Cognitive Behaviour Therapy (CBT) was coined out by Aaron T. Beck in the early 1960s (Beck et al., 1979). It is a psychological intervention that attempts to create a connection between thoughts, feelings and behavior. The way people think affects how they feel about themselves and this in turn affects how they behave.CBT is founded on the belief that how people think (cognition), how they feel (emotion) and how they act (behavior) all interacts together(Beck, Epstein, & Harrison, 1983). That is to say, distinctively, our thoughts determine our feelings and to a large degree, our behavior. It incorporates“treatments that attempt to change overt behavior by altering thoughts, interpretations, assumptions and strategies of responding”  (Dobson & Dobson, 2003). The figure below illustrates how thoughts, feelings and behaviour are interrelated.

The Development of the Cognitive Behaviour Therapy (CBT)

CBT is presently the predominant psychotherapy paradigm being advocated for by psychology practitioners (Allen, 2011). It is claimed to be the most evidence based of all psychotherapies and is therefore assumed to be superior to other humanistic and relationship oriented styles of psychotherapies(Keith, 2009). CBTs have been studied vastly and this is for the reason that they have very limited and simplistic treatment goals which are in turn very straightforwardto measure, distinctfrom repetitive complex interpersonal patterns. CBT also rarely studies persons who have a lot of different psychological problems (Co-Morbid).

The cognitive model forms one of the major components of this therapy. It was first pioneered by psychologist Albert Ellis and later refined by psychiatrist Aaron Beck (Keith, 2009). It is based on the idea that human beings are irrational creatures in that they make a lot logical errors whenever they assess the risks and benefits of various situations and courses of behavior. These irrational ideas result to out-of-control emotions such as unreasonable anger and depression.

A number of treatment approaches exist within the scope of CBT(Dobson & Dobson, 2003). These approaches share the theoretical perspective that assumes internal covert processes called “thinking” or “cognition” occur, and that cognitive events facilitatebehavior change. Many cognitive-behavioral theorists state that because of the mediationalassumption, not only is cognition equippedto alter behavior, but it must alter behavior.

One of the trends in the development of the CBTs has been a growing interest in how cognitive mediation influences behavioral, emotional, and physiological processes, and how these various systems can reinforce each other in practice.  According to Dobson & Dobson (2003), there are three major classes of CBTs have been recognized, as each has a slightly different class of change goals. These classes are coping skills therapies, problem solving therapies, and cognitive restructuring methods. These different classes of therapy orient themselves toward different degrees of cognitive versus behavioral change.

Coping skills therapies are primarily used for problems that are external to the client. In this case, therapy focusses on the identification and alteration of the ways the person may exacerbate the influence of negative events such as. Engaging in anxiety-provoking thoughts and images; or employ strategies to lessen the impact of the negative events such as learning relation skills. Thus, the primary markers of success within this form of therapy involve behavioral signs of improved coping abilities and the concomitant reductions in the consequences of negative events. On the other hand, Cognitive restructuring techniques are used especially when the disturbance is created from within the person. This approach focusses on the long-term beliefs and situation-specific automatic thoughts that engender negative outcomes.

Two historical strands serve as historical bases for the CBTs. The dominant strand relates to behavioral therapies, which is often seen as the primary precursors to CBTs. To a lesser extent, CBTs have also grown out of psychodynamic models of therapy. Behavioral therapy was an innovation from the radical behavioral approach to human problems. It drew on the classical and operant conditioning principles of behaviorism and developed a set of interventions focused on behavior change. However, in the 1960s and 1970s, a shift that began to occur in behavior therapy made the development of cognitive behavior theory possible and CBT, more broadly, a logical necessity. In addition to behaviorism, the second historical strand that conspired to lead to the cognitive-behavioral field was that of psychodynamic and therapy

Strengths of the Cognitive Behaviour Therapy

CBT has widely been accepted as one of the best therapy which can be employed to treat patients suffering from a wide range of mental health problems (Allen, 2011). This is for the reason that it focusses on human thought, which is responsible for many accomplishments and therefore also responsible, the problems. Secondly, these therapies lend themselves to testing (Rimm & Litvak, 1969), and thirdly, most people suffering from psychological disorders, especially depressive, anxiety, and sexual disorders have been found to display maladaptive assumptions and thoughts (Beck, Epstein, & Harrison, 1983). Finally, CBT is widely used because it has been found to be very effective in the treatments of depression and relatively effective for problems of anxiety. CBT has also been found to be very instructive. It deals with the here and now approach and focusses more on strategies to empower the patient to be their own therapist. CBT helps patients understand how to counsel themselves rationally and this gives them the confidence that they will continue to do well.

Other characteristics that CBT exhibits which make it a better technique is that it is short term. The average number of sessions that people spend in CBT across the various approaches to CBT and problem is 16(Durham, 2005). This therefore, makes CBT more cost effective for both the patient as well as the therapist. CBT also emphasize on getting better rather than on feeling better, this it achieves by correcting problematic underlying assumptions which create long-term results as the cause of the problem is addressed.

Limitations of Cognitive Behaviour Therapy

Despite CBT being a first choice treatment for mental health problems by people in the medical profession. A medical practitioner is likely to be face by a myriad of shortcomings when employing it(Allen, 2011). First, this therapy is narrow in its scope, it assumes everything is based on the mind, however, thinking is just one part of human functioning, broader concerns need to be addressed. Secondly, the precise role of cognitive processes is yet to be determined. It is not clear faulty cognitions are a cause of the psychopathology or a consequence of it. The Third issue concerns ethics. This channel is a directive therapy aimed at changing cognitions, at times forcefully(Dobson & Dobson, 2003). This can be considered an unethical approach.

Studies by Hollon & Beck (1994)and Durham (2005) present evidence that CBT is beneficial as an initial therapy to avoid long-term chronic symptoms and therefore functions as a short term therapy. However, it is not effective at treating depression as it is for anxiety disorders and phobias whose main cause is distorted thinking. Certain characteristics of conditions such as these have inaccurate cognitions which CBT can assist in changing. CBT as a form of therapy is also not as affective at helping out people to understand their emotions as well as how the humanistic approaches therapies can do. Most studies have also not compared CBT to other mainstream therapeutic approaches such existential, humanistic or psychoanalytic and thus can not be evaluated on its real effectiveness in comparison to these other forms of therapies.

According to Durham (2005), CBT is not cost effective as proponents of CBT have stated. Despite it being cost effective as a short-term therapy the patients have to receive continuous alternate treatment in the occasion that CBT fails to help them.

Much empirical evidence has been collected over 40 years, to such a point where there is now overwhelming evidence that there is clinical value in utilizingCBT (Dobson &Dozois, 2003). During Cognitive Behavioral Therapy application, the therapist works with the patient in a series of stages to help them identify these distorted thoughts and replace them with others that will help them overcome the present challenge. Cognitive Behavioral Therapy has been widely researched and has proven to be one of the most effective methods of treating certain disorders. Some of the reasons why CBT is so effective is because it is problem oriented, it is structured, it is has a firm emphasis for a strong relationship between the client and the therapist and it teaches strategies and skills that have been used and proven to work.  Some of the disorders that are addressed by CBT include anxiety, impulsive disorders, depression, delusional beliefs, offending behaviour, specific phobias, panic disorder, schizophrenia and psychosis, bipolar disorders, eating disorders and obsessive-compulsive disorder. Different therapists using CBT use different approaches depending on the nature of the problem and their training. However, a common feature in all CBT treatments is that it utilizes the four basic stages of therapy. The first stage is the assessment stage which involves forming a rapport with the client. The therapist acquaints themselves with the nature of the problem and formulates an action plan. During this stage the client may not be aware that the distorted thought patterns are responsible for their current behaviour; it is the work of the therapist to make them aware of these thought patterns. The second stage is called the cognitive stage and it involves the client becoming aware of the distorted thought pattern and linking these thoughts to the undesired behaviour. During this stage, the therapist brainstorms with the client in an attempt to come up with alternative thoughts. The third stage is the behaviour stage and it involves trying to replace the distorted beliefs and thoughts with more helpful ones. The clients will use the new thoughts to develop new feelings which will in turn bring about the desired behaviour. During this stage, the client is experimenting with the new behaviour and the therapist monitors the progress. The final stage involves the client learning to be their own therapist. They have now acquired the new behaviour and they are now working hard to avoid a relapse. CBT treatment has been used in treating patients with manifold and intricate needs, and those that have not had success with other treatments, or those receiving supplementary treatment. The therapy has continued to evolve as support from new research continues to emerge. Much of the evidence that supports the use of CBT comes from expert therapists who work with individuals in 6 to 20 sessions of one hour each. There are also some studies that have reported that CBT is effective in group interventions.  Researchers have incorporated CBT principles in self help resources such as self help books. This paper focuses on three case studies of the application of CBT on patients I have attended to at my workplace, and the outcome of the intervention. It also outlines the fundamentals and principles of CBT.

In order for CBT to be effective, there are some fundamentals that must be met. One of these fundamentals is the quality of the relationship between the client and the therapist. The relationship has to be collaborative for the treatment to work. The client and the counselor work together in an attempt to understand the difficulties that the client is going through and come up with new ways of thinking and acting that will bring about the desired behaviour. Another important fundamental in CBT is goal setting. The CBT counselor and the client set challenging and yet attainable goals which they will work towards. It is also important to note that CBT focuses on the “here and now”. What has happened in the past cannot be changed but the client’s perspective of the past affects their present and future and can be changed. The structure of CBT is also an important factor to consider. Each of the sessions takes one hour and the CBT counselor is trained to be able to pre-determine the number of sessions that they will need. During the first session, the client is given some basics on counseling practice and is informed about issues such as confidentiality. Structure is important in ensuring organization, accountability and monitoring progress. Formulation is also very important. It involves coming up with a model that helps the counselor understand the client better. It is formulated from logs made by the client on the beliefs they have about themselves, how these beliefs make them feel, the evidence to the beliefs and different evidence that will change their belief, feeling and behaviour. The formulation is like the map of the counseling process and it may change as the client brings new information, experiences and new encounters during treatment. Relapse prevention is another important building block of CBT. The ultimate goal of CBT is to help the client acquire new coping skills that they will employ now and in the future. Once the client is equipped with the skills, they become their own therapist and can be able to fight possible relapses in future. Apart from these fundamentals, effective CBT is also based on a set of principles.

• It utilizes an emotional disorder model known as cognitive-behavioural. The relationship between thoughts, feelings and behaviour;
• It is short and has a specific timeframe;
• Calls for a solid rapport and collaborative efforts between the client and the CBT counselor. The CBT counselor is trained and qualified while the client is the expert of their problem and experiences;
• The client is guided to learn new patterns of thinking using specific questions;
• CBT is prearranged, directive and problem-focused;
• It is founded on an educational structure;
• It is inductive in nature utilizing logical reasoning to come up with valid conclusions; and
• New behaviour is tested in between sessions. This is a central feature of CBT.

Working in a hospital has presented me with a number of opportunities for helping patients suffering from several mental disorders. Apart from applying other psychological therapies, I have found CBT very useful while dealing with patients. For instance, while working with Larry, a patient suffering from panic disorder, I decided to use CBT as Clarke et al. (1995) describes it as the best intervention to treat this disorder.  Larry was the son of a prominent businessman in the city who ruled his family with an iron fist. There were certain codes of conduct that Larry was expected to abide by. He was the only child and his father wanted him to work hard and join medical school. Although Larry did not feel comfortable with such high outlooks by his parents, he did his best to live up to their expectations. He worked hard in school and was always in his best behaviour especially in front of his father. His age mates, including girls, would tease him at school and call him a coward for avoiding getting into trouble all the time. As a result, Larry wanted to prove them wrong. One day while in the company of his friends, he was challenged to sniff cocaine by a girl in the group. Larry rose to the challenge and sniffed some. Immediately when he saw the entrance to their house, he realized that his parents might figure out what he had done and he began to panic. His mother noticed his panic but Larry explained that he had seen a gruesome accident near the highway. Larry continued to harbor fear that his parents would find out. The next panic attack happened in a park while walking his dog. This made him avoid going to that park as well as many other social meeting places for fear of another panic attack. Larry did not understand what was happening to him and he thought that he was just being nervous. Sometimes, his heart would pound so hard that he feared it would bust or cause him to have a heart attack. One day, when he had another panic attack and was shacking, panting and had a strong heartbeat, he visited the hospital where I work and the doctor was able to identify symptoms of panic disorder. Larry was referred to me for diagnosis and commencement of treatment.

Some of the symptoms that led me to confirm that Larry was indeed suffering from panic disorder included: shaking, sweating, trembling, chills, abdominal discomfort, fear of not being able to control himself and short breath. Larry would always be concerned about having more panic attacks. Sometimes he thought that the cocaine he sniffed so many years ago was still affecting him. I chose to use CBT considering that Clarke et al. (1995) says that the therapy works well on adults and children. Group treatment of panic disorder has proven to be very effective as people treated in groups did well compared to others. A recommended group counseling to Larry but he preferred individual sessions.  Though I borrowed from a number approaches, I strongly relied on panic control treatment (PCT). The treatment uses relaxation, education, exposure and breathing exercise. While utilizing the exposure technique, I worked with Larry in making him experience panic symptoms in the safety of my office. Provoking and constantly experiencing these symptoms made Larry eliminate the fear he had attached to them as described by Corey (2001). The treatment had proved to be very effective within a period of 11 weeks. The psychological treatment that Larry was receiving was supplemented with pharmacological treatments as put forth by Kampman et al. (2001). Larry came for 20 sessions and was able to learn that many of the symptoms he experienced could be managed. Eventually, Larry was able to visit some of the places he avoided before for fear of panic attacks. Initially I accompanied him to these places but he was eventually able to go alone without having panic attacks or experiencing any of the symptoms associated with panic attacks.

Another case that presented an opportunity to employ CBT techniques was that of 35 year old Brenda who had been using alcohol since she was a teenager.  She also used to occasionally smoke cigarettes and she confessed to having used marijuana for a month while in college. Brenda now works as a graphic designer and is married with a 2 year old son. She had been struggling with overweight and blood pressure. She did not think that her use of alcohol had anything to do with her weight problem. Her husband occasionally raised concern about Brenda’s drinking as it was affecting her work and she was sometimes unable to handle their son properly. Her husband recommended her to see a therapist failure to which he would file for divorce and take custody of their son. Not wanting to break her marriage and lose her son, she came to the hospital looking for help. After the initial diagnosis, I realized that Brenda was suffering from substance use disorder. I immediately realized that CBT would work well for her but would require brief intervention since she wasn’t entirely motivated to stop using alcohol as explained by Barry (1999).  Some of the findings that made me conclude that Brenda was suffering from substance use disorder included: continued use even when problems arising from drinking are clear, withdrawal, drinking more than she intended to, tolerance, reduced time for other important things and failing to play her role at work and at home. Once I had confirmed that Brenda was suffering from substance use disorder, I recommended that we begin with detoxification. I preferred to use the harm reduction perspective. Brenda could not abruptly abstain from using alcohol, so we adopted a short-term moderate substance use.

According to a study by Corey (2001), CBT was found to be more effective when combined with pharmacological treatment, therefore, in this case Brenda supplemented therapy with some prescriptions from the family doctor. I encouraged Brenda to look at the advantages and disadvantages of using alcohol and the advantages and disadvantages of avoiding the use of alcohol. She realized that there are several benefits of quitting alcohol use including weight loss and spending more valuable time with family. Those two goals helped Brenda focus on the moderate drinking plan. I required her to maintain a log that she would write down how much she drank, what were her feelings, where she was and whom she were with. Brenda reported that she felt an unstoppable urge to drink a lot when she felt angry or was stressed. As a result we worked on some alternative methods of coping with these situations including taking her son out and watching her favorite shows on TV. She was now able to keep track of her weight through taking time to cook a healthy meal instead of buying junk food as well as exercising regularly. The results on weight loss were amazingly encouraging as Brenda stopped gaining weight and instead begun to lose weight. Her alcohol use also reduced gradually but she occasionally experienced lapses. I encouraged her to keep trying and remain focused on the set goals as well as the associated benefits. We met for a total of 20 sessions. Brenda’s problem was deep rooted considering that she had used alcohol for many years. However, she was now determined to quit alcohol having already tasted some of the benefits. She received the needed support from me, her husband and the family doctor as emphasized by Birmaheret al. (1998). Since Brenda was now self motivated, I emphasized the importance of self care so that she could effectively deal with craving.  In summary, CBT proved to be very useful in helping clients with panic disorders. The benefits of the treatment were well maintained by the client. It was also evident that CBT requires a trained and qualified therapist to deliver. Administering CBT alongside pharmacotherapy will decrease the chances of relapse. I also found out that it can be very challenging to try and determine which treatment is best for patients with panic disorder.

Another case that I handled which required the use of CBT was one of a patient named Simon who was suffering from depression. Simon lost his wife to a car accident. In the months that followed, Simon found that he did not enjoy doing most of the things that previously made him happy. He thought that it was because his wife was no longer there and there was no point of doing them at all. Most of the time he felt fatigue and would occasionally be late for work because he slept for many hours. His boss realized that Simon was not concentrating at work but was aware that Simon’s wife had passed on and figured out that this may be weighing down on him since he was an excellent worker before the accident. Instead of firing him he decided to relieve Simon some of his duties. This affected Simon as he thought that his boss felt that he was not capable of performing complex tasks. Seeing that the situation was not improving, his boss advised Simon to seek professional help on the matter and he made an appointment to meet with me. After meeting with Simon, I carried out diagnosis and ascertained that Simon was suffering from depression. I immediately recommend CBT treatment and Simon was more than ready to start. Some of the symptoms I observed in Simon that led me to conclude that he was suffering from depression included the following: he felt guilty for his wife’s death and felt that he was worthless because he did not protect her, he slept too much, he was unable to make decisions and had problems concentrating, had lost weight and had no appetite, he felt fatigue and weak and had thought of committing suicide on two occasions. Simon thought that he was losing his mind or that he had developed an incurable mental illness. I explained to him that these were the signs of depression which would subside once he received treatment. CBT was the perfect therapy that helped people with depression and so Simon agreed that we start. The approach we took was that of creating everyday activities that would occupy his daily schedule and hopefully alleviate depression. He kept a log of his daily activities and how they influence his mood. He learnt that being occupied throughout the day improved his mood and gave him more confidence. Simon and I worked on some of the negative words that he used to describe situation and replaced them with more encouraging terms. For example instead of saying that his boss saw him inferior and consequently relieved him of some duties, he would say that his boss considered him resourceful and would rather reduce his duties while he was going through a hard time rather than firing him.

Simon combined CBT with prescriptions from the doctor because the combination of the two has been observed to be more effective than CBT alone. By the end of the 20^th session, Simon had overcome most of the symptoms of depression and his boss was considering reinstating him to his previous position. He also began doing some of the things that he previously used to do and found pleasurable again. During the 20 sessions I worked with Simon, it was clear that CBT has been widely used as a successful treatment for depression.CBT is also very effective in preventing relapse and can be used for both adults and teenagers. However, it was also clear that there is need for more research to establish whether other less researched interventions such as IPT are superior to CBT.   Studies have shown that those patients who have received CBT alongside doctor’s prescriptions as well as those that received CBT after prescriptions have a lower relapse rate compared to those who received only pharmacological treatment (Kroll et al., 1996).

Despite CBT being the widely recommended form of therapy to treat mental health disorders (Dobson, 2009). As a health practitioner one is bound to be faced with some obstacles while using it to treat patients. One key obstacle that is usually apparent during the use of cognitive behavioral therapy is that in order for the client to benefit from the therapy, it requires a considerable level of commitment and involvement on the parts of both the client and therapist. This demand for dedication and participation usually results to exhaustion and dullness especially in the closing sessions. This is exacerbated especially when the progress on the patient is minor and the patient has lost optimism that he will be well. However, this obstacle can be solved by breaking down the overall goal of the CPT Sessions into small achievable objectives which both the patient and therapist can easily perceive, appreciate and relate to. These objectives will serve as a source of encouragement and as a form of progress.

Another obstacle that is likely to be encountered during CBT is that due to its structured nature, it may be difficult to apply on patients who have more complex mental health needs as well as those patients having learning difficulties. To overcome this, it is advisable that the therapist identifies the different aspects of the mental health problem and addresses each facet of the problem independently and progressively. The identification of the different aspects of the mental health need will allow for easier treating of the problem and identification of the best approach to address the problem.

Sometimes, the use of CBT is inadequate to address a particular mental health problem. It is simplistic in its approach and only addresses predominantly current patient problems and focusses on very specific aspects of the patient(Kendall & Kriss, 1983). It fails to address the other possible underlying problems of a particular mental health problem such as an unhappy childhood. To overcome this concern, the therapist will be better positioned to help the patient by employing a more open approach towards the patient. This may extend to even looking for other approaches that can better work on the patient apart from CBT

In conclusion, CBT has proved to be one of the most effective therapies of treating behavioral disorders. It is problem focused, structured and is aimed at helping the client become aware of distorted pattern of thoughts that give rise to negative feelings and eventually these feelings are expressed in behaviour. CBT has especially proven to be very instrumental in treating depression and substance use. The fact that the client learns new way of coping means that CBT equips them with skills that will help them deal with challenges in the future. As far as preventing relapse, CBT has also proven to be effective in preventing clients get back to their old habits. One major challenge that faces CBT is that some clients are incapable of introspection and self analysis which is fundamental for CBT to be successful. Combining CBT with pharmacological treatment has also show to be a superior way of dealing with majority of the disorders. Further research should focus on a closer look at some of the less studied psychological interventions such as IPT.

References

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Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitive-behavioral therapies. In A. E. Bergin , & S. L. Garfield, Handbook of psychotherapy and behavior change (pp. 428—466). New York: Wiley.

Kampman, M., Keijsers, G. P., Hoogduin, C. A., & Hendriks, G. J. (2002). A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive-behavioural therapy alone. Journal of Clinical Psychiatry, 772-777.

Kendall, P. C., & Kriss, M. R. (1983). Cognitive-behavioral interventions. In C. E. Walker, The handbook of clinical psychology: theory, research and practice (pp. 770–819). Homewood, IL: Dow Jones-Irwin.

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