The program drew from the language-development sector of cognitive developmental psychology, particularly the work of Luria and Vygotsky, who suggested that children learn to control their own behavior by overt and eventually covert speech. Researchers and clinicians continue to draw from the cognitive developmental literature to incorporate cognitive strategies and enhance behavior therapy procedures. For example, the literature on social cognition has contributed to notions of self-talk and social skills training, and to our understanding of mechanisms of behavior change.
Problem solving, though once linked with behavioral learning, has a cognitive information-processing flavor. Problem solving within CBT for youth focuses on internal thought processes as one mechanism of change. Several early programs for youth employed problem solving. As evidence of its lasting impact, many current empirically-supported programs for youth have a problem-solving focus. The emphasis on modifying thought processes as a means for producing both behavioral and cognitive change illustrates the integration of CBT and cognitive developmental psychology.
Interventions that targeted self-control were described as a third force behind CBT for youth. Explanations of self-control procedures were progressively cognitive in nature, with influential papers supporting the role of internal factors in self-control. Main beliefs of self-control were being applied to work with children in the mid-1970's, as theoretical advances (e. g., Bandura's self-efficacy buttressed the relationship between overt and covert events. Studies of self-control and self-efficacy advanced the testing of private cognitive experiences in ways that could be integrated within behavioral paradigms.
Anxiety disorders in children are common with causative factors such as school, family relationships, and social functioning. Anxiety disorders in childhood remain under recognized and under treated. It is speculated that as much as 12-20%of children seen in mental health settings suffer from extremes of anxious-nervous manifestations (Knell & Dasari,2006, Schafer,2009). Behavioral problems resulting from anxious reactions to their world, cause disruption, in the child, families, and community. Parents often misunderstand the source of the problem being anxiety and rather describe it as attitude, being spoiled, or attention seeking behavior. A study of children from 7-17who had separation or generalized anxiety disorder were treated with CBT over a years' time span. CBT was a 60 minute session which included various child anxiety assessment tools for data. Medication was introduced to a portion of the group and a combination was used for the remaining group participants. The end results show CBT as an effective treatment. This is rewarding news and will increase parents approach to treatments as well as open the door to increased diagnosis and treatment for children (Walkup,J., Albano,A., Piacentini, J. & Birmaher, B. (2008).
The emerging successes of cognitive therapy for adult disorders influenced the psychological treatment of children. A core assumption of cognitive therapy is that maladaptive cognitive processes produce psychological disorders, which can be improved by modifying these cognitive processes. Ellis' irrational thinking and Beck's cognitive distortions are examples of the key concepts that influenced CBT. Specifically, Ellis and Harper proposed that people engage in maladaptive behavior and/or experience negative mood states because they engage in irrational thought processes. Thus, they argued that the focus in therapy is changing maladaptive ways of thinking. Beck similarly maintained that maladaptive cognitions are associated with psychological disturbance. Many research evaluations have supported cognitive therapy with adults, and clinical work with children has been influenced by, and frequently refers to, the work of Beck and Ellis.
Given the increasing number of studies supporting therapeutic benefit for cognitive therapy, the focus was placed on assessing and understanding cognition despite traditional difficulties with isolating and measuring such phenomena. Some of the early cognitive therapy with adults relied on persuasion and reason, though later efforts underscored the benefit of prospective hypothesis testing and behavioral tasks.
The integration of the strategies of cognitive and behavioral therapy thrived due to the desirability and viability of this combination to produce clinically meaningful outcomes. Indeed, without the favorable research evaluations, the approach would not have gained interest from practitioners nor maintained itself among researchers. Simply put, the use of contingencies to facilitate a child's engagement in exercises that produce cognitive change was both data-supported and clinically appealing.
Though its initial impetus was the wedding and integrating of cognitive (e.g., thoughts influence behavior and emotion) and behavioral (e.g., research evaluation, contingencies) traditions, CBT rapidly evolved and emerged as a treatment informed by a wider set of models. CBT grew and materialized to address salient disorders in youth, as well as developmental vulnerabilities toward psychopathology. Just as the role of cognition has, in its pioneering fashion, come to be incorporated into behavioral therapy, so too have forces related to social environments, genetic vulnerabilities, therapeutic processes, and familial and peer relationships.
As an illustration of expanding models, consider Clark and Watson's] tripartite model as an explanation for the extensive overlap of the otherwise-seen-as-separate disorders, anxiety and depression. The tripartite model describes how anxiety and depression share a common component, negative affect, which accounts for symptom overlap. Negative affect is the sense of high objective distress and includes a variety of affective states such as being angry, afraid, sad, worried, and guilty. The model suggests that negative affect is a shared dispositional vulnerability for emotional psychopathology, specifically anxiety and depression. By contrast, low positive affect is a factor specific to depression and autonomic arousal is a factor specific to anxiety. CBT for addressing emotional disorders, in sync with the tripartite model, also targets overlapping features. However, Barlow suggested that anxiety is different from autonomic arousal. He proposed that negative affect is a pure manifestation of the emotion of anxiety, while autonomic arousal is a manifestation of the emotion of fear. Despite small differences, autonomic arousal, high levels of general distress and negative affect, and low positive affect are seen as important predisposing traits of emotional psychopathology. Targeting and treating these salient factors across disorders is a strategic approach that has been accepted within CBT.
Barlow described a triple-vulnerability model of emotional disorders: (1) a general genetic vulnerability, (2) a general psychological vulnerability characterized by a diminished sense of control, and (3) a specific psychological vulnerability resulting from early learned experiences]. This diathesis-stress model is consistent with how children may develop a sense of diminished control through experiences with both their own highly reactive arousal system and high negative affectivity and with uncontrollable life events. Once a diminished sense of control is developed, a child is more likely to perceive other events as uncontrollable, even those for which the child could potentially manage. For example, over controlling, unresponsive, and unpredictable family environments can foster a sense of uncontrollability and an external locus of control, a major psychological vulnerability. A specific psychological vulnerability can arise from early socialization experiences with the family or peers, and can contribute to experiencing psychopathology in particular areas. In accordance with this vulnerability model, CBT approaches for youth incorporate parent training with an increased focus on contextual issues and the development of children's mastery over their own environment.
Current and Future Directions
Disorder specific applications of CBT for children and adolescents have enjoyed widespread application. A search of key terms 'cognitive behavioral therapy' and 'children' on PsycInfo, an online database of psychological literature, revealed 1192 articles, 1156 of which were published since 1990. Increased interest in and research on CBT has firmly established its presence in the field of clinical child and adolescent psychology and psychiatry. The initial book on CBT with children and adolescents is now in its fourth edition, with numerous chapters describing CBT procedures for specific disorders (Kendall, 1991).
True to its ties with the empirical methods of behavior therapy, CBT with children and adolescents continues to be guided by empirical research. Studies of the nature of specific disorders inform treatment procedures, and evaluations of treatments applied to real cases inform dissemination and practice. To date, an impressive series of empirical research reports support the use of CBT for the treatment and prevention of various psychological disorders in youth. The American Psychological Association Task Force on Promotion and Dissemination of Psychological Procedures established criteria for use in determining whether treatments can be considered empirically-supported (see also Chambless & Hollon's criteria (Chambless , Hollon, 1998).
Based on the criteria, treatments can be categorized as either 'well established,' 'probably efficacious,' 'possibly efficacious,' or 'experimental.' CBT has emerged as the treatment with the most empirical support for numerous internalizing disorders in youth. Specific modalities of CBT have been categorized as 'well established,' such as child-only groups and child groups plus a parent component for youth with depressive disorders. A specific CBT protocol for youth exposed to traumatic events, Trauma-Focused CBT, is also considered 'well-established'. Many other CBT protocols have been categorized as 'probably efficacious' for the treatment of internalizing disorders, including the Coping Cat Program for anxiety and phobic disorders, school-based group CBT for exposure to traumatic events, and individual exposure-based CBT for obsessive-compulsive disorder.
Although less support has been found for the use of CBT for externalizing disorders in youth, group CBT is considered a 'well established' treatment for adolescent substance abuse and some CBT protocols, such as Anger Control Training and Rational-Emotive Mental Health Program, are considered 'probably efficacious' for the treatment of disruptive behaviors in youth (Eyberg, Nelson, Boggs, 2008). Overall, CBT is often considered the 'first line of defense' in the treatment of psychological disorders in youth.
Although additional work is necessary to strengthen the efficacy of CBT for youth, researchers have called for a shift toward examining the mediators, moderators, and predictors of treatment outcome. This call implores researchers to go beyond evaluating the degree to which treatment works and to move toward examining why and for whom it works]. Future research has many worthy candidates of investigations. Potential mediating variables worthy of exploration include the individual components of treatment protocols, therapeutic process variables such as therapeutic alliance and child involvement, and within-client change processes. Future work is also necessary to delineate whether certain pretreatment characteristics, comorbid conditions, and treatment formats moderate or predict outcome. Given the ever-increasing use of technology in society, a particular area ripe for research includes the use of computer technology in CBT protocols.
A pressing concern and an area requiring empirical support is how best to disseminate CBT to community practice (Beidas, Kendall, 2010). The growing empirical support of the efficacy of CBT does not guarantee its use. 'Bridging the gap' between research evidence and clinical practice is an endeavor requiring effort from all parties involved, including researchers, practitioners, policymakers, and mental health consumers (Tansella, Thornicroft, 2009). It can be argued that the pursuit of dissemination constitutes the next chapter in the history of CBT. Engagement in this endeavor will likely lead to global improvements in the mental health care of youth.
CBT represents an integration of behavioral, cognitive, and other (e.g., developmental, social) theories of human behavior and psychopathology. The numerous strategies that comprise CBT reflect its complex and integrative history and include conditioning, modeling, cognitive restructuring, problem solving, and the development of personal coping strategies, mastery, and a sense of self-control. CBT targets multiple areas of potential vulnerability (e.g., cognitive, behavioral or affective) and provides avenues of intervention. CBT is often considered the treatment of choice for mental health disorders in youth. Additional work is needed to understand the mediators, moderators, and predictors of treatment outcome, and to pursue the dissemination of efficacious CBT approaches.
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