Psychological Disorders. The Guilford Press; 2002.

Teasdale JD, Segal Z, Williams JM. How does cognitive therapy prevent depressive
relapse and why should attentional control (mindfulness) training help? Behav Res
Therapy. 1995;33:25–39.
Tsai M, Yoo D, Hardebeck EJ, Loudon MP, Kohlenberg RJ. Creating safe, evocative,
attuned, and mutually vulnerable therapeutic beginnings: strategies from functional
analytic psychotherapy. Psychotherapy (Chic). 2019;56:55–61.
Watson JB, Rayner R. Conditioned emotional reactions. J Exp Psychol. 1920;3:1–14.
Wolpe J. Psychotherapy by Reciprocal Inhibition. Stanford University Press; 1958.

32.9 Cognitive Behavior Therapy

JUDITH S. BECK, PH.D., AND ROBERT HINDMAN, PH.D.

Cognitive behavior therapy (CBT) was developed by Aaron T. Beck, M.D.,

in the 1960s and 1970s. He and colleagues worldwide have continued to
expand and refine the underlying theory and treatment ever since and
Beck’s work, emphasizing the central role of cognition in psychopathology,
has led to a paradigm shift in the field. It is a comprehensive
biopsychosocial system of psychotherapy, with an operationalized
treatment based on an elaborated and empirically supported theory of
psychopathology. CBT has become the most heavily researched and
widely practiced form of psychotherapy in the world. It has been
demonstrated in approximately 2,000 outcome trials to be effective for a
wide range of psychiatric disorders. The benefits of CBT persist after the
discontinuation of treatment, resulting in a lower relapse rate in
comparison to those taking psychotropic medication. CBT has also been
demonstrated to be effective for a range of psychological problems (such
as stress, anger, procrastination, and relationship distress) and medical
conditions with psychological components (such as tinnitus, chronic pain,
and hypertension).
CBT has been adapted and research has demonstrated its
effectiveness in a variety of settings, including outpatient clinics,
psychiatric hospitals, primary care offices, schools, forensic settings, and
community mental health centers. Its efficacy has been demonstrated for
populations from young children through older adults, and for individuals
who vary in gender, sexual orientation, socioeconomic status, and racial
or ethnic background, and who come from a variety of cultures around the
world. Studies also support its efficacy in individual, couples, family, and
group treatment. A substantial number of studies now demonstrate its
efficacy in computer-based programs and telehealth formats.
CBT is based on the cognitive model, which has been widely studied
and has received substantial empirical support. The cognitive model
posits that it is not situations that directly impact one’s reaction (emotional,
behavioral, and physiological). Rather it is one’s perception of the
situation, expressed in automatic thoughts, that is more closely associated
with the reaction. One important component of CBT involves teaching
patients to identify their thoughts that lead to emotional distress or
dysfunctional behavior, to evaluate the accuracy and/or utility of their
thinking, to effectively respond to these cognitions, and to reduce negative
emotion and/or maladaptive actions. Figure 32.9–1 depicts the cognitive
model.
Beck and colleagues developed a manual for CBT for depression to
facilitate treatment fidelity in research studies (Beck et al., 1979).
Manuals, however, often fail to allow clinicians to vary therapy as
appropriate for the individual patient, and most clinicians find their
treatment is significantly more effective when it is based on a cognitive
formulation of the patient’s disorder(s), an individualized cognitive
conceptualization of the patient, and the patient’s personal values and
aspirations. A strong therapeutic alliance is essential for effective
treatment and the relationship is collaborative. Both patients and clinicians
are active in solving problems, evaluating cognitions, and modifying
behavior. CBT is educative; clinicians teach patients how to use the
techniques at home that they have employed in session. The clinician’s
stated goal is to help patients become their own therapists. They
emphasize that the way patients get better is to apply what they have
learned in session to make small changes in their thinking and behavior
every day.
 FIGURE 32.9–1. Cognitive model.

Originally designed as a short-term treatment for depression, CBT has

evolved over the years. Patients with straightforward cases of anxiety and
depression, who were relatively psychologically healthy before the onset
of their disorder, often benefit from a short course of treatment, perhaps 6
to 12 sessions. At the other end of the spectrum are patients whose
disorders are chronic or complex, or those for whom standard treatment
needs to be varied due to comorbidities such as substance use disorders
(SUDs) or personality disorders. They may need many more sessions
over a significantly longer period of time. Those with recurrent episodes or
with serious mental illnesses may require intermittent treatment
throughout their lifetime. This latter group of patients often benefit from a
modified version of CBT: Recovery-Oriented Cognitive Therapy, which
emphasizes empowerment, purpose, and resilience, and focuses on
helping patients operate in an adaptive mode where they are able to live
in alignment with their values and aspirations instead of focusing on
problems and symptoms.

HISTORY
Aaron T. Beck, who was Emeritus professor of psychiatry at the University
of Pennsylvania, had trained and practiced as a psychoanalyst. A scientist
at heart, he conducted a series of studies starting in the late 1950s to test
psychoanalytic theories of depression. Much to his surprise, his research
demonstrated that depression was not a result of retroflected hostility and
did not support a need to suffer. Instead of viewing depression as a result
of unconscious drives, wishes, and defenses, Beck proposed that
depression was associated with highly negative, distorted, and
dysfunctional beliefs and thoughts, the result of biased information
processing. When he began to tailor treatment toward helping his patients
identify and evaluate their biased thinking and change their behavior, they
began to rapidly improve.
In his landmark monograph, Beck (1967) detailed the cognitive triad of
depression: negatively biased cognitions about oneself, one’s world
(including other people), and the future. He described the role of
schemas, hypothesized mental structures that organize information, and
he outlined a treatment approach that emphasized testing the accuracy of
patients’ cognitions. Ten years later, the first randomized controlled trial of
CBT for depression was published (Rush et al., 1977). Patients in the
CBT group responded slightly better to treatment than patients in the
psychopharmacological group and had fewer relapses after treatment.
Later studies confirmed these findings and showed that CBT was effective
for severe depression.
Throughout the decades, Beck and colleagues studied other disorders.
They used clinical material to identify and specify key cognitions and
behaviors characteristic of a number of psychiatric problems. They used
existing rating scales or constructed and validated new instruments to
measure relevant clinical variables, adapted the general cognitive model
and treatment interventions for each disorder, and created treatment
manuals for randomized controlled trials.
In developing CBT, Beck was influenced by Greek Stoic philosophers
and theorists contemporary to the time, such as Adler, Alexander,
Sullivan, and Horney, as well as Kelly, Lazarus, and Arnold. Behaviorists
and cognitive behaviorists such as Ellis, Meichenbaum, Mahoney,
Lewinsohn, and Bandura were also influential in the development of his
theories and treatment.

THEORETICAL ISSUES
Most automatic thoughts are verbal in nature, but some are in the form of
mental images.
 As Kevin was thinking about looking for job opportunities on the
internet, he pictured telling a potential interviewer how long he had
been out of work. He imagined the interviewer looking scornfully at
him, shaking his head.

Core Beliefs
Individuals display characteristic, recurrent themes in their thoughts which
are associated with a deeper level of cognition, their core beliefs,
representing the content of cognitive schemas. Core beliefs are one’s
most central ideas about the self, other people, and the world. These
beliefs are generally identified by asking patients for the meaning of their
thoughts. Core beliefs develop during childhood. The interaction between
one’s genetic predisposition (toward certain personality traits and styles of
thinking) and their experiences affects the way they interpret their
experiences.
People without significant psychological difficulties tend to view
themselves throughout their lives as reasonably effective, able to protect
themselves, likable, and worthwhile. If they develop an acute disorder
such as depression, however, previously latent negative schemas may
become activated and dysfunctional beliefs become manifest. Patients
begin to view themselves, their worlds, and/or other people through a
negative lens, interpreting their experience in a highly negative way, and
may then overgeneralize the meaning of a situation. They may see
themselves as ineffective, vulnerable, inferior, unlikeable, and/or
worthless. They may view others as potentially hurtful, rejecting, or
superior. They may see their world as unpredictable or unsafe. During
times of psychological distress, these individuals tend to regard their
negative core beliefs as fixed, absolute truths, which make these deeper-
level ideas less amenable to change than automatic thoughts.
 Throughout his school years, Kevin performed at a level slightly below
average but more or less at the level of most of his friends. He did not
value getting good grades and was more interested in developing his
above-average athletic skills. He felt competent enough academically
and saw himself as a success athletically. His parents, however, had
unrealistic academic expectations for him and criticized him when he
did not perform as well as they desired (which was much of the time).
Accordingly, from time to time, especially when his parents were
harsh, he viewed himself as a failure. Fortunately, these episodes
were generally fleeting, and his view of himself as basically adequate
and competent predominated. It was not until Kevin was fired from his
job and could not quickly obtain another one that he began to view
himself as a failure. The dominance of this negative core belief
contributed to the onset and maintenance of his depression.

Coping Strategies
The activation of a negative core belief typically leads patients to engage
in maladaptive coping behaviors as an attempt to decrease or avoid
distress.

As Kevin began to view himself as a failure, he started to avoid tasks

that he assessed were difficult, at which he could fail. He gave up job
hunting after a few weeks and spent a considerable amount of time
sleeping, watching television, or playing video games. He began to
withdraw from his wife, family, neighbors, and friends, believing that
they all saw him as a failure, too.

Intermediate Beliefs
Intermediate beliefs are ideas at a deeper level than automatic thoughts
but are more malleable than core beliefs. They consist of generalized
rules, attitudes, and assumptions, and can be a link between patients’
deeper core beliefs and their coping strategies. Patients generally believe
that if they engage in certain coping strategies, their negative core beliefs
may not be evident; however, if they do not, they believe these beliefs will
likely be shown to be true.
 Once Kevin became depressed, several key assumptions became
activated. “If I take on challenges, I’ll fail, but if I avoid difficult tasks, I’ll
be okay (at least for the moment).” He also held the attitudes that “It’s
terrible to fail” and “Failing means I’m a failure as a person.” His
related rules, which often took the form of “should” statements,
included “I should do great at everything I do.”

Schemas and Modes

Schemas are responsible for processing, storing, and retrieving different
types of information, including perceptions, goals, expectations,
memories, fantasies, and prior learning. They provide meaning and, when
activated, affect the way individuals process their experiences. Their
function is to aid the individual in selecting the most relevant information
from the practically infinite amount of information in the environment.
Schemas may be cognitive, behavioral, motivational, or affective. They
range from adaptive to dysfunctional and vary in complexity, strength,
flexibility, permeability, level of abstraction, and valence.

When Kevin is depressed and his maladaptive depressive schemas

are activated, he is likely to process information in a distorted manner
that confirms his core beliefs. For example, he views his difficulty
getting out of bed in the morning as a sign that he is a failure, even
after receiving psychoeducation about the effect depression has on
patients’ thinking, motivation, and behavior. He fails to register the
tasks he completes at home or the ways he is helpful to his wife even
in the face of severe depression. He discounts his wife’s positive
comments, believing that she is “just trying to be nice.”

The diathesis-stress model (Beck, 1967) posits that schemas are

triggered when individuals experience events relevant to their underlying
vulnerability.
 Kevin had had negative experiences from time to time throughout
adulthood, such as the death of his best friend, arguments with
coworkers, and conflict with a neighbor. These incidents, however, did
not activate his depressive schemas as they did not match his
underlying vulnerability toward interpreting a deficit in performance as
signifying failure. His depressive mode was activated only after he was
fired from his job for “negligence and incompetence” and was unable
to secure a new job. These events matched stimuli from his “failure”
schema, which led to its activation.

Modes are a complex organization of multiple schemas related to

individuals’ self-evaluations, rules, memories, and expectancies. Primal
modes are related to survival; constructive modes allow the individual to
increase resources. Modes help explain the complex symptoms that
patients experience and their global, systematic bias. Each psychiatric
disorder is characterized by a particular mode. One constellation of
schemas, for example, characterizes a depressive mode, while a different
constellation is involved in an anxious mode.

The Generic Cognitive Model

In recent years, Beck has described an expansion of the cognitive model.
This “generic cognitive model” explains how cognitive schemas contribute
to the development and maintenance of psychopathology.
Neurophysiologic hyperactivity is genetically influenced and may, in turn,
negatively bias individuals’ attention and memories, resulting in
dysfunctional cognitive schemas. Beck also describes the nature of
individuals’ functioning along a continuum from adaptive to maladaptive,
the process by which schemas are activated, the nature of dual
processing (through the automatic and then reflective processing
systems), and protoschemas (which quickly but crudely detect and
interpret critical stimuli), along with an expanded theory of modes and
common processes (such as rumination, worry, attentional fixation) across
psychopathologic states.

Strength-Based Cognitive Conceptualization

Increasingly, the field has recognized the importance of adding a strength-
based conceptualization and focus on understanding and treating
patients. CBT clinicians identify patients’ historic adaptive cognitions and
coping strategies, often by questioning them about the best period in their
lives and focusing on their achievements, strengths, positive qualities, and
resources. During these best periods, individuals often had core beliefs
such as “I’m reasonably competent/safe/likeable/worthwhile.” They usually
had relatively benign and realistic beliefs about people: “Many people are
trustworthy or neutral and will not intentionally harm me” and their worlds:
“The world is reasonably safe and predictable.” Their intermediate beliefs
tend to be functional (“If I try, I can succeed, at least to some degree”; “If I
interact with most people, they’ll accept me.”) When they face challenges,
they tend to persevere because of their adaptive automatic thoughts. (“I
can probably solve this problem, but if I can’t, I can ask for help.”)
In contrast to a more traditional, problem-based treatment, therapists
ask clients for their goals for each session. They help them draw
realistically positive conclusions about the positive experiences they had
in the previous week. They use standard techniques to resolve obstacles
that could interfere with their ability to take steps in alignment with their
values and aspirations.

Applications Across Specific Disorders

According to the cognitive model, psychiatric disorders are characterized
by an interaction among triggers, cognitions, behaviors, emotions, and
common psychological processes. Each psychiatric disorder is
characterized by a specific set of beliefs and behavioral strategies. The
following is an overview of the cognitive theories for several disorders.

Depression. The maladaptive cognitions specific to depression are

referred to as the cognitive triad: negative beliefs about oneself, one’s life
experience (and the world in general including other people), and one’s
future (Beck, 1967). Depressed patients often predict that they will
inevitably face only unending problems and pain; these predictions affect
both their mood and their behavior. They tend to be excessively self-
focused. They are likely to disproportionately allocate attention to their
negative thoughts, feelings of sadness, and physiologic symptoms.
Depressive rumination typically results in an exacerbation of symptoms
and continued inactivity. As the depressive mode continues to be active,
individuals’ sense of hopelessness about the future may increase and
lead to increased suicidal ideation when they believe suicide is the only
solution to their problems.

Bipolar Disorder. The schemas of bipolar patients are activated when

biologic and psychological processes interact with external and internal
triggers, leading to depression, mania, or mixed-mood episodes. In a
depressed state, these patients display the same kinds of cognitive biases
and dysfunctional beliefs as patients with unipolar depression, especially
negative cognitions about the self, the world and other people, and the
future. In a manic state, patients with bipolar disorder tend to view
themselves in an inflated, expansive way. Hyperpositive core beliefs (“I
am powerful”; “I am invulnerable”; “I am amazing”) predominate. Their
behavior changes are consonant with the changes in their thinking. They
become impulsive, minimize potential threats, and take risks. Typical
conditional assumptions include: “If something seems like a fantastic idea,
it must be”; “I should follow my impulses and take action immediately”; “If
I’m feeling great, I don’t have to take meds or be careful about my daily
habits.” In a euthymic mood, patients with bipolar disorder may think, “I
have to drive myself hard to make up for how little I accomplished when I
was depressed.” This belief may lead them to overextend and over-
stimulate themselves, particularly in reference to goal-oriented behavior;
they may then sleep poorly and ultimately become hypomanic.

Anxiety Disorders. When patients have anxiety disorders, they tend to

significantly overestimate the risk of a situation and greatly underestimate
their ability to cope. Worry about a variety of events or activities is
common, especially among individuals with generalized anxiety disorder
(GAD), as are futile attempts to control the worry process.
Many clients with anxiety disorders have maladaptive core beliefs such
as “I’m incapable and vulnerable,” and “The world is a dangerous place.”
Individuals with social anxiety disorder (SAD) tend to see themselves as
defective and unlikable and predict that others will reject them; they
become hyperalert for signs of anxiety which they try to hide from others;
paradoxically, they therefore sometimes behave in a way that others find
odd.
Cognitive models for obsessive-compulsive disorder (OCD) propose
that intrusive thoughts, images, or urges develop into obsessions when
they are given excessive importance. Patients with OCD believe that their
intrusive thoughts and images are uncontrollable, that they will be
responsible if bad things happen, and that they cannot overcome the
urges to engage in compulsive behaviors that they hope will neutralize the
threat.
The automatic thoughts of patients with anxiety tend to center around
potential future catastrophes. Their attention becomes fixed on signs of
threat, danger, and/or uncertainty. When clients have panic disorder, for
example, they predict that a bodily or mental sensation (or a small set of
sensations) will precipitously increase and lead to a catastrophe.
Behaviorally, clients with anxiety disorders tend to engage in
maladaptive “safety behaviors,” coping strategies to ward off anxiety, such
as avoidance of situations in which they feel vulnerable, reassurance
seeking (from other people and the internet), and excessive checking.
These strategies prevent individuals from being exposed to situations that
would have demonstrated to them that anxiety, while uncomfortable, is not
dangerous.
Anxiety and worry are often triggered by an intolerance of uncertainty,
or a view of ambiguous or uncertain situations as upsetting and stressful.
When worrying about uncertainties, individuals experience a negative
problem orientation. They do not trust their ability to solve the problems
that are the focus of worry, and they perceive problems as threats. They
continue to predict unfortunate or even catastrophic outcomes and they
continue to worry, hoping to find just the right solutions. Worry has also
been proposed to be a form of cognitive avoidance.

Eating Disorders. Anorexia nervosa and bulimia nervosa have been

extensively studied and a cognitive model has been developed for each
disorder. However, Fairburn and colleagues (2003) proposed that the
disorders share the same underlying psychopathology. Their
transdiagnostic model postulates that individuals diagnosed with eating
disorders evaluate their self-worth disproportionately both in terms of their
eating habits, shape, or weight and in their ability to control these factors.
Their preoccupation with how they see themselves may have been
influenced by early life factors, such as parents or peers who placed too
much emphasis on or were overly critical of their weight or shape.
The difference between the two disorders is hypothesized to be the
result of the compensatory behavior used to cope with negative self-
evaluations or other triggers related to eating, body image, or sense of
control. Patients with anorexia predominantly cope by restricting food
intake and/or engaging in excessive exercise, while individuals diagnosed
with bulimia use a compensatory strategy such as purging when they
perceive they have overeaten or engaged in binges. In contrast, patients
with binge-eating disorder do not use compensatory strategies after a
perceived binge.
Many patients with binge eating disorder or bulimia have difficulty with
emotion regulation and turn to food as a means of eliminating negative
affect. Although their mood temporarily improves while they are eating,
negative affect returns more intensely afterward in the form of disgust,
embarrassment, guilt, or depression, further strengthening negative
beliefs about the self.

Substance Use Disorders. Individuals may begin to use substances to

obtain pleasure; feeling “high” may improve their experience of activities.
Or they may begin to use substances to decrease or eliminate unwanted
experiences such as negative emotion or physical pain. Once substance
use has started, several factors may contribute to becoming dependent on
the substance, including beliefs such as, “If I use, I can endure the stress
and frustration of life;” “I can escape or avoid distress.” Individuals for
whom substance use is a problem also tend to have negative core beliefs.
The activation of these beliefs leads to dysphoria; the individual focuses
on the negative emotion and then has a permission-giving cognition which
leads to the compensatory behavior of substance use to alleviate or cope
with the distress. They may also use because of their belief, “I won’t enjoy
myself if I don’t use.” As substance use becomes more frequent, external,
and internal triggers become associated with use. These triggers also
become associated with the experience of cravings and urges; they may
believe “I have no choice; I have to give in to urges,” “Cravings are
uncontrollable,” and “This craving will never go away unless I use.”
As substance use increases, individuals are likely to encounter
financial, social, and/or medical problems about which they have negative
cognitions, leading to negative mood states and subsequent substance
use. Their focus of attention is excessively inward, as they monitor
themselves for dysphoria. They generally minimize potential
consequences or develop additional permission-giving beliefs. The cycle
of substance use is maintained by the dysfunctional beliefs about the self,
substance use, cravings and urges, permission to use, and negative
mood states.
 Schizophrenia. The negative symptoms of schizophrenia are mediated
by dysfunctional beliefs: “I’m powerless”; “I’m defective”; “People will
reject me”; “I’ll fail at anything I try.” Delusions are believed to develop, in
part, due to information processing biases, cognitive errors, and impaired
reality-testing. Individuals experiencing delusions tend to perceive
themselves to be the center and central focus of events, while also
interpreting their subjective experiences as having an external causation.
A cognitive model of hallucinations describes factors that are precursors
to hallucinations, lead individuals to fixate on them, and then maintain
their occurrence. One predisposing factor is a low threshold for internal
auditory and visual imagining that seems real or almost real. This low
threshold interacts with activated cognitive schemas that produce
cognitions related to the schema and not to reality. For instance, an
individual with a “failure” schema may have an intrusive, automatic
thought that is perceived as an auditory hallucination saying, “You can’t do
anything right.” The hallucination is perceived as coming from an external
source due to externalization bias, cognitive errors, and impaired reality
testing. Hallucinations are maintained by dysfunctional beliefs such as
“These voices are real.” Safety behaviors, such as avoidance, are also
used to minimize the presence or impact of hallucinations.
Beliefs about positive symptoms, in addition to the symptoms
themselves, influence the development and maintenance of negative
symptoms of schizophrenia. Moreover, as positive symptoms are often
triggered in social situations, individuals may develop an aversion to
socialize and choose to reduce social contact. Overall activity level may
also decrease as individuals become excessively focused on delusions
and/or hallucinations and less focused on engaging in valued activities.
Additional factors that influence the development and maintenance of
negative symptoms are negative beliefs about one’s performance, low
expectations for obtaining pleasure and success, and the perception of
having limited resources for engaging in activities, for example, too little
energy.

Personality Disorders. As with the previously discussed disorders,

personality disorders develop from the interplay of genetic and epigenetic
factors and the meaning individuals put to their early adverse or traumatic
experiences. The schemas present in individuals with personality
disorders resemble those present in other syndromes, but they tend to be
more rigid and remain activated on a more or less continuous basis.
Each personality disorder is characterized by a specific set of beliefs,
assumptions, and coping strategies. An individual with dependent
personality disorder, for example, may have a belief of helplessness and
cope by attaching to and depending on others. An individual with avoidant
personality disorder usually has core beliefs of emotional vulnerability and
unlovability and avoids not only social interactions but also thinking about
situations that could lead to emotional distress. When individuals have
comorbid personality disorders, they often hold multiple sets of
dysfunctional beliefs that cross diagnostic lines.

TECHNIQUES
The goal of CBT is to help clients reach collaboratively set treatment
goals, live a valued life, facilitate remission of their presenting problems
and/or psychiatric disorders, and prevent or reduce relapse by teaching
patients skills they can use for their lifetime, within a highly supportive,
collaborative relationship. Both patients and clinicians are active
participants, jointly resolving current issues, especially those that interfere
with goal attainment, through a variety of strategies, including teaching
patients to evaluate their cognitions and working toward needed
behavioral change. As a result, patients’ symptoms are reduced, their
mood and day-to-day functioning improve, they are able to live in greater
accordance with their values and aspirations, they are more resilient, and
they have an increased sense of purpose, hope, and well-being. Many
patients achieve treatment goals and remission without exploration of
childhood issues. When longstanding highly dysfunctional beliefs acquired
in childhood interfere with “standard” treatment focused on present-
moment experiences, as may be the case when working with patients with
personality disorders, clinicians may help patients restructure the meaning
of early experiences and apply what they have learned to help them
overcome current difficulties.
In this section, we describe how clinicians use CBT techniques in a
standard 50-minute appointment with an individual outpatient. Many of the
techniques, however, can be used in brief sessions.
Clinicians may adapt techniques from almost any psychotherapeutic
modality, using them in the context of a cognitive conceptualization of the
patient. In recent years, cognitive therapists have drawn on techniques
from the range of evidence-based therapies, including dialectical behavior
therapy, exposure therapy, cognitive processing therapy, acceptance and
commitment therapy, and compassion-focused therapy. Techniques from
positive psychology, psychodynamic psychotherapy, mindfulness-based
therapies, interpersonal therapy, and others are adapted and used with
some patients.
As part of the initial assessment, clinicians collect data to diagnose
patients’ difficulties. Treatment is guided by both a problem-focused and a
strength-focused formulation. Clinicians begin to formulate a cognitive
conceptualization of individual patients and their strengths and difficulties;
they refine this conceptualization at each session, as they receive
additional data. They hold their hypotheses as conditional, subject to
confirmation by the patient.
Clinicians use this ongoing conceptualization to plan treatment across
sessions and within sessions. An accurate conceptualization allows the
clinician to appropriately select and adapt techniques. Clinicians also take
into consideration the patient’s goals, stage of treatment, degree of
distress, personal characteristics and preferences, and values and
aspirations. They consider the strength of the therapeutic alliance, the
nature of the problem or goal under discussion, the amount of time
remaining in the session, and other factors. When suggesting an
intervention, they provide a rationale and elicit the patient’s agreement.
They often check on the intensity of patients’ emotions before and after an
intervention, to assess whether additional strategies might be needed.
Two questions also help guide the selection of techniques: How can I help
the patient feel better by the end of the session? How can I help the
patient have a better week?
The strategies described below are somewhat artificially grouped, as
many techniques fall into more than one category. For example, most
behavioral techniques contain both cognitive and behavioral components
and vice versa.

Therapeutic Relationship Techniques

Clinicians use good Rogerian counseling skills: warmth, support, accurate
understanding and reflection, genuineness, empathy, realistic optimism,
and compassion. They use positive reinforcement to praise and
encourage change. They show genuine interest in their patients and may
deliberately be more conversational at times, for example, when inquiring
about positive experiences patients had in the previous week. They also
make judicious use of self-disclosure. Clinicians are highly collaborative
and seek patients’ feedback. During sessions, they are attuned to
patients’ affect, and when they notice a negative shift, they ask patients
how they are feeling and what they are thinking. When patients provide
negative feedback, clinicians positively reinforce them and mutually
develop a plan to address patients’ concerns. Clinicians also routinely ask
for feedback at the end of sessions: “What did you think of the session?…
Was there anything that bothered you or anything you thought I didn’t
understand? . . . . . Is there anything you want to do differently next time?”
Some patients, especially those with personality disorders, bring
dysfunctional beliefs about other people and relationships to treatment
and may react to clinicians in dysfunctional ways. Clinicians work through
therapeutic relationship problems, helping patients evaluate their beliefs
about the clinician. They then help clients generalize what they have
learned to other relationships. It is essential for clinicians to vary their
interpersonal style according to the preferences and sensitivities of
patients. Some patients prefer a close, warm relationship while others
react poorly to direct expressions of empathy or self-disclosure and prefer
a more clinical approach.
Finally, research has demonstrated that a reduction in symptoms leads
to a better therapeutic alliance. Therefore, it is important to spend
sufficient time developing a good working relationship with patients, but
clinicians need to keep as their central focus the facilitation of cognitive,
emotional, and behavioral change so patients are equipped to deal more
effectively with their difficulties outside of the therapy session.

Structuring Techniques
CBT sessions tend to follow a standard structure, as it allows patients to
gain the most from the appointment. The structure is implemented flexibly,
though, and sometimes has to be modified, especially initially, if patients
react negatively.
At the beginning of sessions, clinicians do a mood check. Research has
shown that psychotherapy is more effective when including feedback on
treatment progress. Clinicians ask for an update (of positive and negative
events) since the previous session, and elicit patients’ conclusions about
their positive experiences, successes, or improvement to foster positive
beliefs and build confidence. Patients’ Action Plans (therapy homework)
are reviewed; these self-help assignments have been demonstrated to
enhance therapy outcomes. Clinicians also set an agenda for the current
session (“What problems/issues do you most want my help in solving
today?” or “What are your goals for today’s session?”). Clinicians may
contribute items to the agenda, too. Then they collaboratively prioritize
agenda items. If later in the session patients bring up items that were not
on this initial agenda, the clinician notes the change of topic, and they
make a collaborative decision about whether to return to the initial item
under discussion or to continue discussing the newly identified topic or
difficulty.
In the middle of sessions, clinicians focus on the problem or goal that is
most important to the patient. They ask patients to recall a specific recent
instance in which they felt the most distressed about the problem or they
may ask clients to identify a problem they expect to encounter in the
coming week as they are pursuing an important goal. Therapists then
seek additional data, summarize their perception of the patient’s
experience in the form of the cognitive model, and ensure that they
correctly understood the patient.
The clinician might then propose an intervention aimed toward any part
(or at several parts) of the cognitive model. For example, they might do
problem-solving about the problematic situation, evaluate the client’s
automatic thoughts, elicit, and examine the patients’ deeper beliefs, teach
the patient emotional regulation skills, or do behavioral skills training.
When they have finished discussing the problem or goal, patients are
asked what they want to remember (and clinicians might suggest
additional points). This summary is recorded as therapy notes that clients
read daily as part of their Action Plan. At the end of sessions, clinicians
ensure that patients have a good grasp of key points of the session and
are highly likely to read their therapy notes and carry out their Action
Plans. Then they elicit and respond to feedback.

Cognitive Techniques
The clinician elicits patients’ thinking when they have experienced a
significant affect shift, have engaged in significantly dysfunctional
behavior, or have experienced an obstacle to progress. Clinicians
generally ask, “What was just going through your mind?” or “What were
you thinking?” Automatic thoughts may be in verbal and/or imaginal form.
Clinicians share their conceptualization with the patient; then they often
collaboratively decide to evaluate the patient’s thoughts.
Guided discovery, primarily through Socratic questioning, is the major
methods for helping patients assess their thinking. Typical techniques
involve labeling distortions, reality testing the evidence for and contrary to
the thoughts, seeking alternative explanations, decatastrophizing,
examining the utility of the thought, and asking patients to consider how
they would advise another person who had the same thoughts (Fig. 32.9–
2).
If the process of evaluation results in a positive affect shift, the clinician
makes sure patients’ new understandings are recorded, on cards, in a
notebook, or on a smartphone so patients can reflect on these new ideas
daily. When thoughts are in imaginal form, clinicians often use imaginal
techniques in addition to or instead of verbal techniques.
Sometimes a realistic appraisal of patients’ thinking indicates that a
given thought is largely valid. In this case, the clinician may engage them
in problem-solving, identifying, and assessing the deeper meaning they
have attached to their thoughts, and/or moving toward acceptance of the
situation, along with focusing on ways to enrich other parts of their lives.

FIGURE 32.9–2. List of Socratic questions. (Reprinted from © Beck J.

Cognitive Behavior Therapy: Basics and Beyond. 3rd ed. Guilford Press;
2020.)

Behavioral experiments are commonly used to help patients evaluate

their predictions. Examples of techniques used in session include panic
inductions (so patients can learn that no matter how intense their
symptoms become, a feared catastrophe does not happen), reading a
paragraph in a book (so depressed patients can learn that they have not
lost the ability to concentrate), or rubbing their hands on the bottom of
their shoes and refraining from washing (so patients with OCD and a fear
of contamination can learn that their obsessions are inaccurate, they can
withstand the anxiety, and the anxiety that arises does not increase
indefinitely without resolving when they prevent themselves from
engaging in a compulsion). Clinicians also help patients devise behavioral
experiments to test predictions about situations that arise outside of
session (such as expressing a strong preference to see if a friend
becomes angry).
To identify patients’ underlying beliefs (their assumptions and basic
beliefs about themselves, their worlds, and others), clinicians ask patients
for the meaning of their thoughts (referred to as the “downward arrow
technique”), examine the recurrent themes in patients’ thoughts, directly
elicit a rule or attitude, review a questionnaire patients have completed,
such as the Personality Belief Questionnaire (J. Beck, 2005), or provide a
list of common core beliefs to see which one(s) resonate.
Clinicians use a variety of techniques to help patients assess and
respond to their deeper-level cognitions. They use psychoeducation to
explain how the patient’s information processing system automatically
processes data that seems to support their beliefs but discounts or fails to
register data that contradicts it. Socratic questioning, examining
advantages and disadvantages of maintaining a given belief, formulating a
more adaptive, realistic belief, and historical tests of the belief are
frequently used techniques. Clinicians also teach patients how to
continually identify and reframe evidence that seems to support the old
belief and how to identify evidence that is contrary to this belief but
supports the new belief. These techniques help patients change their
ideas at an intellectual level. To modify their ideas at a deeper, “gut” or
“emotional” level, other techniques may be necessary. Imagery, behavioral
experiments, acting “as if” the patient fully accepts the new belief as true,
metaphors, and experiential techniques (such as roleplaying or
psychodrama to restructure the meaning of specific current or childhood
experiences) can facilitate a new understanding.

Behavioral Techniques
Problem-solving is a key technique for most patients unless they have a
circumscribed problem with anxiety (e.g., specific phobia). Some patients
also need to learn effective methods for solving problems and making
decisions on their own. For younger patients or those with limited
problem-solving skills, a more structured problem-solving approach can
be used (e.g., ITCH: Identify the problem; Think about solutions; Choose
one solution to put into action; “How did it work out?”).
Behavioral activation, accomplished through activity scheduling, is very
important for most depressed patients and others, especially those with
entrenched avoidance. Clinicians ask patients to verbally describe or track
their hour-to-hour activities. They discuss which activities, usually passive
and solitary, are maladaptive if overused because they maintain or worsen
their mood (for example, napping, resting, watching excessive television,
surfing the web, and playing video games) and which activities have the
potential to bring patients a sense of mastery and pleasure or are more in
line with their values. Then they formulate a plan in session to increase
their active engagement, either creating a model schedule with specific
activities for the full day or scheduling specific activities throughout the
week. Clinicians help patients predict and respond to unhelpful thoughts
just before, during, and after their activities and help them set up
reminders (e.g., by setting alarm reminders or posting their schedule in a
prominent place).
Some patients, especially those who are depressed, have difficulty
making decisions. Creating a four-square chart of costs and benefits or
advantages and disadvantages of one option versus another option can
help.
Graded task assignments are important for patients who are depressed,
procrastinating, or overwhelmed by what they have to do. The clinician
teaches them to break a large task into smaller components. A patient
whose apartment is quite messy might initially just tackle the dishes in the
sink or go one room at a time with a trash bag, looking for obvious things
to throw away. Tasks can also be broken down by time: spend 10 minutes
separating junk mail from important mail, spend 10 to 15 minutes paying
bills.

Exposure Exercises
Exposure exercises are used with anxiety disorder clients to counteract
avoidance and test feared predictions. Prior to engaging in the exposure
exercise, clinicians identify the patient’s predictions. They then develop a
plan to engage with the stimulus, including how to determine if their feared
predictions are accurate and how to cope more effectively. Clinicians
emphasize an inhibitory learning approach during the exposure, which
involves taking note of discrepancies between the feared predictions and
what actually occurs. Patients are instructed to record the outcome
immediately after the exposure, and clinicians help them draw helpful
conclusions.
Various forms of exposure exercises are used based on what stimulus
the patient fears and avoids. Interoceptive exposures are used to expose
panic disorder clients to feared sensations (heart racing; dizziness).
Imaginal exposures expose patients to feared memories or images
(intrusive memories of a traumatic event). In-vivo exposures expose
patients to feared and avoided external situations (driving over a bridge;
answering a question during a class).
Exposure and response prevention is often used with patients who have
OCD. In a graded fashion, the clinician exposes patients to feared
situations that often trigger obsessions, coaching them to refrain from
engaging in compulsions so they can test their predictions related to
feared outcomes and increase their tolerance of anxiety.

Motivational Techniques
Patients vary in their interest and engagement in therapy. To boost
motivation to engage in treatment, work collaboratively in sessions, and
follow through with Action Plans between sessions, clinicians may use a
variety of techniques including motivational interviewing, reminders of
patients’ key values and goals, an examination of advantages and
disadvantages of various behavioral options, and Socratic questioning of
cognitions that decrease their willingness to change.

Emotional Regulation Techniques

An important therapeutic goal is for patients to understand and accept
their negative emotions and to discover that they can tolerate negative
emotion without turning to maladaptive strategies such as avoidance, self-
harm, aggression, or the use of substances. Psychoeducation, Socratic
questioning of beliefs about the experience of emotion, and behavioral
experiments to test these beliefs are often used to facilitate this
understanding.
Patients also benefit from learning specific skills to better regulate their
emotional arousal. They include mindfulness techniques, relaxation
exercises, refocusing on an engaging or valued activity, reading therapy
notes, evaluating automatic thoughts, positive social interaction or seeking
support from others, and self-soothing activities such as listening to
music, physical contact with a pet, walking in nature, or focus on a
sensory experience. Patients may also benefit from learning self-
compassion skills if their distress is related to a high degree of self-
criticism.

Environmental Interventions
Some patients continually face such adverse circumstances that an
environmental change is required. Patients who are emotionally or
physically abused in their living environment, for example, may need help
to identify a new place to live for some period of time. Other patients might
benefit from an examination of the pros and cons of staying in a hostile
work environment, and, if needed, coaching on job-seeking and
interviewing skills.

Interpersonal Techniques
Techniques focus on solving interpersonal problems, teaching social skills,
and modifying maladaptive beliefs about themselves, others (including, at
times, the clinician), and relationships. Roleplaying is often used to help
patients increase their facility in initiating and sustaining casual
conversation, being appropriately assertive, accurately reflecting what an
intimate has said, and skillfully conversing during emotional interactions.
Including a family member or intimate in session, whether or not there is
friction in their relationship, can help clinicians round out their
conceptualization of patients and their problems and provide an
opportunity for psychoeducation and cooperation in helping patients reach
their goals.

Biologic Interventions and Treatment Adherence

It is important for clinicians to look broadly at patients and, for some, to
encourage healthier habits: facilitating change, for example, in eating
habits, caffeine intake, use of substances, and exercise. CBT for insomnia
(CBTi) has been shown to be effective (van der Zweerde et al., 2019).
Medication adherence can be increased by considering advantages and
disadvantages of taking medication, examining interfering cognitions,
promoting tolerance of side effects, behavioral experiments (such as
taking the first dose in the office), and checking on practical matters such
as potential problems in affording and obtaining the medication or
remembering to take it.

CLINICAL ISSUES
Indications
CBT may be used to (1) eliminate or moderate the symptoms of a
psychiatric disorder or psychological distress as an independent treatment
or in combination with medication and/or other biologic treatment; (2)
modify underlying beliefs and schemas that contribute to the development
and maintenance of disorders; (3) address psychosocial problems (e.g.,
marital discord, job stress, caregiver burnout) that may have preceded,
coincided with, or been caused by the disorder; (4) reduce the likelihood
of relapse or recurrence of a disorder after symptoms have resolved; (5)
increase adherence to recommended medical treatment (e.g., medication,
weight-loss, diabetes management); or moderate the impact of a medical
condition on level of functioning (e.g., chronic pain, cancer); (6) live a
more valued, fulfilling life.

Patients. Ideal CBT patients quickly learn to recognize and label their
emotions, automatic thoughts, behaviors, and the connection between
these experiences. Nonetheless, patients who initially have difficulty with
this kind of self-monitoring are typically able to learn these skills through
instruction and practice. When patients have learning difficulties or
impaired intellectual skills, they often learn better when clinicians arrange
experiences and help them draw conclusions that fortify their adaptive
cognitions. Accordingly, even average intelligence is not a prerequisite for
treatment. Motivation for therapy is also helpful, but not required, as
patients who are hopeless, unmotivated, or lethargic may become more
invested in treatment as they begin to experience improvement. Patients
who are new to psychotherapy often report appreciating the CBT
approach as they see it as being pragmatic and comprehensible. Some
long-term patients of other psychotherapy approaches may have an initial
period of adjustment due to CBT’s more structured nature. Nonetheless,
most patients are able to make the transition, and structure can be
employed flexibly for others.
 Clinicians. The ideal cognitive therapist is attentive, empathic, and
nonjudgmental, as is desired in most models of psychotherapy. To be
maximally effective in an active treatment such as CBT, clinicians need to
be moderately directive in a collaborative manner. They also must be able
to ask for and receive feedback in a nondefensive manner. Although a
skilled clinician knows how to sit back and listen when appropriate, they
do not allow long silences as a matter of routine, and they are willing to
answer most questions with a therapeutically direct answer. CBT
clinicians aim to be transparent and share their conceptualization and
rationales for interventions. Treatment frequently lasts for weeks or
months, but not usually years.
As would be expected, several studies have demonstrated a high
correlation between a clinician’s level of competency, as measured by the
Cognitive Therapy Rating Scale (Young & Beck, 1980) and successful
treatment outcomes. Competency in CBT requires more than a passive
knowledge of the theory and techniques. Clinicians who wish to specialize
in CBT usually require a minimum of 1 year of supervised clinical
experience based on the theoretical formulation of the cognitive model,
though periodic training and supervision are recommended as research
validates refinement in cognitive formulations and associated treatment.
Ideally, supervision is performed by an expert cognitive therapist who
reviews, rates, and provides feedback on recordings of therapy sessions.

Limitations
Early outcome studies on CBT indicated that depressed patients could
show significant improvement in approximately 12 weeks (of biweekly and
weekly sessions). Likewise, individuals with panic disorder evinced a
significant reduction in panic attacks after 4 to 8 sessions of CBT. While
the short-term results are impressive, they have, at times, been
interpreted too broadly, creating an inaccurate perception that all types of
pathology and clinical presentations will respond as rapidly.
Research on CBT for individuals diagnosed with bipolar disorder,
chronic depression, schizophrenia, and personality disorders allow for a
longer course of treatment (e.g., 1 year), and results have been
promising. Moreover, even for uncomplicated cases, booster sessions at
longer intervals (e.g., 3 or 6 months) after termination of the course of
regular treatment can help with the maintenance of treatment gains and
prevent relapse.
Complications
At present, there are no known complications caused by CBT when it is
used properly and in the appropriate context. The model is designed to
teach patients a variety of skills to manage their presenting problems,
which gives them a sense of empowerment and self-efficacy. Accordingly,
the CBT model does not encourage patient dependence on the clinician.
Termination issues, which are relevant in any form of psychotherapy, are
dealt with proactively by the clinician who explicitly educates the patient
about the time-effectiveness of treatment, the importance of learning to be
one’s own therapist, and the use of booster sessions and self-therapy
sessions. Unhelpful cognitions related to termination are addressed
through standard techniques.
Clinical crises are handled with a combination of standard risk-reduction
procedures (e.g., increased frequency of sessions, inclusion of significant
others, emergency consultations, hospitalizations), along with a cognitive
conceptualization of the crisis situation. Once an acute crisis subsides,
clinicians explore the patient’s vulnerability (the activation of their
schemas) that was triggered by the activating event and help the patient
develop alternative coping strategies for similar future situations. The goal
is to help patients prevent such instances, gain confidence in their ability
to cope in the future, and become generally less vulnerable to life
stressors.

Contraindications
CBT has been demonstrated to be efficacious as part of a treatment
package for severe and persistent mental illness, although it is generally
recommended that pharmacotherapy options be assessed as part of the
treatment regimen for disorders such as schizophrenia and bipolar
disorder.

GOALS OF TREATMENT
CBT has three major goals. The first is to reduce patients’
symptomatology and suffering as quickly as possible and help them reach
remission. The second is to help clients live a more fulfilling life consistent
with their values. The third is to teach them skills that they can employ
long-term to increase their resilience, maintain improvement, and reduce
relapse.
ETHICAL ISSUES
The ethical issues that arise in many forms of psychotherapy also may
arise in CBT: eliciting informed consent, reporting child abuse, breaking
confidentiality when the patient’s life or the lives of other people are in
imminent danger, maintaining appropriate boundaries, and avoidance of
dual relationships. Additionally, clinicians are cognizant of not continuing
regularly scheduled sessions when ongoing treatment is no longer
deemed necessary. Once patients have made strides in accomplishing
their goals, are no longer experiencing acute symptoms, and have
demonstrated an ability to maintain treatment gains, clinicians may
suggest tapering the frequency of sessions, followed by scheduling only
periodic “booster” sessions.

RESEARCH AND EVALUATION

CBT has more research evidence in support of its efficacy and
effectiveness than any other form of psychotherapy, and as a result, has
been argued to be the gold standard of psychotherapy (David, Cristea, &
Hofmann, 2018). Systematically controlled studies have demonstrated the
efficacy of CBT for a range of psychiatric disorders, including serious
mental health conditions. A review of meta-analyses concluded that the
strongest support for CBT therapy exists in the treatment of anxiety
disorders, somatoform disorders, bulimia, anger, and general stress. CBT
has been successfully adapted across populations of different ages,
ethnicities, gender and gender identities, sexual orientation,
socioeconomic status, and cultural backgrounds, in a wide variety of
settings, including real-world settings.
A common misconception in psychological intervention research is the
notion of the Dodo Bird verdict, which concludes that all psychological
treatments are equal in their effects. A meta-analysis, however, concluded
that CBT was significantly more efficacious than other bona fide
interventions (e.g., psychodynamic, interpersonal, and supportive
therapies) for anxiety and mood disorders and is considered the first-line
treatment for anxiety disorders. CBT has also demonstrated superiority to
other treatments when comparisons are limited to studies with high
methodologic quality (e.g., random assignment, evaluator blind to
condition). Additionally, Hofmann and colleagues (2012) noted that 7 of 11
meta-analyses demonstrated higher response rates for CBT than
comparison conditions, while only one identified lower response rates for
CBT.
Researchers have used functional neuroimaging to study the influence
of psychological interventions on brain function. Neuroimaging studies
have demonstrated that individuals with psychological disorders tend to
have different brain functioning than nonclinical controls. Interestingly,
studies have found that following CBT, the brain functioning of individuals
with certain psychological disorders resemble control subjects (who did
not receive CBT). Neuroimaging research has also compared brain
functioning of individuals undergoing treatment with CBT to those taking
psychotropic medication. The results indicated that CBT causes similar
changes in brain function to psychotropic medication in the treatment of
OCD, SAD, specific phobias, and depression. Nonetheless, there are
differences in how disorders present in terms of both symptoms and brain
function. A more nuanced study found some differences in brain function
between successful CBT and pharmacotherapy.
CBT has been adapted to be administered using telehealth, the
internet, and computer-based formats. Video-delivered CBT has been
demonstrated to be as efficacious as in-person treatment when compiling
outcomes across studies. A meta-analysis concluded that internet- and
computer-based CBT demonstrated large effect sizes when compared to
a control group in the treatment of all disorders that were studied
(depression, panic disorder, SAD, and GAD). Moreover, patient
adherence was good, and patients reported being satisfied with treatment.
In sum, although CBT was originally developed as a treatment for
unipolar depression and anxiety disorders, it has been successfully
adapted to treat various clinical populations, including patient groups who
were traditionally thought to be unresponsive to psychosocial treatments
(e.g., schizophrenia). A growing body of research has demonstrated the
efficacy and effectiveness of CBT in addressing various disorders and
patient populations. While some researchers study mechanism of change,
additional studies, using mediational analyses, should be conducted to
continue to establish empirical support for the cognitive model and to aid
in refining treatment. Additionally, as researchers become better able to
identify biologic processes of psychological disorders, future research
may attempt to integrate biologic processes with the cognitive model,
consistent with the National Institute of Mental Health Research Domain
Criteria initiative, which was implemented to develop an alternative, more
homogenous and etiologically relevant, psychological disorder
classification system to the DSM. Finally, efforts to disseminate CBT to
clinicians have lagged behind the growing efficacy and effectiveness
research base. Future research should place a greater emphasis on
determining the most effective and efficient methods to disseminate CBT
to clinicians so that patients have greater access to competently delivered
evidence-based treatment.

FURTHER READINGS
Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety
and depressive disorders is effective, acceptable and practical health care: a meta-
analysis. PLoS ONE. 2010;5:e13196.
Beck JS. Cognitive Therapy for Challenging Problems: What to Do When the Basics
Don’t Work. Guilford Press; 2005.
Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 3rd ed. Guilford Press; 2020.
Beck AT. Depression: Clinical, Experimental and Theoretical Aspects. Hoebner Medical
Division, Harper and Row; 1967.
Beck AT, Davis DD, Freeman A. Cognitive Therapy of Personality Disorders. 3rd ed.
Guilford Press; 2015.
Beck AT, Finkel M, Beck JS. The theory of modes: applications to schizophrenia and
other psychological conditions. Cognit Ther Res. 2021;45:391–400.
Beck AT, Grant P, Inverso E, Brinen A, Perivoliotis D. Recovery-Oriented CBT for Serious
Mental Health Conditions. Guilford Press; 2020.
Beck AT, Rector NA, Stolar N, Grant P. Schizophrenia: Cognitive Theory, Research, and
Therapy. Guilford Press; 2009.
Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. Guilford Press;
1979.
Beck AT, Wright FD, Newman CF, Liese BS. Cognitive Therapy of Substance Abuse.
Guilford Press; 1993.
Clark DA, Beck AT. Scientific Foundations of Cognitive Theory and Therapy of
Depression. John Wiley & Sons; 1999.
Clark DA, Beck AT. Cognitive Therapy of Anxiety Disorders: Science and Practice.
Guilford Press; 2010.
David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold
standard of psychotherapy. Front Psychiatry. 2018;9:4.
DeRubeis RJ, Hollon SD, Amsterdam JD, et al. Cognitive therapy vs medications in the
treatment of moderate to severe depression. Arch Gen Psychiatry. 2005;62:409–416.
Dugas MJ, Marchland A, Ladouceur R. Further validation of a cognitive-behavioral model
of generalized anxiety disorder: diagnostic and symptom specificity. J Anxiety Disord.
2005;19;329–343.
Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a
“transdiagnostic” theory and treatment. Behav Res Ther. 2003;41:509–528.
Fernandez E, Woldgabreal Y, Day A, Pham T, Gleich B, Aboujaoude E. Live
psychotherapy by video versus in-person: a meta-analysis of efficacy and its
relationship to types and targets of treatment. Clin Psychol Psychother. 2021;28;1535–
1549.
Fuchs T. Neurobiology and psychotherapy: an emerging dialogue. Current Opinion
Psychiatry. 2004;17:479–485.
Furmark T, Tillfors M, Marteinsdottir I, et al. Common changes in cerebral blood flow in
patients with social phobia treated with citalopram or cognitive-behavioral therapy.
Arch Gen Psychiatry. 2002;59:425–433.
Goldapple K, Segal Z, Garson C, et al. Modulation of cortical-limbic pathways in major
depression: treatment-specific effects of cognitive behavior therapy. Arch Gen
Psychiatry. 2004;61:34–41.
Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The efficacy of cognitive
behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36:427–440.
Hollon SD. Is cognitive therapy enduring or antidepressant medications iatrogenic?
Depression as an evolved adaptation. Am Psychol. 2020;75;1207–1218.
Kazantzis N, Whittington C, Zelencich L, Kyrios M, Norton PJ, Hofmann SG. Quantity
and quality of homework compliance: a meta-analysis of relations with outcome in
cognitive behavior therapy. Behav Ther. 2016;47:755–772.
Knapp P, Kieling C, Beck AT. What do psychotherapists do? A systematic review and
meta-regression of surveys. Psychother Psychosom. 2015;84:377–378.
Kovacs M, Rush AJ, Beck AT, Hollon S. Depressed outpatients treated with cognitive
therapy or pharmacotherapy. Arch Gen Psychiatry. 1981;38:33–39.
Miller SD, Duncan BL, Brown J, Sorrell R, Chalk MB. Using formal client feedback to
improve retention and outcome: making ongoing, real-time assessment feasible. J
Brief Ther. 2006;5:5–22.
Newman CF, Leahy RL, Beck AT, Reilly-Harrington NA, Gyulai L. Bipolar Disorder: A
Cognitive Therapy Approach. American Psychological Association; 2002.
Rush AJ, Beck AT, Kovacs M, Hollon S. Comparative efficacy of cognitive therapy and
pharmacotherapy in the treatment of depressed outpatients. Cognit Ther Res.
1977;1:17–37.
Strunk DR, Brotman MA, DeRubeis RJ, Hollon SD. Therapist competence in cognitive
therapy for depression: predicting subsequent symptom change. J Consult Clin
Psychol. 2010;78:429–437.
Tolin DF. Is cognitive-behavioral therapy more effective than other therapies? A meta-
analytic review. Clin Psychol Rev. 2010;30:710–720.
van der Zweerde T, Lampros B, Kyle SD, Lancee J, van Straten A. Cognitive behavioral
therapy for insomnia: a meta-analysis of long-term effects in controlled studies. Sleep
Med Rev. 2019;48:101208.
Wells A. Metacognitive Therapy for Anxiety and Depression. Guilford Press; 2009.
Wenzel A, Liese BS, Beck AT, Friedman-Wheeler DG. Group Cognitive Therapy for
Addictions. Guilford Press; 2012.
Wright JH, Sudak DM, Turkington D, Thase ME. High-Yield Cognitive-Behavior Therapy
or Brief Sessions: An Illustrated Guide. American Psychiatric Publications; 2010.
Young J, Beck AT. Cognitive Therapy Rating Scale. Beck Institute for Cognitive Behavior
Therapy; 1980.