Download - CBT Essay
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Anxiety is a biological response which serves as an essential warning adaption in humans
(Rowney & Hermida, 2010). Anxiety can develop into a pathologic disorder when it is
triggered excessively and uncontrollably, requiring no specific stimulus, and manifesting with
a variety of physical and affective symptoms altering behaviour and cognition (Davison &
Neale, 2005). In the year 2000 the American psychiatric association created a certain
category for anxiety disorders in the DSM-IV, this category included the following disorders:
a) panic disorder without agoraphobia, b) panic disorder with agoraphobia, c) agoraphobia
without a history of panic disorder, d) social phobia, e) generalised anxiety disorder, f)
specific phobia, g) posttraumatic stress disorder, h) acute stress disorder, i) obsessive
compulsive disorder, j) anxiety disorder due to a general medical condition and k) substance
induced anxiety (APA, 2000). For all of the subtypes under this classification it must be
acknowledged that each condition shares a similar psychological process involving either or
both cognitive distortions and automatic negative thoughts (ANT) (Davison & Neale, 2005).
Considering the homogeneity of anxiety disorders the recommended treatment is cognitive
behavioural therapy (CBT) (Holmes, 2002). Indeed, cognitive behavioural therapy has much
positive support due to its apparent efficiency across a number of psychiatric disorders
(Holmes, 2002), however the question this paper aims to answer is what exactly is the
empirical status of cognitive behavioural therapy? The current paper will firstly introduce
CBT leading on to the efficacy of CBT for childhood and adolescent anxiety disorders,
following this a review of the empirical evidence supporting adult and older adult treatment
using CBT will be outlined with a final note being given to technological extensions of CBT.
In the past, behaviour therapy (the ‘BT’ in CBT) advanced adhering to the phenomena
proposed by classical and operant conditioning, however it has continued to progress and
evolve incorporating a cognition element due to the recognition that person – environment
interactions are interceded by cognitive processes (Van Hasselt & Hersen, 1993). Nowadays
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purely behavioural therapists work with clients to alter behaviours in order to reduce stressful
thoughts and emotions (Compton, March, Brent, Albano, Weersing & Curry, 2004).
Contrastingly, cognitive therapists work to modify the initial distressing thoughts and
feelings, with improvements in behaviour following simultaneously (Compton et al., 2004).
A defining aspect of CBT is that it proposes that symptoms and dysfunctional behaviours are
more often cognitively mediated and therefore improvements require the transformation of a
negative, dysfunctional thought process into a realistic or positive way of thinking (Dobson &
Dozois, 2001). Despite the popular view that CBT is a unitary treatment, CBT actually
incorporates an assortment of dense and subtle interventions from the social learning outlook
(Compton et al., 2004). CBT involves the development of a case formulation for a client. The
CBT case formulation guides the therapist in administering therapy adapting the techniques
to suit the patient’s presenting mental issues (Compton et al., 2004). Cognitive behavioural
therapy is diverse in its patient base, however, despite the differences in clientele the
intervention method shares five features: 1) Adherence to the scientist-clinician model, in that
treatments are deciphered according to demonstrated evidence. 2) Functional analysis of
target behaviours and cognitive distortions which aid the maintenance of the symptoms. 3)
Prominence of psycho-education. 4) Problem specific treatment and 5) relapse prevention
(Compton et al., 2004). Particularly with the anxiety disorders category CBT employs
techniques such as cognitive restructuring and exposure in order to extinguish inappropriate
fears and thoughts (Compton et al., 2004). As a direct result of how structured and scientific
this method of therapy is, CBT can be recommended as a reliable approach for paediatric
mental illness (Barrett, Duffy, Dadds & Rapee, 2001).
Children’s acquisition of socio-emotional abilities develop with time, however the
failure to develop such skills at relatively the same pace as matched controls may suggest
capacity limitations, a problematic environment or a mental illness (Compton et al., 2004).
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When CBT is applied to child therapy the therapist must gain an in depth understanding of
the presenting issues and view the environment of the child to learn of any possible
developmental constraints. This information must then be used in the formulation to form a
detailed therapeutic strategy with the aim of restoring the child’s level of development to that
of their healthy peers (Compton et al, 2004). Children suffering an anxiety disorder often
view the world as threatening and respond to their perceived threatening stimuli through
avoidance (Compton et al., 2004). Cognitive behavioural therapy for children assists the child
to reconceptualise those situations which trigger fear and build a new successful coping
template (Barrett, Duffy, Dadds & Rapee, 2001). Treatment for children regularly includes
relaxation training, imagery, development of problem solving skills, role play and in-vivo
exposure (Compton et al., 2004). It was long thought that CBT was not applicable for
children with mental illnesses however Albano and Kendall (2002) investigated the efficacy
of CBT for childhood panic disorder and found that this prior view of childhood CBT was
incorrect. Findings from this study supported the results revealed by earlier researchers such
as Borkovec and Costello (1993) comparing relaxation therapy to CBT for children with
generalised anxiety disorder. Overall results showed in favour of CBT as being the most
effective method of treatment.
Kendall (1994) conducted a randomised clinical trial of cognitive behavioural
therapy with anxious children between nine and thirteen years of age. Children selected to
participate in the CBT trial received sixteen CBT sessions. An analysis of self-repost
measures, parental reports and behavioural observations indicated significant improvements
in the children who received CBT in comparison to those who as the control group did not.
This experiment followed up the initial findings with a maintenance test one year later. It was
discovered that only sixteen sessions of CBT for anxious children sustained the benefits
originally gained even after a period of one year post-treatment (Kendall, 1994).
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In 2001 Barrett, Duffy, Dadds and Rapee followed up a study originally started by
Barrett, Dadds and Rapee in 1996 in which it was identified that CBT was effective for
childhood anxiety problems. The researchers included Fifty two of the original seventy nine
children who had received CBT treatment approximately 6.17yrs earlier. The aim of the
study was to test the efficacy of CBT in the long-term. Results were impressive revealing that
85.7% were no longer classified as suffering an anxiety disorder thus supporting the idea that
CBT is a long-lasting therapeutic method for children (Barrett, Duffy, Dadds & Rapee,
2001).
Cognitive behavioural therapy as a form of psychotherapy has been researched at
length. In excess of one hundred and twenty controlled clinical studies have been published
between 1986 and 1993 with this trend extending each year (Hollon & Beck, 1994). This
surge in CBT research is understood to be related to the realisation that CBT is applicable for
a wide range of mental disorders (Beck, 1997). CBT for adults diagnosed with an anxiety
disorder focuses on modifying thought and transferring learned skills from therapy to the
client’s everyday life (Butler, Chapman, Forman & Beck, 2006). CBT makes adults their own
therapist in order to alter cognitive distortions (Beck, 1997). The major attribute of CBT
which has given this treatment style the edge over other methods is its evident effectiveness
in the long-term (Dobson & Dozois, 2001). Borkovec and Costello (1993) compared the
long-term effectiveness of CBT and relaxation therapy for generalised anxiety disorder
(GAD) in adults. The researchers identified a superior result of 58% of CBT patients no
longer meeting criteria for GAD, comparatively relaxation therapy revealed a 38% statistic of
those patients no longer within range of a diagnosis of GAD (Borkovec & Costello, 1993).
In relation to the successful treatment of panic disorder Gould, Otto and Pollack
(1995) conducted a meta-analytic comparison of purely cognitive intervention therapies and
CBT using exposure treatment. The CBT approach combining the exposure technique was
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distinguished as the most productive in treating patients with panic disorder. This
combination of interventions is the method of choice for CBT practitioners. Oei, Llamas and
Devilly (1999) studied the efficacy of CBT for patients suffering panic disorder with
agoraphobia comparing their anxiety levels to that of undiagnosed community members. It
was discovered that CBT can produce anxiety levels lower than that of the community by the
final therapy session and these scores were consistent during a follow up study conducted one
year later (Oei, Llamas & Devilly, 1999). Another form of anxiety disorder also linked to
social situations is social phobia. DeRubeis and Crits-Cristoph (1998) reviewed the long-term
validity of CBT for this particular disorder and it was concluded that CBT is also an effective
therapy for social phobia.
Previously in psychology the prevalent method for the treatment of obsessive
compulsive disorder (OCD) was simply exposure with response prevention, the ERP of
counselling psychology, now however due to the level of support for CBT there is also
growing evidence that CBT incorporating exposure is more effective than exposure treatment
alone (Chambless & Ollendick, 2001). This hypothesis was tested by van Balkom, van
Oppen, Vermuelen, van Dyck, Nauta and Vorst (1994), the authors concluded that CBT led
to substantial reductions in obsessive thoughts and compulsive behaviours. According to
patients ratings and clinical assessments CBT showed more impressive results than the more
traditional method of simple exposure treatment even at a twelve month follow up report (van
Balkom et al., 1994).
In 2005 the royal college of psychiatrists and the British psychological society
completed a thorough meta-analysis of clinical research to date on posttraumatic stress
disorder (PTSD).The patient population reviewed was extensive incorporating backgrounds
such as survival from a serious accident, sexual assault, domestic violence, military combat
and refugees. CBT was by and large identified as the most effective treatment for PTSD
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(RCP & BPS, 2005). This conclusion was later supported by Hofmann and Smits (2008)
comparing CBT in PTSD patients to a placebo controlled trial.
Despite impressive advances observed for CBT since it first emerged in the 1980’s
not a lot of attention has been focused on treating anxiety disorders in the older adult (Beck &
Stanley, 1997). According to Flint (1994) the prevalence of anxiety disorders in the elderly is
considerably lower than that of the younger population. Lawton, Kleban and Dean (1993)
provide an explanation for this by asserting that the nature of anxiety is different in older
adults. In their study the researchers included two hundred and seven young adults, two
hundred and thirty one middle aged adults, and eight hundred and twenty eight older adults.
The aim of the study was to compare the varying age groups on response to affect terms. The
results revealed that elderly participants reported less of most of the negative emotional states
particularly anxiety. Regardless of the reduction in prevalence of anxiety disorders among the
elderly Regier, Boyd, Burke, Rae, Myers and Kramer (1988) report that GAD in older adults
is as prevalent as major depression and that in general anxiety disorders are more of an issue
among the elderly than mood disorders. However, the question remains, can CBT benefit the
elderly who do suffer some form of anxiety disorder? Older people consume a large share of
anti-anxiety medications which in itself suggests that anxiety is an issue worth addressing in
the elderly population (Graham & Vidal-Zeballos, 1998). Anxiolytic pills including
benzodiazepines are among the most common medications provided to the elderly for the
treatment of anxiety (Blazer, George & Hughes, 1991). However, the major issue with this
method of treatment involves the risk of cognitive impairment which is linked to these
medications (Blazer, George & Hughes, 1991). This calls for a new more acceptable way of
treating anxiety disorders in the elderly.
In the year 2001 Barrowclough, King, Colville, Russell, Burns and Tarrier found that
home delivered CBT for the elderly suffering GAD was more effective than supportive
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counselling. This method also allowed the patient to relax as the therapy was carried out in
the comfort of their own home. Wetherell, Gatz and Craske (2003) conducted another study
to test the value of CBT for GAD in an elderly patient base. CBT was compared to a
discussion group and a waiting period group. There were a total of seventy five participants,
averaging in age at sixty seven years. Participants in both the CBT and discussion group
showed benefits over the waiting period group, however in a long-term follow up of twelve
months CBT showed stronger lasting effects (Wetherall, Gatz & Craske, 2003). This suggests
that the empirically supported hypothesis that CBT acts as a sound alternative to medication
for the elderly suffering from anxiety disorders can with future research gain even more
appreciation.
Another less well highlighted area within cognitive behavioural therapy is its apparent
effectiveness in the treatment of anxiety disorders following traumatic brain injury (TBI)
(Williams, Evan & Fleminger, 2003). Williams, Evan and Fleminger (2003) studied patient
‘DC’ who acquired TBI subsequent to a serious accident. DC suffered amnesia, attention
difficulties and self-doubt as a result which manifested as OCD. DC’s self-doubt stemmed
from his amnesia which likely caused him to develop obsessive thoughts and checking
compulsions. DC developed a maladaptive coping strategy of avoidance behaviours
involving avoiding social situations. Anxiety disorders are thought to be quite common in
TBI patients however, the difficulty in distinguishing an anxiety disorder from other
impairment consequences often leads to an overlook of the problem (Williams, Evan &
Fleminger, 2003). It must also be considered that chronic anxiety in a patient has been shown
to produce neurotoxins decreasing the size of the hippocampi through cell atrophy (Bremner,
Randall, Scott, Bronen, Seibyl, Southwick, Delaney, McCarthy & Charney, 1995). CBT as
previously expressed by this paper has been regarded as a highly effective method of treating
anxiety disorders. A combination of CR (cognitive rehabilitation) and CBT has been
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emphasised as the appropriate measure for treating anxiety disorders in neurologically
impaired individuals (Williams, Evan & Fleminger, 2003). Cognitive behavioural therapy
applied to the case of ‘DC’ involved exposure, response prevention and management of
automatic negative thoughts which maintained his self-doubt. Overall the treatment for DC
which comprised of CBT reduced significantly DC’s automatic negative thoughts allowing
him to build his self-esteem. Exposure treatment helped reduce the obsessions and
compulsions which accompanied DC’s OCD (Williams, Evan & Fleminger, 2003).
Thus far this paper has not considered medication in direct competition with CBT, the
efficacy of imipramine versus CBT for panic disorder in adults will now be discussed.
Barlow, Gorman, Shear & Wood (2000) identified a lifetime prevalence for panic disorder of
approximately three percent. The researchers questioned whether medication, CBT or a
combination of both would aid the recovery from panic disorder. Randomised, double blind,
placebo controlled trials were created in four major anxiety research clinics following three
hundred and twelve patients over a seven year period. Eighty three patients were randomly
assigned to the imipramine study. Seventy seven patients were selected at random for the
CBT study. Twenty four patients were assigned to the placebo only study. Sixty five patients
were allocated to the CBT plus imipramine study while the remaining sixty three took part in
the CBT plus placebo study. The combination of imipramine and CBT revealed the most
impressive results. CBT alone and imipramine alone showed equal efficiency in the twelve
month follow up study (Barlow, Gorman, Shear & Woods, 2000).
Finally the current paper will consider some of the technological tools which have
been manufactured in recent years to aid the efficacy of CBT. Newman, Consoli and Taylor
(1999) describe the Palmtop computer program developed for the treatment of GAD.
According to the authors, identified advantages of this program include continuous,
unobtrusive collection of process data on treatment adherence, therapy in the patient’s natural
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setting, therapy beyond the set hour with a therapist and the insurance of homework
completion. Palmtops allow repeated assessment and the program has been created to cater
for specific responses modifying the therapy given depending on the situation presented. The
device has been programmed to provide cognitive restructuring, exposure, relaxation training,
breathing retraining, and positive imagery (Newman, Consoli & Taylor, 1999). Newman,
Kenardy, Herman and Taylor (1997) reported that from their studies involving patients Miss
Q, Mr. J and Mr. K the use of palmtop computers as an extension of CBT in conjunction with
normal CBT therapist applied therapy was even more beneficial than CBT alone. CBT is
particularly well suited for technological aid as it is well described, structured and specific
(Anderson, Jacobs & Rathbaum, 2004).
Virtual reality therapy is another form of exposure utilised by CBT particularly for
those suffering agoraphobia as they must overcome their fear of leaving their home
environment (Anderson, Jacobs & Rathbaum, 2004). Virtual environments afford the client
the opportunity to participate in the environment in which they feel anxious however, this
environment is completely controlled by the therapist, this allows the exposure to be graded
according to the exact requirements of the patient (Pull, 2005). Rothbaum, Hodges, Ready,
Graap and Alarcan (2001) utilised virtual reality exposure treatment in conjunction with CBT
for PTSD in Vietnam veterans. This overcame the inability to ethically create in-vivo
exposure and produced gains significant at the six month follow up period. In 2002
Emmelkamp, Krijn, Holsbosch, de Vries, Schuemie and van der Mast (2002) compared the
relative efficacy of in-vivo exposure and virtual reality exposure for a specific phobia, the
fear of heights. Results showed that virtual reality exposure was as efficient as in-vivo
exposure for reducing anxiety and avoidance behaviours (Emmelkamp et al., 2002).
This paper has considered the relative efficacy of cognitive behavioural therapy for
children, adults, the elderly and neurologically impaired patients suffering from anxiety
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disorders. Each of the patient groups were provided with satisfactory empirical evidence
further revealing the adaptive and successful nature of this therapeutic method. The key to the
success shown by CBT is its incorporation of the classic behavioural technique and the more
modern cognitive treatment measure (Holmes, 2002). As a result of the research noted in this
paper it can be concluded that cognitive behavioural therapy does in fact have an empirically
supported evidence base which is even more concentrated when combined with a
technological device such as the palmtop computer or virtual reality therapy.
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