Handbook of Cognitive Behavioral Therapy, volume 1 1433833522, 9781433833526

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Handbook of

COGNITIVE B E H AV I O R A L THERAPY

Volume 1

Edite d by

OVERVIEW AND

A MY WENZEL

APPROACHES

Copyright © 2021 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. The opinions and statements published are the responsibility of the editor and authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 https://www.apa.org Order Department https://www.apa.org/pubs/books [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from Eurospan https://www.eurospanbookstore.com/apa [email protected] Typeset in Meridien and Ortodoxa by TIPS Technical Publishing, Inc., Carrboro, NC Printer: Gasch Printing, Odenton, MD Cover Designer: Mark Karis Library of Congress Cataloging-in-Publication Data Names: Wenzel, Amy, editor. Title: Handbook of cognitive behavioral therapy / edited by Amy Wenzel. Description: Washington, DC: American Psychological Association, [2021] | Includes bibliographical references and index. | Contents: v. 1. Handbook of cognitive behavioral therapy: overview and approaches—v. 2. Handbook of cognitive behavioral therapy: applications. Identifiers: LCCN 2020033268 | ISBN 9781433833526 (v. 1; hardcover) | ISBN 9781433833502 (v. 2; hardcover) Subjects: LCSH: Cognitive therapy—Handbooks, manuals, etc. Classification: LCC RC489.C63 H356 2021 | DDC 616.89/1425—dc23 LC record available at https://lccn.loc.gov/2020033268 https://doi.org/10.1037/0000218-000 eISBN 978-1-4338-3351-9 Published in the United States of America 10 9 8 7 6 5 4 3 2 1

CONTENTS

About the Editor ix Contributors xi Introduction: The Evolution and Main Components of Cognitive Behavioral Therapy xv Amy Wenzel

I. CONTEXT 1 1. Philosophical and Historical Foundations

3

Robert L. Leahy and Christopher R. Martell

2. Theoretical Framework

31

Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann

3. The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders 51 Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, Pim Cuijpers, and Claudi L. H. Bockting

4. Empirical Status of Mechanisms of Change

91

Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, Amy Wenzel, and Jasper A. J. Smits

5. Cognitive Case Formulation

131

Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler

6. Dissemination and Implementation

157

Bradley E. Karlin

7. The Therapeutic Relationship

175

Amy Wenzel  v

vi Contents

II. STRATEGIES AND TECHNIQUES 8. Cognitive Restructuring

205 207

Christine Purdon

9. Behavioral Activation

235

Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter

10. Exposure Therapy

275

Lauryn E. Garner, Emily J. Steinberg, and Dean McKay

11. Motivational Interviewing

313

Deborah H. A. Van Horn, Amy Wenzel, and Peter C. Britton

12. Regulation of Physiological Arousal and Emotion

349

Holly Hazlett-Stevens and Alan E. Fruzzetti

13. Relapse Prevention

385

John Ludgate

III. PSYCHOTHERAPY PACKAGES 14. Cognitive Therapy

415 417

Amanda Fernandez, Keith Dobson, and Nikolaos Kazantzis

15. Rational Emotive Behavior Therapy

445

Debbie Joffe Ellis

16. Emotion-Centered Problem-Solving Therapy

465

Arthur M. Nezu and Christine Maguth Nezu

17. Schema Therapy

493

Eva Fassbinder and Arnoud Arntz

18. Dialectical Behavior Therapy

539

Hollie F. Granato, Amy R. Sewart, Meghan Vinograd, and Lynn McFarr

19. Acceptance and Commitment Therapy

567

Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin

20. Mindfulness-Based Cognitive Therapy

595

Amanda Ferguson, Lê-Anh Dinh-Williams, and Zindel Segal

21. Metacognitive Therapy

617

Peter L. Fisher

22. Applied Behavior Analysis

637

Raymond G. Miltenberger, Diego Valbuena, and Sindy Sanchez

23. Cognitive Bias Modification

673

Emily E. E. Meissel, Jennie M. Kuckertz, and Nader Amir

24. The Unified Protocol: A Transdiagnostic Treatment for Emotional Disorders Todd J. Farchione, Julianne G. Wilner Tirpak, and Olenka S. Olesnycky

701



Contents  vii

25. Contemporary Cognitive Behavioral Therapy

731

Nikolaos Kazantzis, Hoang Kim Luong, Hayley M. McDonald, and Stefan G. Hofmann

Index 757

ABOUT THE EDITOR

Amy Wenzel, PhD, ABPP, is a licensed clinical psychologist, owner, and director of the Main Line Center for Evidence-Based Psychotherapy, faculty member at the Beck Institute for Cognitive Behavior Therapy, and certified trainer-consultant with the Academy of Cognitive Therapy. She has authored or edited 25 books and treatment manuals, many on cognitive behavioral therapy. She lives in the Philadelphia, Pennsylvania, suburbs. Visit http://dramywenzel. com and http://mainlinecenter.com for descriptions of her books, videos, trainings, and clinical practice. Follow her on Facebook at Dr. Amy Wenzel, Clinical Psychology and on Twitter @dramywenzel.

 ix

CONTRIBUTORS

Nader Amir, PhD,Director, Center for Understanding and Treating Anxiety (CUTA), Department of Psychology, Joint Doctoral Program at San Diego State University/University of California San Diego, San Diego, CA, United States Arnoud Arntz, PhD,Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands Eni S. Becker, PhD,Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands Peter J. Bieling, PhD,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Emanuele Blasioli, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Claudi L. H. Bockting, PhD,Department of Psychiatry, University Medical Centers, Academic Medical Center (AMC-UvA), Amsterdam, The Netherlands Peter C. Britton, PhD,Department of Psychiatry, University of Rochester School of Medicine and Dentistry and Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, NY, United States Pim Cuijpers, PhD,Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands Rianne A. de Kleine, PhD,Institute of Psychology, Leiden University, Leiden, The Netherlands Lê-Anh Dinh-Williams, MA,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada  xi

xii Contributors

Keith Dobson, PhD,Department of Psychology, University of Calgary, Calgary, AB, Canada Debbie Joffe Ellis, MDAM,Department of Clinical and Counseling Psychology, Columbia University, New York, NY, United States Todd J. Farchione, PhD,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Eva Fassbinder, MD,Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany Amanda Ferguson, MA,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada Amanda Fernandez, PhD,Alberta Health Services, Calgary, AB, Canada Peter L. Fisher, PhD,Psychological Sciences, University of Liverpool, England, United Kingdom Dara G. Friedman-Wheeler, PhD,Center of Psychology, Goucher College, Baltimore, MD, United States Alan E. Fruzzetti, PhD,McLean Hospital and Harvard Medical School, Belmont, MA, United States Lauryn E. Garner, MA,Department of Psychology, Fordham University, Bronx, NY, United States Hollie F. Granato, PhD,Department of Psychiatry, University of California Los Angeles, Los Angeles, CA, United States Holly Hazlett-Stevens, PhD,Department of Psychology, University of Nevada, Reno, Reno, NV, United States Stefan G. Hofmann, PhD,Department of Psychology, Boston University, Boston, MA, United States Jonathan W. Kanter, PhD,Department of Psychology, University of Washington, Seattle, WA, United States Bradley E. Karlin, PhD, ABPP,Solutions for Mental Health Change, PLLC, Cary, NC; Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States Nikolaos Kazantzis, PhD, FAPS,Principal Researcher and Research Director, Translational Clinical Psychology Research Division, Institute of Social Neuroscience, Melbourne, Australia John R. Keefe, PhD,Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States Jennie M. Kuckertz, PhD,Obsessive Compulsive Disorder Institute, McLean Hospital/Harvard Medical School, Boston, MA, United States Robert L. Leahy, PhD,Director, American Institute for Cognitive Therapy, New York, NY, United States Eric B. Lee, PhD,Department of Psychology, Southern Illinois University, Carbondale, IL, United States Lotte H. J. M. Lemmens, Department of Clinical Psychological Science at Maastricht University, Maastricht, The Netherlands Michael E. Levin, PhD,Department of Psychology, Utah State University, Logan, UT, United States



Contributors  xiii

Lorenzo Lorenzo-Luaces, PhD,Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, IN, United States John Ludgate, PhD, CBT Center, Asheville, NC, United States Hoang Kim Luong, BSc (Hons),Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia Christopher R. Martell, PhD,Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, MA, United States Hayley M. McDonald, Private Practice, Sydney, Australia Lynn McFarr, PhD,Department of Psychiatry, University of California Los Angeles, Los Angeles, CA, United States Dean McKay, PhD, ABPP,Department of Psychology, Fordham University, Bronx, NY, United States Emily E. E. Meissel, BA,San Diego State University/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States Raymond G. Miltenberger, PhD, BCBA-D,Professor, Department of Child and Family Studies, University of South Florida, Tampa, FL, United States Gabriela A. Nagy, PhD,Department of Psychiatry and Behavioral Sciences and School of Nursing, Duke University, Durham, NC, United States Arthur M. Nezu, PhD, DHL, ABPP,Distinguished University Professor of Psychology, Professor of Medicine, and Professor of Public Health, Drexel University, Philadelphia, PA, United States Christine Maguth Nezu, PhD, ABPP,Professor of Psychology and Medicine, Drexel University, Philadelphia, PA, United States Olenka S. Olesnycky, MA, Department of Psychology, Hofstra University, Hempstead, NY, United States Benjamin G. Pierce, PhD,School of Psychology, Utah State University, Logan, UT, United States Christine Purdon, PhD,Department of Psychology, University of Waterloo, Waterloo, ON, Canada Ajeng J. Puspitasari, PhD, LP, Departments of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States Sindy Sanchez, PhD, BCBA-D, Comprehensive Behavioral Consulting, LLC, Tampa, FL, United States Maria M. Santos, PhD,Department of Psychology, California State University, San Bernardino, San Bernardino, CA, United States Zindel Segal, PhD,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada Amy R. Sewart, PhD,Department of Psychology, California State University, Dominguez Hills, Carson, CA, United States Jasper A. J. Smits, PhD,Department of Psychology, The University of Texas at Austin, Austin, TX, United States Emily J. Steinberg, MA,Department of Psychology, Fordham University, Bronx, NY, United States

xiv Contributors

Julianne G. Wilner Tirpak, MA,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Michael P. Twohig, PhD,Department of Psychology, Utah State University, Logan, UT, United States Diego Valbuena, PhD, BCBA-D,Comprehensive Behavioral Consulting, LLC, Tampa, FL, United States Deborah H. A. Van Horn, PhD,Deborah H. A. Van Horn, PhD, LLC, West Deptford, NJ, United States Meghan Vinograd, PhD,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System; Department of Psychiatry, University of California San Diego, La Jolla, CA, United States Janna N. Vrijsen, PhD,Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center; Depression Expertise Center, Pro Persona Mental Health Care, Nijmegen, The Netherlands Amy Wenzel, PhD, ABPP,Main Line Center for Evidence-Based Psychotherapy, Havertown, PA, United States

INTRODUCTION The Evolution and Main Components of Cognitive Behavioral Therapy Amy Wenzel

C

ognitive behavioral therapy (CBT for short)—what a term that evokes a distinctive reaction in mental health professionals, in scholars and researchers in medicine and related fields, and in clients who struggle with mental health problems! What began as a simple alternative to the dominant treatments for mental health problems in the second half of the 20th century (i.e., pharmacotherapy, psychoanalysis, person-centered therapy) has evolved into a powerhouse of a theoretical and clinical framework that drives the understanding and treatment of countless emotional, behavioral, and adjustment problems. CBT is arguably the best researched of all the psychotherapeutic approaches that can be delivered to clients in need, and results from empirical studies confirm that CBT is highly efficacious in reducing psychiatric symptoms and problems in functioning and in improving satisfaction in relationships and quality of life (Butler et al., 2006). There is no succinct definition of CBT. It originated as an active, problemfocused, and time-limited approach to psychotherapy in which interventions had their foundation in the notion that problematic styles of thinking contributed to and exacerbated psychiatric symptoms (Beck, 1967). Perhaps the best way to put it is that cognitive behavioral interventions were designed to be strategic, in that regardless of what they actually involved, their goal was to shift clients’ thinking from thinking that is excessively negative, exaggerated, and/or shortsighted to thinking that is accurate, balanced, and wise. In some of the first CBTs that were developed in the 1960s and 1970s (i.e., Aaron T. Beck’s cognitive therapy [CT] and Albert Ellis’s rational emotive behavior therapy [REBT]), much of the intervention was centered directly on reshaping problematic thinking, either through guided questioning, in the case of CT, or more overt challenging of irrational logic, in the case of REBT.  xv

xvi Introduction

Although cognitive constructs gained significant attention and continue to hold central importance in explaining psychiatric symptoms, the role of behavioral explanations and interventions for psychiatric symptoms could not be dismissed. Indeed, behavioral psychotherapeutic approaches served as an alternative to psychoanalysis and person-centered psychotherapy in the time preceding the proliferation of cognitive approaches, and they regained traction in the 1980s when combined cognitive and behavioral treatments were developed and optimized for the treatment of anxiety disorders and obsessivecompulsive disorder (OCD; Barlow, 1988; Rachman, 2015; Salkovskis, 1985). It was at this time that the phrase “cognitive behavioral therapy” began to be used by scholars and clinicians (as opposed to “cognitive therapy” or “CT”), emphasizing the relatively equal importance of cognition and behavior in understanding and treating psychopathology. In fact, many regard the early behavioral approaches to treatment based in classical and operant conditioning as a “first wave” of evidence-based psychotherapy, and they view cognitively focused psychotherapeutic approaches as a “second wave” of evidence-based psychotherapy, such that the scientific principles of behaviorism were applied to internal cognitive phenomena. As many readers likely know, many scholars and clinicians regard the field as currently being immersed in a “third wave” of evidence-based psychotherapy that is characterized by two important features: (a) a focus on function, as opposed to form (e.g., purposes and consequences of thought process instead of modification of thought content); and (b) the inclusion of a focus on acceptance and mindfulness, as opposed to a dominant focus on cognitive and behavioral change and symptom reduction (e.g., Hayes et al., 1999, 2012). It is important to note that some leaders in the field do not necessarily buy into the notion of these three “waves” and them as manifestations of the same underlying principles (Hofmann & Asmundson, 2008). Nevertheless, there is no question that the family of CBTs has been heavily influenced by the proliferation of development in the areas of context, function, acceptance, and mindfulness and that contemporary cognitive behavioral practitioners readily incorporate these constructs into their case formulations and emergent treatment plans (Wenzel, 2017). In fact, I often tell my clients that CBT as it is practiced today in “real-life” settings can be represented as a three-legged barstool, with cognitive change, behavior change, and acceptance being represented by each of the legs. I state (a bit humorously) that CBT should be renamed “CBAT,” or “cognitive-behavioral-acceptance-based therapy.” Thus, as of summer 2019 when I am writing this introduction, I define CBT as an active, problem-focused, time-sensitive psychotherapeutic approach that focuses on cognitive change, behavior change, and acceptance as they apply to a host of mental health conditions and adjustment problems. In addition, I highlight several additional features of CBT that many believe are definitional in and of themselves. First, the foundation of the cognitive behavioral understanding and treatment of any one client is the case formulation, or the application of cognitive behavioral theory to understand a client’s presenting problem, developmental history, and way of experiencing their current life circum-



Introduction  xvii

stances. In fact, over an intellectually stimulating lunch that took place in 2014, Dr. Beck and I agreed that the case formulation is the “heart” of CBT beyond any specific strategy or technique. Second, CBT is semistructured. Many people mistake this to mean that CBT is rigid or formulaic. As the reader will see throughout this two-volume set, there are many, many ways to conduct CBT, and it cannot be boiled down to a specific formula or step-by-step guidelines. Nevertheless, most cognitive behavioral therapists work with their clients to focus the session on at least a couple of aims that they hope to accomplish, and they strategically work toward achieving those aims rather than talking endlessly without purpose. Finally, cognitive behavioral therapists believe that the most significant change occurs when the therapy’s principles are applied outside of session, so clients in CBT are encouraged to complete “homework,” or to engage in some sort of practice or application that will allow them to generalize the principles and skills that they are acquiring in session.

DEFINITIONS OF SPECIFIC CBT TERMS Within the broad CBT framework, there are several constructs that are mentioned in many chapters in this two-volume set. Some of the constructs that are noted most frequently in the chapters are defined below, so it is hoped that this section will serve as a reference point for the reader who is just beginning to become familiar with the nuances of CBT. Therapeutic Alliance Cognitive behavioral therapists believe that a strong therapeutic relationship is essential (though not sufficient in and of itself) to a positive outcome in treatment. Interestingly, cognitive behavioral therapists’ stance on the therapeutic relationship has long been misunderstood by clinicians who practice from different theoretical orientations. In one of his earliest books, Dr. Beck included a chapter on the therapeutic relationship, and when he lectures, he makes clear that he was heavily influenced by giants like Carl Rogers (Beck et al., 1979). Many cognitive behavioral therapists continue to publish scholarship and research on the role of the therapeutic relationship in CBT, most notably the construct of the therapeutic alliance. According to Bordin (1979), the therapeutic alliance is characterized by three constructs: (a) the mutually agreed-upon goals of therapy, (b) the tasks that take place within the process of therapy in the service of reaching therapeutic goals, and (c) the bond between the therapist and client. Research that has examined the contribution of the therapeutic alliance to outcome in CBT typically measures the therapeutic alliance using some version of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Thus, when chapter authors reference research on the therapeutic alliance, unless otherwise specified, the reader can assume that this is the self-reported perception of the client about the goals, tasks, and bonds in therapy.

xviii Introduction

Cognition and Its Modification A core strategy in the cognitive behavioral treatment of almost all mental health problems is cognitive restructuring, or the process by which therapists help their clients identify, evaluate, and, if necessary, modify unhelpful thinking that exacerbates emotional distress. Because of its central importance, this strategy is mentioned in most of the chapters in the handbook set. The type of cognition that is most commonly subjected to cognitive restructuring is the automatic thought, named as such because it is a thought that emerges seemingly instantaneously when a person is faced with a challenging or aversive situation. The specific nature of the automatic thoughts that are observed are typically influenced by the contents of a person’s underlying core beliefs, or fundamental beliefs that people hold about themselves, others, the world, or the future. Core beliefs usually develop through early life circumstances and experiences, although they can be altered (sometimes radically) by notable events that take place during adulthood. The astute reader will note that many chapter authors use the term schema, which also encompasses these underlying beliefs that shape the way a person views their life experiences. Although a few chapter authors imply that their use of schema is synonymous with core beliefs, many cognitive behavioral experts view schemas as encompassing core beliefs from a content perspective but as being a bit broader to reflect biases in information processing, or the way in which people filter information. Figure 1 depicts the way in which I view the relation between schemas and core beliefs. Cognitive restructuring uses a process of guided questioning to help clients arrive upon their own conclusions regarding the accuracy and helpfulness of their thinking, called guided discovery. The questioning used in guided discovery is called Socratic questioning, which has its roots in the teaching style of the Greek philosopher Socrates, who asked questions of his students to elicit critical thinking, rather than simply lecturing to his students and telling them what to think. Although it should be noted that guided discovery is often used by writers to capture the full extent of the cognitive restructuring process—from the identification of unhelpful cognition to the arrival of more balanced thinking—I have also seen guided discovery defined primarily as the process of uncovering previously unacknowledged problematic thinking that is associated with emotional distress. Moreover, guided discovery can also refer to the more general process, both within the process of cognitive restructuring as well as within the process of other BT strategies, in which the therapist asks questions to help the client consolidate the learning that is occurring (e.g., “What did you learn from doing this exercise?” and “How can you apply this knowledge to other circumstances in your life?”). Cognitive restructuring is typically implemented in the spirit of promoting a sense of collaborative empiricism between the therapist and client. Collaborative empiricism means that the therapist and client work together as equal members of a team (i.e., collaborative) to examine facts and evidence (i.e., empiricism) to arrive upon the most accurate way of viewing a situation. Collaborative empiricism is a fundamental tenet of CBT. Although it is referenced most often



Introduction  xix

FIGURE 1. Schemas and Core Beliefs

in the context of cognitive restructuring, as I mentioned is the case with guided discovery, it can be applied more broadly for clients to test the effectiveness of a wide range of strategies as they learn to live their lives in a different, more balanced manner. Finally, a very specific term that is referenced in many chapters is the thought record, or a form in which clients can record their cognitive restructuring work that they do in sessions and in between sessions for “homework.” Many versions of thought records exist, including those in which clients simply record thoughts that arise in upsetting situations; thought records in which clients record thoughts that arise in upsetting situations along with the evidence that does and does not support their thinking; and thought records in which clients also construct a new thought that is more accurate, helpful, and balanced as a result of Socratic questioning. Although, traditionally, thought records took the form of sheets of paper on which clients would write using a pen or pencil, over the past several years, many clients have kept “virtual” thought records whereby they record their cognitive restructuring work in electronic computer files or mobile phone applications. Behavioral Activation Behavioral activation is a common strategy in the cognitive behavioral treatment of depression. It aims to increase clients’ engagement in their lives by encouraging them to do things that give them a sense of joy, pleasure, accomplishment, and/or meaning. It is anticipated that, by more actively engaging in these sorts of activities in their lives, clients will attain a sense of response-contingent positive reinforcement, which has the potential to be just as potent as taking an antidepressant pill. Many cognitive behavioral therapists who implement behavioral activation in their sessions use an activity log so that clients can record

xx Introduction

the activities in which they are engaging, activities that they are attempting to work into their routines, ratings capturing the benefits that they receive from those activities (e.g., the degree of mastery or pleasure associated with each activity), and an overall depression rating for each day. The idea behind the activity log is that clients will readily see patterns in the “data” that they collect in support of the benefits of behavioral activation and that these benefits will contribute to clients’ motivation to adopting the principles of behavioral activation into their everyday lives. As the reader will see in the chapter on behavioral activation, research shows that it is just as efficacious as a full package of CBT (i.e., a package consisting of behavioral activation, cognitive restructuring of automatic thoughts, and cognitive restructuring of core beliefs; Dimidjian et al., 2006; Jacobson et al., 1996). Although behavioral activation is a strategy that was originally included in Dr. Beck’s traditional CT for depression approach (Beck et al., 1979), its current version (Martell et al., 2010) is also viewed by many as a member of the third wave of CBTs because of its current emphasis on recognizing the function that depressive rumination has on behavioral inactivity and on engagement of activities consistent with one’s values. Exposure The counterpart of behavioral activation in the behavioral treatment of anxiety is exposure, or the intentional and systematic contact with a feared stimulus or situation (Abramowitz et al., 2011). Many of the chapters on anxietyrelated disorders describe exposure as being a central technique in the cognitive behavioral treatment of the condition. There are many types of exposure, including (a) in vivo exposure, or contact with a “real-life” feared situation or stimulus; (b) imaginal exposure, or the facing of upsetting images, memories, or intrusive thoughts; (c) virtual reality exposure, or the use of technology to facilitate simulated contact with a feared situation or stimulus; and (d) interoceptive exposure, or participation in an activity that provokes feared bodily sensations associated with the experience of fear and anxiety themselves. When cognitive behavioral therapists facilitate exposure, they usually work with their clients to develop a fear hierarchy, or an ordered sequence of feared stimuli and situations ranging from those that are least to most anxiety provoking. The fear hierarchy serves as a guide for the selection of exposures both in and out of session. As with behavioral activation, research shows that exposure is just as efficacious as a full package of CBT involving exposure and cognitive restructuring (e.g., Foa et al., 2005; Hope et al., 1995). My observation is that clients can do wonderful cognitive restructuring work, but if they continue to avoid feared stimuli and situations, then additional intervention is necessary (and exposure is almost always the necessary intervention). In addition, the field has evolved regarding the ultimate goal of exposure. From the traditional theory based on the work of Foa and Kozak (1986), exposure was hypothesized to work via



Introduction  xxi

habituation, or a reduction in fear, and newer approaches to understanding exposure emphasize fear tolerance and the violation of outcome expectancies (Craske et al., 2008, 2012). Many cognitive behavioral therapists implement exposure in the form of a behavioral experiment, or an instance in which clients “test out” negative predictions and assumptions about what they expect to happen when they face a feared situation. Behavioral experiments facilitate exposure because clients face situations that they dread or of which they are fearful in “real time.” At the same time, they, equally, achieve the important aims of cognitive restructuring because they provide “real-life” data to reshape their negative predictions, assumptions, and expectations. Behavioral experiments are perhaps the quintessential example of the notion that cognitive and behavioral change strategies cannot be fully separated from one another, such that change achieved in one area has important implications for change in the other.

ORIENTATION TO THE TWO-VOLUME SET The reader is about to embark on an ambitious two-volume set that is meant to cover, certainly not exhaustively, the range of contemporary cognitive behavioral scholarship that defines the field today. Volume 1, Overview and Approaches, consists of three main sections. Part I provides a contextual background to understand the roots of CBT, its major theoretical and empirical findings, and current issues in the field. In Chapter 1, Robert L. Leahy and Christopher R. Martell, two giants in the field, take on the essential task of summarizing CBT’s philosophical and historical roots. Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann contribute, in Chapter 2, an equally essential piece on CBT’s theoretical foundations. Chapter 3 turns to the empirical status of CBT outcome, and Claudi Bockting and her impressive collaborators (i.e., Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, and Pim Cuijpers) updated a summary of outcome studies primarily targeting depression, anxiety disorders, OCD, and posttraumatic stress disorder (PTSD). Strategically placed immediately after this outcome chapter, Chapter 4, authored by Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, me, and Jasper A. J. Smits, extends the general notion of outcome and focuses on the mechanisms of change in successful CBT. Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler provide an excellent critical analysis of case formulation, what I view as the heart of CBT, in Chapter 5. In Chapter 6, on dissemination and implication, Bradley Karlin focuses on the practice of “real-life” CBT in real-life settings with real-life clients—an issue that is essential if we in the field are to ensure that CBT is accessible by people with mental health problems in need. In the final chapter of Part I, Chapter 7, I discuss a topic that is near and dear to my heart— the therapeutic relationship—and consider many ways in which CBT facilitates the therapeutic relationship and ways in which optimal CBT can be conducted with its focus on issues arising in the therapeutic relationship.

xxii Introduction

Part II of this set focuses on strategies and techniques that are used across many specific approaches within the family of CBTs. I define a strategy as a general intervention approach that is meant to operate according to a specific hypothesized process of change (e.g., cognitive restructuring, behavioral activation) and a technique as a specific practice that is implemented to achieve the aim of the strategy (e.g., the thought record). In Chapter 8, Christine Purdon presents a thoughtful description of cognitive restructuring and techniques to achieve that aim. Chapters 9, by Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter, and 10, by Lauryn Garner, Emily Steinberg, and Dean McKay, describe the tried-and-true behavioral strategies of behavioral activation and exposure, respectively. In Chapter 11, my colleagues, Deborah H. A. Van Horn and Peter Britton, and I describe the well-established motivational interviewing approach and the way in which it has been used prior to the commencement of CBT to increase readiness for change and during CBT when therapists face ambivalence in their clients. Chapter 12, on the regulation of physiological arousal and emotion, by Holly Hazlett-Stevens and Alan E. Fruzzetti, is an amalgam of two chapters that I had originally proposed for the set: (a) breathing retraining and muscle relaxation and (b) mindfulness and acceptance. The authors presented a compelling argument as to why these strategies should be placed together, and I agreed. Finally, John Ludgate’s discussion of relapse-prevention techniques in Chapter 13 is an important reminder for cognitive behavioral therapists to be thoughtful in their strategic approach to ending therapy, consolidating the gains made in therapy, and planning for obstacles that clients might encounter after therapy has ended. The last section of Volume 1, Part III, focuses on cognitive behavioral psychotherapy packages. The chapters in this section generally follow a format that describes the history of the approach, its main procedures, outcome data, mechanisms of change, applications to diverse populations, and dissemination. At times, chapter authors include clinical examples. In Chapter 14, Amanda Fernandez, Keith Dobson, and Nikolaos Kazantzis describe traditional cognitive therapy established by Aaron T. Beck and his colleagues, and subsequently, Debbie Joffe Ellis discusses her late husband Albert Ellis’s REBT in Chapter 15. Arthur M. Nezu and Christine Maguth Nezu summarize emotion-centered problem solving in Chapter 16. Interestingly, I had initially identified this chapter as one on problem solving as a strategy that would be included in Part II; however, the magnitude of the body of literature on problem-solving therapy over the past 30 years suggests that it is an important cognitive behavioral treatment package in its own right. Chapter 17 turns to a consideration of schema therapy by Eva Fassbinder and Arnoud Arntz, complete with two case examples of clients with personality disorders that are followed throughout the chapter to illustrate specific schema therapy techniques. In Chapter 18, Hollie F. Granato, Amy R. Sewart, Meghan Vinograd, and Lynn McFarr describe another cognitive behavioral approach for the treatment of personality disorder and/or chronic conditions: dialectical behavior therapy, a treatment package that balances delivery strategies focused on acceptance and those focused on



Introduction  xxiii

behavior change. The subsequent three chapters illustrate other cognitive behavioral treatment packages that incorporate a strong focus on acceptance: (a) Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin’s chapter on acceptance and commitment therapy (Chapter 19); (b) Amanda Ferguson, Lê-Anh Dinh-Williams, and Zindel Segal’s chapter on mindfulnessbased cognitive therapy (Chapter 20); and (c) Peter L. Fisher’s chapter on metacognitive therapy (Chapter 21). Chapter 22, by Raymond G. Miltenberger, Diego Valbuena, and Sindy Sanchez, describes applied behavior analysis (ABA). Although ABA is a field unto itself and was not specifically developed as a member of the CBT family, it is included here because many of its principles are incorporated into treatment packages with a strong behavioral basis to modify problem behavior. Emily E. E. Meissel, Jennie M. Kuckertz, and Nader Amir present a unique treatment in Chapter 23 on cognitive bias modification, which focuses on information-processing biases toward or against pathology-relevant stimuli rather than the contents of cognition itself. Part III ends with two chapters on contemporary manifestations of CBT: Chapter 24, by Todd J. Farchione, Julianne G. Wilner Tirpak, and Olenka S. Olesnycky, focuses on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, and Chapter 25, by Nikolaos Kazantzis, Hoang Kim Luong, Hayley M. McDonald, and Stefan G. Hofmann, focuses on the modern practice of CBT. The second volume of the set, Applications, opens with Part I, with chapters on applications to clinical populations. Here, chapter authors contribute pieces on the cognitive behavioral treatment of specific mental health problems and other conditions for which clients often seek treatment. The first group of chapters in this section focus, broadly, on the emotional disorders (i.e., depression and anxiety). In Chapter 1, Daniel R. Strunk, Benjamin J. Pfeifer, and Iony D. Ezawa focus on the treatment of depression, describing many specific cognitive behavioral approaches to treating depression and considering the impact of conditions with which depression is often comorbid. Kamila S. White and Vien Cheung describe the cognitive behavioral treatment of anxiety in Chapter 2, providing detailed information about the nature and efficacy of treatment for an array of specific adult and childhood anxiety disorders. Christine Purdon takes on the treatment of OCD in Chapter 3, emphasizing central cognitive behavioral constructs important in understanding this disorder’s descriptive psychopathology and corresponding pathways for intervention. In Chapter 4, Anke Ehlers and Jennifer Wild describe principles of the cognitive behavioral treatment of PTSD and emphasize the delivery of their own treatment, cognitive therapy for PTSD. The remaining chapters in this section focus on CBT for other mental health disorders and conditions that bring clients into treatment. In Chapter 5, Madelyn Ruggieri, Courtney McCuen-Wurst, and Kelly C. Allison provide a thorough description of the treatment and outcomes for the three main eating disorders—bulimia nervosa, binge eating disorder, and anorexia nervosa. Chapter 6, by A. Tom Horvath, turns to the contemporary cognitive behavioral treatment for clients with addiction; Chapter 7, by Cory F. Newman, outlines a

xxiv Introduction

comprehensive cognitive behavioral framework for understanding and treating bipolar disorder; Chapter 8, by Neal Stolar and Rebecca M. Wolfe, provides a detailed examination of CBT for psychosis; and Chapter 9, by Jason G. Ellis, Michael L. Perlis, and Donn Posner, focuses on the innovative and welldisseminated CBT for insomnia (CBT-I). The next three chapters in this section focus on cognitive behavioral approaches for externalizing problems: (a) anger (Chapter 10 by Michael Toohey), (b) suicide attempts (Chapter 11 by Abby Adler, Shari Jager-Hyman, and Gregory K. Brown), and (c) adult attentiondeficit/hyperactivity disorder (Chapter 12 by J. Russell Ramsay). The section ends with two chapters on CBT for clients with medical conditions: (a) chronic pain (Chapter 13 by John D. Otis, Alex E. Keller, and Lydia Chevalier) and (b) obesity (Chapter 14 by Jena Shaw Tronieri). Part II of the set is geared toward consideration of the delivery of CBT in various modalities and settings beyond the traditional outpatient individual psychotherapy format. In Chapter 15, Elizabeth J. Pawluk and Randi E. McCabe describe CBT as delivered in group settings and include important discussion on challenges that can be encountered in group CBT. Frank M. Dattilio and Norman E. Epstein present CBT for couples and families in Chapter 16, providing a rich theoretical and contextual background for the delivery of CBT in this modality. Medical settings are considered in the next two chapters, with Robert A. DiTomasso, Scott Glassman, Christina Berchock Shook, Anna Zacharcenko, and Michelle R. Lent discussing CBT delivered in primary care settings in Chapter 17 and Aaron Brinen discussing CBT delivered in inpatient settings in Chapter 18. Gerhard Andersson and Per Carlbring engage in a fascinating discussion of CBT delivered via the internet in Chapter 19, taking care to comment on the way in which the internet delivery of CBT compares with in-person delivery. In Chapter 20, Jesse H. Wright, Stephen O’Connor, Jessica Reis, and Michael E. Thase provide guidance on the combined delivery of pharmacotherapy and CBT, including rich data on the efficacy of a combined approach for the major mental health disorders. Finally, in Chapter 21, Donna M. Sudak and Robert P. Reiser present a compelling evidence-based approach to supervision in CBT. The final section, Part III, focuses on applications to diverse populations that are typically encountered in treatment. The first three chapters in this section focus on CBT across the lifespan, with R. Trent Codd  III and Nathan Roth describing CBT as applied to children and adolescents with externalizing disorders in Chapter 22; Amber Calloway, Nicole Fleischer, and Torrey A. Creed describing CBT as applied to children and adolescents with internalizing disorders in Chapter 23; and Kenneth Laidlaw describing CBT as applied to older adults in Chapter 24. In Chapter 25, Maegan M. Paxton Willing, Larissa L. Tate, and David S. Riggs discuss mental health conditions most often encountered in military populations and ways in which CBT can be adapted to veterans and military servicemembers. Next, in Chapter 26, Trevor A. Hart, Julia R. G. Vernon, and Tae L. Hart consider guidelines for the cognitive behavioral treatment of gay, lesbian, bisexual, and transgender individuals. Gayle Y. Iwamasa presents a compelling framework for adaptations of CBT for cultural and ethnic minorities, along with results from available empirical research with specific



Introduction  xxv

cultural groups, in Chapter 27. Finally, Chapter 28 by Moses Appel and David H. Rosmarin, ends the two-volume set with a fascinating consideration of CBT as applied to individuals of various religious groups. Two additional notes about this set are warranted. First, the astute reader will notice that some chapters refer to consumers of services as “patients,” whereas other chapters refer to consumers of services as “clients.” Indeed, the use of terminology for this purpose has sparked quite a bit of debate (e.g., Joseph, 2013). There is no absolute “correct” way to remedy this issue, so I allowed chapter authors to use their preferred terminology. I saw that a number of chapter authors used “client,” another large chunk of chapter authors used “patient,” and still other chapter authors alternated between “client” and “patient” (which prompted me to ask them to choose one or the other and use it consistently throughout, as it activated my own obsessive-compulsive tendencies). Regardless of the terminology used, cognitive behavioral therapists hold the utmost respect for each of their clients (patients), and they truly view themselves as being in a collaborative partnership with their clients (patients) in which all parties bring valuable knowledge to the working alliance. In addition, the astute reader might also notice that many of the chapters (other than the chapters in Part IV, which were targeted toward specific mental health conditions) focus on depression and anxiety much more than other mental health disorders. This is not for want of my trying diligently to encourage authors to comment on the full range of pathology beyond depression and anxiety, including bipolar disorder, psychosis, eating disorders, substance use disorders, and personality disorders. However, the continued focus primarily on depression and anxiety led me to see that this emphasis reflects the state of the literature—that empirical research on cognitive behavioral theory is much more sophisticated, to date, in its application to depression and anxiety than other mental health disorders. I elaborate upon this much more in the conclusion, where I propose tangible directions for future research that will advance the field.

LOOKING AHEAD The editorial staff at APA Books and I recognize that there are many CBT handbooks on the market. Why is another handbook warranted, and what makes this one unique? When I read comprehensive reviews on an important aspect of CBT for my own scholarly work, my reaction is that multiple chapters on the same topic, even if there is overlap, help reinforce central information and provide unique perspectives and supporting evidence to fill in the overall picture. Moreover, the field is always evolving, so there are references to empirical research in the chapters in this set that would not have been made available to authors of chapters in even recent handbooks. However, most importantly, I strove to include a balance of traditional and innovative topics. Although this handbook includes many chapters on subjects that are included in other CBT handbooks, there are a number of fairly unique

xxvi Introduction

chapters in this handbook. I take great pride in the emphasis on the therapeutic relationship in the chapter that I drafted for the handbook, as well as its consideration in other chapters. Increasingly, the field is turning its attention to dissemination and implementation of CBT, so Karlin’s chapter on this topic is timely in its summarization in the literature and work that remains to be completed. In addition to chapters on fairly “traditional” CBT approaches (e.g., CT, REBT, exposure), I also included chapters on more recent developments in CBT, such as metacognitive therapy (MCT; Fisher), cognitive bias modification (CBM; Meiseel, Kuckertz, & Amir), the United Protocol for the Transdiagnostic Treatment of Emotional Disorders (Farchione, Wilner Tirpak, & Olesnycky), and insights into the delivery of CBT from a modern, or contemporary, perspective (Kazantzis, Luong, McDonald, & Hofmann). In the realm of special populations and issues, CBT for veterans and military servicemembers (Paxton Willing, Tate, & Riggs) and religious individuals (Appel & Rosmarin) has become a popular focus for blog posts and podcasts of late. Even when authors took on fairly traditional topics, they were strongly encouraged to adopt an innovative approach to their presentation by including the latest, cutting-edge research and considering mechanisms of change, applications to special populations, dissemination, and case illustrations on client engagement or the resolution of tricky clinical issues. My hope is that, after finishing the desired chapters, readers can see the significant theoretical and empirical foundation on which the family of CBTs and its strategies and techniques rest, as well as the promise for its optimization, dissemination, and implementation in the future. CBT has transformed the lives of countless individuals, yet many individuals who suffer from mental health disorders continue not to have access to CBT. This two-volume set represents the latest attempt to highlight the rigor, power, and promise of CBT’s application in an ever-changing world.

REFERENCES Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety: Principles and practice. Guilford Press. Barlow, D. H. (1988). Anxiety and its disorders. Guilford Press. Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. Harper and Row. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16(3), 252–260. https://doi.org/10. 1037/h0085885 Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. https://doi.org/10.1016/j.cpr.2005.07.003 Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27. https://doi.org/10.1016/j.brat.2007.10.003



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Craske, M. G., Liao, B., Brown, L., & Vervliet, B. (2012). Role of inhibition in exposure therapy. Journal of Experimental Psychopathology, 3(3), 322–345. https://doi.org/10. 5127/jep.026511 Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., Gallop, R., McGlinchey, J. B., Markley, D. K., Gollan, J. K., Atkins, D. C., Dunner, D. L., & Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670. https://doi.org/10.1037/0022-006X.74.4.658 Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized trial of prolonged exposure for PTSD with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. https://doi.org/10.1037/0022006X.73.5.953 Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909. 99.1.20 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press. Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28(1), 1–16. https://doi. org/10.1016/j.cpr.2007.09.003 Hope, D. A., Heimberg, R. G., & Bruch, M. A. (1995). Dismantling cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy, 33(6), 637–650. https://doi.org/10.1016/0005-7967(95)00013-N Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Consulting Psychology, 36(2), 223–233. https://doi.org/ bzjxtr Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295–304. https://doi.org/10.1037/0022-006X.64.2.295 Joseph, S. (2013, August 4). Patients or clients? What word should psychologists use to describe the people they help? Psychology Today. https://www.psychologytoday.com/ us/blog/what-doesnt-kill-us/201308/patients-or-clients Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. Guilford Press. Rachman, S. (2015). The evolution of behaviour therapy and cognitive behaviour therapy. Behaviour Research and Therapy, 64, 1–8. https://doi.org/10.1016/j.brat. 2014.10.006 Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. https://doi.org/bt7qmf Wenzel, A. (2017). Innovations in cognitive behavioral therapy: Strategic interventions for creative practice. Routledge. https://doi.org/10.4324/9781315771021

I CONTEX T

1 Philosophical and Historical Foundations Robert L. Leahy and Christopher R. Martell

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sychology was not always a discipline separate from philosophy—and, indeed, one can recognize the importance of philosophical assumptions when we realize that psychology is the study of the “psyche,” that is, the “soul.” Cognitive and behavioral models developed from a long history of philosophical debates, beginning with Plato, Epictetus, and Seneca and continuing on to Immanuel Kant, Edmund Husserl, William James, Gilbert Ryle, the early Ludwig Wittgenstein, logical positivism, British analytic philosophy, and the emergence of common language philosophy. Indeed, for much of this historical overview, the “debate” was between those giving precedence to cognition (reason, rationality, logic) and those giving precedence to emotion (the tragic sense of life, intuition) and, later, those philosophical behaviorists who rejected the “ghost in the machine”—that is, concepts of “mind” (such as thoughts, memory, intention). In the first section of our review, we will describe how these issues of rationality, emotion, choice, and value evolved over the last 2,400 years, leading to the current debates within the cognitive behavioral field. In fact, as will become clear, we hope, these debates are alive and well and are the focus of the differences among the “three waves” that continue to dominate the field. Behaviorism as a philosophical position developed as an “antidote” to the mentalism underpinning cognitive models, but the debate about the legitimacy of studying cognition and the role of cognition continues to the present time. For the sake of clarity, we will refer to cognitive therapy in our discussion of the focus on thought processes in psychopathology and to behavior therapy in our discussion of the influence of

https://doi.org/10.1037/0000218-001 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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behavioral and learning models. The field has emerged to include a synthesis that is now called cognitive behavioral therapy (CBT). Within the more general rubric of CBT, there are considerable differences that have arisen, some placing greater emphasis on cognitive content (cognitive therapy, rational emotive therapy), some placing emphasis on behavior and its consequences (behavioral activation therapy), some placing emphasis on how one relates to one’s thoughts (acceptance and commitment therapy [ACT], mindfulness, metacognitive therapy), and some placing emphasis on emotion regulation and skill acquisition (dialectical behavior therapy [DBT]). In this chapter, we have divided our discussion into two broad areas—the influences on the cognitive models and the influences on the behavioral models. Of course, the current “larger camp” of DBT can include—or not include—a synthesis of both. So let us begin with the Greeks, from whom much wisdom originates.

PHILOSOPHICAL FOUNDATIONS OF COGNITIVE THERAPY The cognitive model has a long history in philosophy, beginning with Plato, Socrates, Aristotle, Epictetus, and all the Stoics, and continuing throughout the last 2,400 years of Western philosophy. The central role of thinking as a fundamental determinant of emotion, value, and choice has privileged “rationality” over “emotion.” Indeed, one can argue that the dialectic in Western philosophy has been between those who emphasize rationality and cognition in general as contrasted with those who emphasize emotion. On the side of rationality, we have almost all of ancient Greek philosophy; on the side of emotion, we have almost all of Greek tragedy. We will see that behavioral theories developed much later in philosophical discussion. The cognitive model places considerable emphasis on the role of thinking in the activation, maintenance, and escalation of psychopathology, while recognizing that evolutionary, genetic, environmental, socialization, and significant current and past life experiences can contribute to current cognitive processes and emotional difficulties (A. T. Beck & Haigh, 2014). In the cognitive model, cognition is the “proximate” cause, suggesting that modification of the content of or the way one responds to one’s thoughts will have enduring effects on emotion. The question, of course, is whether cognition is primary or even essential—a central point in much of Western philosophy. Epistemology: The Nature of Knowing The cognitive model is based on the view that knowledge is determined partly by the structure of thinking—or the categories of thought through which we experience “external reality.” Epistemology is the study of how we know—or even whether it is possible to “know”—external reality. We can trace the origins of the epistemological model to Plato in The Republic, which describes the



Philosophical and Historical Foundations  5

following: A group of men are chained facing a wall where they observe shadows dancing across the wall in front of them. They have never known that these shadows are due to figures near the entrance to the cave moving behind them in front of a fire. To these men, the shadows are reality. One day one of the men turns around and sees that there are figures moving behind him casting their shadows across the wall in front of him. From that day on, the “reality” of the shadows no longer exists. We might view cognitive therapy as the attempt to get patients to unchain themselves and see outside the cave—to see the forms. Plato goes on to argue that the men will find it difficult to go back to their prior beliefs in the shadows on the wall now that they have been enlightened. A fundamental element of Plato’s theory of knowledge is that the true forms of reality lie within us—as innate ideas—and that inquiry and philosophical examination allow one to access the truth by questioning one’s logic. Thus, knowledge is “education” or “leading out”—“recollection”—as exemplified by Plato’s description in Meno, where he helps a young boy understand a problem in geometry (Cornford, 2003). What is essential here is that the nature of “reality,” for Plato, is the forms, or ideas, that are intrinsically knowable by a guided discovery. Through guided discovery, the questioner (Plato or, in cognitive therapy, the therapist) asks a series of questions to “uncover” or “elicit” an awareness of the potential contradictions or problems in the individual’s thinking. This is different from lecturing or memorizing “facts,” which would bypass developing the capacity for reasoning in the person questioned. Guided discovery is a key element in Beck’s cognitive therapy. Implicit in Plato’s theory of knowledge is the argument that one is inclined to prefer the logically consistent argument—what we might describe as the rational principle. Another element of Plato’s theory of knowledge was that emotion interferes with correct and rational thinking. In his allegory of the charioteer, Plato describes a horseman trying to direct and control two horses—one that is obedient (“spirit”) and the other that is wild. This tripartite psyche finds its parallel in psychoanalytic models of the ego, superego, and id. The wild horse, representing emotion and impulse, is brought under control by the charioteer who directs the horses toward a specific goal. In Plato’s model, the “goal” that is preferred represents wisdom or virtue—that is, the direction toward a “higher” functioning (Sorabji, 2000). One can view this as a series of “movements,” the first movement being the awareness of something disturbing (in Plato’s terms, “the fluttering of the soul”), followed by standing back and considering what is happening, then considering the virtuous goal (e.g., courage), and then directing the psyche or choices toward that goal (Sorabji, 2000). Indeed, we can see several of the elements of third wave thinking in The Republic, which was written 2,400 years ago. It is important to recognize that Plato’s model was one of idealism—in the sense that knowledge was based on categories of thinking, ideal forms, and the elicitation of these innate functions of mind. This is different from the Beckian model, which attempts to test out the veridicality of thoughts by collecting

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evidence in the “real world.” The Socrates in Plato’s writings bases his examination and disputation of thinking on internal logical contradictions, not on collecting information empirically. Ironically, in a true sense, the Beckian “Socratic dialogue” is not really Socratic—because the examination of thinking in the Beckian model is pragmatic, empirical, and, of course, logical (Kazantzis et al., 2014). Plato’s model was completely rational and placed little emphasis on pragmatics or empirical discovery of facts. Aristotle, who was a student of Plato’s, combined an interest in collecting information about biological specimens and historical records but was not as limited in relegating emotion and empirical facts to a lower status. In the Nichomachean Ethics, Aristotle develops a guide to living a life of “flourishing” or “happiness” based on the assumption that one’s happiness and satisfaction in life (eudemonia) will be determined by living a life consistent with virtue. Aristotle’s model of virtue was based on the character traits that one would admire in another person—that is, the goal was to become the person that you would admire. As in Plato, one’s intention and thoughts about choices were paramount in determining virtue, and correct action was to be determined by the balance of qualities—the right amount at the right time for the right reason. Thus, it would be virtuous to choose to defend a friend if the intention was to show loyalty and courage rather than to gain approval or gain advantage. Although the model of eudemonia has had little impact on the cognitive model advanced by Beck and others, it has been a major source of ideas for positive psychology, which emerged out of CBT models in general. Thus, the emphasis on what leads to happiness, flourishing, and meaning has a great deal to do with the development of character, values, and virtues, as reflected in the work of Martin Seligman, Mihaly Csikszentmihalyi (1990), Barbara Fredrickson, and others. The recognition of the importance of “a valued life” or “a life worth living” is also reflected in current developments in ACT (Hayes et al., 2011) and in DBT (Linehan et al., 2007). The Stoics—such as Zeno, Epictetus, Seneca, and Cicero—followed in the tradition of Plato and Aristotle in placing considerable emphasis on the role of reason and logic in epistemology and ethics. Epictetus proposed in the Enchiridion that circumstances or external reality (such as life events) do not determine how we feel, but rather it is our interpretations of these events that moves us: “It isn’t the events themselves that disturb people, but only their judgments about them.” Epictetus argued that our beliefs that something is necessary for our happiness, our attachment to objects or people, or our concern about the opinions of others will determine how unhappy we are. The goal in the Stoic model was to be the master of the self, to turn toward one’s own will and ideas to determine choices and emotions and to free oneself from depending on external sources of esteem and value. For example, in Enchiridion, Epictetus argued that to become too attached to another person (such as a family member) meant that one was relinquishing one’s freedom to something external to the self. The Stoic model stressed the idea that one’s happiness could be achieved by focusing on one’s own beliefs and willpower to do what is



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difficult to do and, thereby, maintain one’s freedom from the vicissitudes of everyday life. The Stoic model was one of self-sufficiency and the freedom to determine one’s emotions based on one’s thoughts rather than external consequences or convention. In the Stoic model, as in Plato’s model, emotions were viewed as in competition with rational and ethical thinking that was viewed as the only means by which flourishing or happiness could be attained. The Stoics and the Greek and Roman philosophical tradition had a considerable influence on Albert Ellis and, later, Aaron Beck in the development of their respective rational emotive therapy and cognitive therapy. Although originally trained in psychoanalytic therapy, Ellis found the psychodynamic model to be slow and ineffective, and he began to draw on the work of Epictetus and other Stoics to develop a more “rational” model that emphasized conscious thinking at the present moment while actively disputing the client’s verbal statements and beliefs. Ellis credits Epictetus with influencing his model of rational emotive behavior therapy, which stresses the idea that it is our beliefs (cognitions) that determine how we feel. Ellis outlined a wide range of “irrational beliefs” that contributed to psychopathology, including awfulizing (“It’s terrible that this happened”), should statements (“I should be successful”), low frustration tolerance (“I can’t stand being bored with work”), and other “distortions” in thinking. In the long history of Western philosophy, the primacy of the rational is a common thread that finds its strongest expression in the last 400 years in Rene Descartes’s cogito ergo sum—“I think, therefore I am.” Indeed, in Discourse on Method, Descartes argued that one could doubt any statement about external reality; “perhaps it is only a dream or hallucination,” one might speculate. But the foundation of indisputable knowledge is that I am thinking. Thus, the analysis of one’s thoughts and the primacy of cognition for one’s very existence is the cornerstone of his epistemology. I can doubt my speculations about reality, but I cannot doubt that I am thinking. The cognitive epistemology (i.e., the analysis of thought itself) is the focus in Kant’s metaphysics. For example, Kant’s (1782/2004) philosophy of mind was based on the view that reality (noumena) is never directly knowable but rather is “known” through “categories of thinking” (phenomena). Some of these categories are viewed as innate, prior to experience—the synthetic a priori: for example, categories of quantity, intensity, time, and cause and effect. Other categories of thinking are acquired, but all knowing of the noumena or external world is through the lens of the categories. Thus, “reality” is never known directly. One can see the resemblance to contemporary models of schematic processing—that is, our experience of events is determined by the categories or schemas that mediate the process of knowing, such as perception, attention, and memory. Consequently, reality is never directly knowable; we only know reality through the schemas. Moreover, Kant argued that morality or duty could be determined by a universal “categorical imperative”—that is, a logically consistent rule such that whatever rule is applied could be applied universally. For example, rather than base a moral rule on convention, authority, practical

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consequences, religious tenet, or legal agreements, the categorical imperative required that the moral rule be applied universally to all people in all circumstances. Thus, this “logically derived” rule proposed that lying is always wrong, regardless of the circumstances. This contrasts with the utilitarian model of ethics or morality, specifically, Bentham—“The greatest good for the greatest number of people.” In contrast to Kant’s emphasis on innate categories, British empiricists, such as David Hume, Jeremy Bentham, and John Locke, argued that our understanding of reality was simply a matter of “associations” of events. Locke’s (1689/1975) view (Essay Concerning Human Understanding) was that the mind at birth is a blank slate (tabula rasa) upon which external reality imprints itself—or “writes itself.” The contiguity or association of these events, often accompanied by reward or punishment, would determine the knowledge and the value that developed through experience. Locke’s view was a complete rejection of the model of innate ideas, ideal forms, or the Platonic model. Thus, if we saw that two events occurred together, we might correctly or incorrectly conclude that one was a cause of the other. Since empiricism argued that knowledge is somewhat arbitrarily based on experience—not on universal categories—it followed that “knowledge” was precisely in one’s point of view. Thus, knowledge became “relativistic” just as moral rules became relativistic. This, of course, is in contrast to the model of virtue in Aristotle and Plato and in contrast to the universal categorical imperative proposed by Kant. The emphasis on how we experience the world—rather than the emphasis on universal innate categories—gave rise to phenomenological theories of knowledge (Husserl, 1960). The phenomenologist is less interested in what “reality really is” and more interested in how reality is experienced (i.e., the “phenomenal experience”). Cognitive therapy is partly derived from this tradition: Although the therapist may assist the patient in testing their cognitions against “reality,” there is considerable emphasis in cognitive theory on the “subjective” experience of the patient. Challenges to Logical Positivism In the 1920s and 1930s, philosophy underwent a revolution led by the Vienna Circle of Logical Positivists. A major figure was the young Ludwig Wittgenstein (1923/1974), whose Tractatus Logico-Philosophicus proposed the core tenets of logical positivism. This model of epistemology argued that all statements are meaningless unless they can be verified (the verifiability principle). Thus, the meaning of a statement is determined by the means by which we observe its consistency with the facts; statements about “reality” are pictures of the world, in Wittgenstein’s formulation. Although this model had considerable influence, it was Wittgenstein himself who led the rejection of logical positivism, in Philosophical Investigations (Wittgenstein, 1967). In this seminal text—one of the most influential works of the last century in philosophy—Wittgenstein turned logical positivism on its head. He now emphasized that meaning is determined by the function or use of language and that meanings are determined by “lan-



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guage games” and the “rules” that are followed. This gave rise to the influential “common language school” of philosophy. For example, J. L. Austin (1975) indicates that the following statement is meaningful, even though we could not imagine how the verifiability principle could be applied: “Please get me a cup of coffee.” Moreover, the idea that science was driven by the discovery of facts according to the verifiability principle was disputed by those like Norwood Russell Hanson (1958), who described “patterns of discovery” (that investigation was driven by hypotheses, that is, thoughts and models) or that scientific progress was characterized by “paradigm shifts,” as proposed by Thomas Kuhn (1970). Further, philosophical debates against strict behavioral models included the classic essay “What Is It Like to Be a Bat” by Thomas Nagel (1974), which argued that behavioral descriptions cannot describe the experience that a bat has that differs from that of human experience, and arguments by others, such as John Searle (1980), that one can observe another’s behavior but not know their intention. In more recent years, Searle, a leading philosopher, has suggested that the mind–body dichotomy can be resolved, not by reductionist behaviorism but rather by positing that thinking or consciousness is a computational process analogous to software and that the hardware is the neuroscience that underlies the software. This view is consistent with Beck’s recent formulation of the cognitive model as rooted in neuroscience. Epistemology and the Cognitive Model The cognitive model is “constructivist” in that individuals “construct” or “interpret” reality rather than have reality imposed on them (e.g., as if reality forms an impression on the mind). CBT is based on a model, in which cognition and perception may often be based on arbitrarily associated events and that moral rules are individual constructions (rather than universal ideals). Thus, the early founder of cognitive therapy, George Kelly (1955), might say, “That is your construction of reality,” as if all constructions of reality are on equal footing. One can see that the Beckian model does not follow the Platonic model of innate ideas, but it does reflect both the schematic model advanced by Kant and an empiricist model, in which one’s beliefs are determined by experience. One could say that cognitive theory is derived from both the empiricism of the British associationists and the subjectivism of the phenomenological school. These traditions are integrated in what we could call dynamic structuralism—that is, the recognition that the structures of experience (schemas) are continuously modified by the individual’s interactions with reality. In a sense, the cognitive therapist assists the patient in deconstructing their experience. Just as the deconstructionists might argue that the meaning of a text is in the reader (Derrida, 1973; Fish, 1980), the cognitive therapist assists the patient in recognizing that the meaning of experience is in the perceiver. However, unlike the deconstructionists, who seem to imply that reality is unknowable, the cognitive therapist has a more “optimistic” view: that is, that the perceiver’s (patient’s) beliefs can be tested against reality. Cognitive theorists

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are not empirical nihilists like the deconstructionists; rather, they are “structuralempiricists.” This implies that the structures of knowledge—the patient’s schemas—may be tested in the real world.

THE COGNITIVE REVOLUTION IN PSYCHOLOGY In the 1960s, psychology was dominated by two major influences: psychodynamic theory and learning theory. We will discuss the development of the behavioral and learning theory models in a separate section, but here we will review how a number of developments in psychology, beginning with F.  C. Bartlett’s and Jean Piaget’s ideas about schemas, contributed to the development of the cognitive model of psychopathology. The Primacy of Cognition The primacy of cognition was a focus of a heated debate between Robert Zajonc and Richard Lazarus. Zajonc argued that “preferences need no inferences”— that is, that our decisions and emotions were not based on cognition but were rather “automatic” (Zajonc, 1980). This was in contrast to the argument made by Lazarus that cognition was a prerequisite for emotion and choice (Lazarus, 1982). One can view this as turning on the issue of automaticity—that is, some thoughts may be automatic, without reflection or awareness—as suggested by Daniel Kahneman’s (2011) Thinking, Fast and Slow. In contemporary research and theory on the nature of consciousness and automaticity, it has been argued that “conscious awareness” is seldom a key element in how people make decisions; these arguments are based on research that demonstrates that individuals are seldom aware of the stimuli or prior events that actually elicited their emotions, choices, or behavior (Bargh & Morsella, 2008). In this view, consciousness—or one’s report of one’s thoughts about a choice—is an after-thefact accounting, very much like a careless bookkeeper trying to estimate the inputs and outputs after a hangover. The issue of automaticity is important in evaluating the cognitive model because the nature of automatic thoughts involves reflection on the thoughts that one had that give rise to emotion. If one’s attempt to make conscious what are automatic processes is dubious, according to John Bargh and others, we might question whether these automatic thoughts in the Beckian model were truly the thoughts that were functioning. Cognitive Processes The cognitive revolution in psychology in the United States got a jump start with the publication of George Miller’s classic paper “The Magical Number Seven, Plus or Minus Two” in 1956 in Psychological Review. Miller (1956) contended that memory was limited and, therefore, selective, and an entire gen-



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eration followed after exploring the role of cognition in perception, memory, attention, and language acquisition. Ulric Neisser’s 1967 classic text Cognitive Psychology (Neisser, 1967/2014) provided an overview that would influence research and theory for the next 20 years. Major developments in the cognitive revolution included the following: research on episodic and semantic memory by Tulving (2002) in autobiographical memory revealed selective memory rather than simple associations; the rise of artificial intelligence in the work of Newell and Simon (1972), who proposed that computers could simulate human thinking; the development of computational models of information processing; and the introduction of the concepts of heuristics (or rules of thumb) that constituted the automatic and shortcut guides that people use (Kahneman & Tversky, 1979). Indeed, the influence of these cognitive models was not limited to laboratory studies of memory—the models would have influence on evaluating distortions in eyewitness testimony (Loftus, 1979) and on a growing field called behavioral economics (Thaler, 1992). It was in this new field of economics that the cognitive processes were elucidated and that a number of psychologists and economists won Nobel Prizes: Herbert Simon, Daniel Kahneman, Robert Shiller, and Richard Thaler. Schematic Processing A core feature of the Beckian cognitive model and, to some extent, the Ellis model is the importance of schemas. We can think of schemas as habitual patterns of perceiving or thinking based on internal models (i.e., cognitive or perceptual models). Frederick Bartlett was an early proponent of schema theory, by which he proposed that memory was reconstructive according to mental representations (schemata) rather a mere copy of previously learned stimuli (Bartlett, 1932). The role of cognition also found its way into learning theory in Edward Tolman’s (1948) model of response versus place learning, whereby organisms learned a cognitive map (or place)—that is, an internal representation—rather than simple responses that were reinforced. The concept of category or schema that determines attention, learning, and evaluation was a central element of the work on “natural categories” and “prototypes” such that categorization of color or sound appeared to follow a universal set of natural “best examples” (exemplars), stimuli closer to the prototype were easier to learn, and many of the perceptual stimulus categories could be demonstrated before the acquisition of language (Rosch, 1973). The cognitive revolution of the 1970s was also led by work by Bruner on the “new look” in perception, according to which drives and needs affect how people perceive reality (Bruner, 1956). In experimental psychology, there was growing interest in “schematic processing” in memory, including attention, valuation, recall, and reconstruction, indicating that trait concepts serve as prototypes directing attention and modifying recall and recognition (Cantor & Mischel, 1977; Taylor & Crocker, 1981). Schemas that are introduced to subjects in a study can affect recall of information subsequently presented to

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subjects, as indicated by research on false memory or false recall (Loftus, 1979). Thus, individuals may falsely recall information consistent with a schema that has been introduced by the experimenter. These aspects of the schema model were integrated into Beck’s formulation of cognitive theory of depression, which postulated that early negative concepts or schemas about self or others would perpetuate depression by biasing the attention, recall, and valuation of negative information to the exclusion of countervailing positive information. Moreover, even the area of Pavlovian conditioning began to see the importance of mediation, or what we might call “cognition,” in a classic essay by Robert Rescorla on Pavlovian conditioning as involving learning the “relationships” among stimuli (Rescorla, 1988). Owing to the work by Tolman on cognitive maps, the nature of learning was increasingly viewed as based on models of stimulus relations. Piaget’s Constructivism Constructivism gained considerable attention in the first half of the 20th century through the work of Jean Piaget. Rather than viewing the acquisition of knowledge as a simple collection of facts or associations or through direct learning, Piaget proposed what he eventually described as “genetic epistemology.” By “genetic” he meant not “inherited” but rather the growth or genesis of knowledge through a separate distinct order of stages. Rejecting the Kantian idea of the synthetic a priori, the Platonic idea of innate ideas, and the tabula rasa model advanced by Locke and later associationists, Piaget argued that concepts of substance, causality, quantity, morality, and other concepts were constructed through the child’s interaction with the external world (Piaget, 1971). The process of development was characterized by the reciprocal relationship between processes of assimilation (taking in experiences through the schemas) and accommodation (changes in the schemas as a result of successive experience). The process or genesis of knowing was not a direct copy of experience but rather an interaction between the knower and the external world—or symbolic content in formal operational thinking. Piaget traced several universal stages of the growth of knowledge from sensorimotor to preoperational to concrete operational to formal operational thinking. Piaget distinguished between what he called scheme and schema, which reflect operative and figurative intelligence, respectively. Operative intelligence was characterized by the active changes or operations—for example, sensorimotor intelligence involved understanding moving or effecting changes on objects; concrete operations involved understanding how changes in one dimension (height) are compensated by changes in another dimension (width), resulting, in this case, in conservation of quantity or volume; and formal operations involved the understanding of how symbolic or abstract content can be coordinated in a series of relationships. Piaget advanced the idea of decentering to describe the ability to flexibly step away from one dimension or stimulus element to understand how various elements in the system are coordinated through a system of reciprocal transforma-



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tions (Piaget, 1950/1954). Thus, the process of knowing is based on a two-part schema model—scheme and schema—reflecting the active, flexible coordinating operative intelligence and the static, content, figurative intelligence, respectively. As Beck became disenchanted with the psychoanalytic model, he turned to the work of Piaget and George Kelly on constructivism. One might argue that the Beckian and Ellis models describe the “depressive construction of reality.” Language Acquisition Device Concurrent with the rising importance of the cognitive model was Noam Chomsky’s rejection of B. F. Skinner’s reinforcement model of language. The Skinnerian model was one of associationism and reinforcement, which might have been an adequate model for learning words in a vocabulary list but, according to Chomsky, was entirely inadequate for learning language (Chomsky, 1965, 1968). Several lines of evidence were brought to bear to reject the behaviorist model of language: (a) The rules of syntax are so complicated even linguists cannot clearly define them. (b) Language has a creative element—the “generative” function. That is, speakers can generate sentences that they have never heard before. (c) Language involves a system of rule-guided transformations. We understand the deep structure or meaning of a sentence even though the surface structure is different. For example, “the boy threw the ball” has the same meaning as “the ball was thrown by the boy.” (d) Languages worldwide have similar rules of syntax. (e) When young children mimic their parents’ language, it is not a direct imitation but rather one of reducing the complexity to a simpler form. Chomsky (1965) proposed that humans have a “language acquisition device,” very similar in his view to innate ideas, as reflected in his books Aspects of Theory of Syntax (1965) and Language and Mind (1968). Explanatory Style and Attribution Theory The cognitive model of depression also was strongly influenced by work in social psychology, especially the work on attribution processes advanced by Bernard Weiner and others (Weiner, 1974; see also Kelley, 1972). Weiner proposed that individuals seek to explain the causes of their behavior and that of others by relying on several dimensions of causal attribution that include stable and unstable causes and internal and external causes. For example, one individual might explain their poor performance by attributing it to lack of ability (internal/stable), whereas a more optimistic individual might attribute their poor performance to lack of effort (internal/unstable) or bad luck. Seligman, Alloy, Abramson, and their colleagues noted that although noncontingency might account for rats giving up on future tasks—“learned helplessness”—it could not account for individual differences in self-esteem or self-criticism (Abramson et al., 1989; Seligman, 1975). Thus, they argued that an attribution model of depression could draw on Weiner’s attribution model to help expand

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the noncontingency model first advanced by Seligman and to account for the selfcriticism in depression that cannot be explained simply by noncontingency. Cognitive Models of Psychopathology In clinical psychology, Beck’s cognitive model was preceded by three richly elaborated cognitive models advanced by Victor Frankl (1963), George Kelly (1955), and Albert Ellis (1962). Frankl was an Austrian psychoanalyst during the 1930s who was imprisoned by the Nazis at Auschwitz. In 1946, he published Man’s Search for Meaning, which was an existential theory of how the construction of meaning and value can help individuals thrive in the most degrading and hopeless of circumstances. What was especially significant was Frankl’s break from the traditional model of psychoanalysis that stressed unconscious motivation, repression, drive, and the id-ego-superego, as well as the emphasis on the limiting effects of earlier unresolved childhood conflicts. Frankl’s model is clearly existential—indeed, the original English language title was From Death-Camp to Existentialism. As indicated earlier, the rise of existentialism, especially in Continental European philosophy during the 1920s through the 1950s, had emphasized the importance of phenomenal, conscious experience; the sense of agency and personal freedom of choice; and the central role of individuals constructing their own values. Readers familiar with current ACT may see similarities between these approaches. Kelly’s model was strictly constructivist and placed considerable emphasis on the actual structural and process aspects of knowing (Kelly, 1955). Kelly focused on how individuals construct reality by utilizing concepts that had polarity (good-bad, intelligent-stupid), permeability, and other dimensions. The underlying principle is that each person constructs their world through a series of concepts (which we might view as schemas), that these constructs limit what is known or considered relevant, and that they are often difficult for the person to disconfirm. In Kelly’s model, the individual is viewed as a scientist of sorts, seeking answers to questions generated by their constructs—such as, “Is this person trustworthy?”—often leading to selective attention to confirmatory evidence. The analogy to the schema model proposed by Beck is clear, but there are significant differences between Kelly’s and Beck’s models. Beck has identified the content of the negative “constructs” (e.g., the negative triad of depression is a negative view of self, future, and experience), whereas the content of Kelly’s construct theory is the idiosyncratic constructions of individuals. Moreover, Kelly lacks a developmental or even an experiential model, focusing almost entirely on the current conscious categorizations that people make. Albert Ellis had advanced rational emotive therapy before Beck’s cognitive model, arguing that anger, depression, and anxiety are due to specific thinking errors, such as awfulizing, “shoulds,” low frustration tolerance, and other problematic styles of thinking. Influenced by the Stoic philosopher Epictetus, Ellis drew heavily on the idea that it is not events but our interpretations of events that lead to psychological suffering. For example, the idea that “I need this” can



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be reframed to “I prefer this,” and the idea that “this is awful” can be reframed to the view that “nothing is awful if there are rewards or positive experiences available.” The Ellis model was an actively disputatious model whereby the therapist would actively point out “errors” in thinking and directly offer alternative, presumably adaptive beliefs. Unlike Beck, Ellis did not focus on the specific content of the beliefs associated with different categories of psychopathology. For example, the Beckian model posits specific content for each of the anxiety disorders, depression, personality disorders, and eating disorders. Further, Beck’s model stresses the primacy of early schemas that are established during childhood, and his model provides a cognitive architecture (i.e., levels of cognitive appraisal) with automatic thoughts, conditional beliefs or assumptions, and personal and interpersonal schemas. Ego Psychology and Cognitive Therapy The 1940s and 1950s were a time in the development of psychoanalytic thinking that moved away from certain components of Sigmund Freud’s theory, including the drive model, the topographic theory, and the emphasis on Oedipal conflicts. Emerging during this time was the ego psychology movement that focused on the “preadaptive functions” of the ego that were independent from drive conflicts. Heinz Hartmann (1939/1958) was one of the leaders of this movement, attempting to give importance to the role of reality testing, ego control, and independence of drive—as well as the work by Ernst Kris (1951), Anna Freud (1968), and Margaret Mahler (1969). The role of thinking, imagery, and reality adaptation was initially the groundwork for Beck’s cognitive model, which he viewed as a psychodynamic model during his early development of his theory. It is important to recognize that Beck had begun as a psychoanalyst with his early experiment on the dreams of depressed individuals as an attempt to test the psychodynamic model, in which depression was a result of repressed anger turned inward. He expected that the dreams of depressed patients would be characterized by an increase in hostile imagery and content because the repressive function would be lifted during dreaming. Surprisingly, Beck found that the dreams of depressed patients were filled with content of loss and defeat—not hostility. Although Beck had developed a new model of psychopathology and treatment, he continued for many years hoping that his model would be accepted by the psychoanalytic community, but these efforts were to no avail. In the 1960s and 1970s, the psychodynamic model had a challenge from within its community in the work of John Bowlby on attachment theory (Bowlby, 1968, 1973, 1980). Rejecting the drive reduction and Oedipal models that were so central to psychodynamic theory, Bowlby took an evolutionary approach to attachment, demonstrating that the bond between the infant and caregiver was not reducible to drive reduction (i.e., feeding) but rather was a predisposed tendency that was universal and was based on evolutionary forces that led infants to focus on a responsive figure of attachment—usually, but not

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always, the mother. Moreover, Bowlby’s attachment model had a core cognitive element—the internal working model—which was a cognitive schema or construction that represented the infant’s and later the child’s model of attachment figures (i.e., “Were they responsive, were they predictable, would they protect?”). Indeed, current attachment theory follows on from this cognitive model, attempting to trace the developing attachment styles of adolescents and adults that are putatively determined by these early attachment experiences and their consequent internal working models. Conclusions The cognitive models, developed by Beck and Ellis, follow a long tradition in Western philosophy beginning with the work of Plato, Aristotle, Epictetus, and others. Indeed, one can argue that a good preparation for learning how to do cognitive therapy might be to read Plato and the Stoics, especially following the nature of inquiry depicted in Socratic dialogues. The cognitive model of psychopathology was part of the cognitive revolution in many areas of psychology, including work on natural categories and prototypes, schematic processes in memory, impression formation, Pavlovian conditioning, the child’s construction of reality, language acquisition, attribution processes, causal inference, and even ego psychology in psychoanalytic thinking. However, in parallel with the development of cognitive models, we have equally important precursors of behavioral models and models of associationism, learning, and reinforcement. We turn now to review these developments.

THE PHILOSOPHICAL AND HISTORICAL PRECURSORS OF BEHAVIORAL MODELS The behavioral underpinnings of learning theories did not follow a strictly linear path. Current cognitive behavioral treatment approaches are informed by different schools of behaviorism. Early in the 20th century, there were varied ideas concerning what constituted the area of legitimate study as psychologists grew increasingly dissatisfied with traditional psychoanalytic ideas and with introspection as a method of psychological investigation. The evolution of the field of CBT has included research using human subjects as well as basic research that, on occasion, went unnoticed for decades before having a major impact on the theory and practice of behavior therapy and CBT. While a full history of learning theory and the variety of theorists who made substantial contributions cannot be covered in a chapter, we will trace the major figures in the development of behavior therapy and its evolution to CBTs. Broadly, the strongest influence on behavior therapy came from the discipline of learning theory. However, the field of learning theory is replete with theories and findings regarding how learning occurs; the nature of reinforcement; what is reinforced; the effects of punishment; and the importance of



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need, perception, and information in the establishment of behavioral responses. As is true in the nature of psychological science generally, the behaviorists and cognitive behaviorists often conducted research from unrelated labs and came to similar conclusions, and some research was conducted with the explicit intent to disprove the theories of others within the same behavioral orientation. Our focus will be on the trajectory of theories and research that are at the heart of CBT. These ideas did not develop in a clean series of uninterrupted ideas in a timely, systematic fashion. Rather, many researchers explored their ideas contemporaneously with varied emphases and with adherents to particular philosophies or treatment strategies, all under the rubric of CBT. Similarly, the philosophical traditions that influenced behavior therapy varied in importance within the specific behavioral theories that were articulated. Behaviorism is not a unitary idea but rather a set of ideas and traditions that have evolved into differing paths, which we will elucidate throughout this chapter. The psychologists and physicians who pioneered behaviorism as a scientific method and as a treatment practice were not philosophers, but they were influenced by developments in modernity—that is, explaining the world through observation and discovery rather than by a belief in an ultimate truth or the workings of spiritual forces. A core philosophical basis for behaviorism, broadly defined, is not so much the philosophical positions adhered to but rather the philosophy that was opposed—namely, Cartesian dualism. The behaviorists did not differentiate mind and matter, particularly because mind was considered an elusive conception. They were logical positivists, insisting upon linking what was abstract and theoretical to what could be observed. This was Aristotelian and naturalistic as opposed to Platonic and mentalistic. The subject of study was behavior itself, not what behavior symbolized or represented. Skinner differentiated between two types of behaviorism: methodological behaviorism and radical behaviorism. According to Skinner (1974), methodological behaviorism “might be thought of as a form of logical positivism or operationalism” (p. 16). He concluded that although the issues of concern to the methodological behaviorists differed from those of the logical positivists and operationalists, the former maintained that mental events are unobservable. Skinner (1974) would conclude that the methodological behaviorists were successful in disposing of “many of the problems raised by mentalism” (p. 16) but that there continued to be problems in that “most” methodological behaviorists “granted the existence of mental events while ruling them out of consideration” (p. 17). He stated the position of his radical behaviorism differently: “What is felt or introspectively observed is not some nonphysical world of consciousness, mind, or mental life but the observer’s own body” (Skinner, 1974, p. 17). Early Behaviorism and Learning Theory Early behaviorism was articulated by researchers in many parts of the world. Ivan Pavlov was a Russian physiologist who won the Nobel Prize for his research

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on what was then known as the conditioned reflex. It was not likely the intention of Pavlov to be the forbearer of a movement that would change the practice of psychiatry, psychology, and other fields that addressed human behavioral and mental functioning. However, Pavlov’s finding about salivating dogs (Pavlov, 1927) and buzzers represents some of the earliest—but not the only— findings in associative learning and the beginning of modern behaviorism. In associative learning, an unconditioned stimulus (in Pavlov’s case, dog food powder) results in an unconditioned response (such as salivation in Pavlov’s dogs). An unconditioned stimulus is a stimulus that is not learned and that elicits a response, the unconditioned response. With repeated pairings of a conditioned stimulus (in Pavlov’s case, a bell or buzzer) with the unconditioned stimulus, the conditioned stimulus takes on the same function of the unconditioned stimulus. In the classic Pavlovian studies, the dogs would salivate at the sound of a buzzer (the conditioned stimulus) even when the food powder (unconditioned stimulus) was not presented. Several decades before publication of Pavlov’s notable findings, Edward L. Thorndike had written his doctoral dissertation at Teachers College, Columbia University, in the United States on associative processes in animals (Thorndike, 1898, as cited in Bolles, 1979). Thorndike showed that hungry cats would relatively rapidly learn to manipulate a small string with their paw in order to escape from a box and get food. There were individual differences in the learning curves, but all showed a steady decline in the number of seconds it took to escape from the box, demonstrating that learning had taken place. Thorndike also noted that the behavior of the cat was dependent on the type of consequence upon leaving the box. Receiving food upon opening the door resulted in the cats quickly manipulating the rope in order to escape from the box and eat. When the cat was punished for leaving the box, it would not leave. Thorndike called this the “law of effect” as learning occurred because the behavior had an effect on the environment (Bolles, 1979). The law of effect proposes that behavior that is reinforced increases in frequency. Thorndike’s law of effect was in line with the philosophy of associationism dating back to Aristotle and continuing with Hobbes, Locke, Hume, Wundt, and others (Postman, 1947). Thorndike’s theory also reflected the work of Darwin. Darwin’s evolutionary theory of natural selection of species informed the law of effect, which emphasized the selection of behavior by its consequences (Catania, 1999). Leo Postman also argued that a third philosophical idea was important to the law of effect, specifically hedonism. According to Postman (1947), “Associationism is concerned with the laws of connection of mental elements: it has little to say about the role of motives in the acquisition of learned responses” (p. 490). Postman proposed that the philosophy of hedonism, which emphasized the governing principles of pleasure and pain, influenced the law of effect. Thus, Postman suggested that this philosophy dates back as far as Plato and Aristotle, to Hobbes’s proposition that humans seek pleasure and avoid pain, and to the doctrine of utilitarianism, “which regarded self-interest as a sufficient principle to account for most of individual and social action” (Postman, 1947, p. 490).



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While agreement with Thorndike’s conclusions vary, his influence on behavioral and cognitive behavioral psychology is beyond doubt. Academic psychology in the United States was also heavily influenced by behaviorism following the work of J. B. Watson in the early 20th century. Watson rejected traditional introspection and questions about the mind as legitimate subjects for scientific inquiry. Watson was solidly a logical empiricist, rejecting as meaningless anything that could not be directly observed by an outsider. The interest initially was academic, investigating the acquisition of fear and the application of principles of conditioning to human as well as animal behavior. Watson—and then graduate student Rosalie Rayner—conducted experiments in fear conditioning based on the associative learning principles of his behavioral theory that was later published in the classic case of “Little Albert” (Watson & Rayner, 1920). “Albert,” a toddler who showed no fear of rats, rabbits, or other fluffy animals, was conditioned to respond with fear through the pairing of a presentation of a stimulus (i.e., a white rat, and then a white rabbit) with the loud clang of a metal bar from behind as soon as he reached for the stimulus. After repeated pairings of the rat with the loud noise, Albert began to cry when the rat alone was presented (without the startling clang). The Little Albert experiment is one of the most cited research papers on early conditioning, but later reviews have shown the limitations of that work. Researchers today would not use a single case to confirm an entire theory, but the impact of this study was substantial for the field. Also, because there was no follow-up with Albert, who has basically been lost to history, it is unclear whether the conditioned fear response was temporary or whether Albert maintained his fear of white furry animals. Recently, several teams have reviewed archived information to discover the identity of Albert, but there is disagreement as to the veracity of the results (H.  P. Beck et al., 2009; Powell et al., 2014). Watson did not have the opportunity to experiment with deconditioning the fear that was experimentally induced, but 3 years later Mary Cover Jones (1924) conducted an experiment with the case of “Peter,” whom she described as “almost to be Albert grown a bit older” (p. 309). In other words, Peter was not afraid of anything except white furry animals (i.e., a rat, a rabbit) and objects (i.e., a little fur rug, a white fur coat, and to some extent, cotton). Although this was not a true deconditioning experiment because the fear was not a conditioned fear, Cover Jones and colleagues were able to extinguish the fear of a rabbit by pairing proximity to the rabbit with food that Peter enjoyed. They also demonstrated that Peter was more likely to touch the rabbit if he observed others doing so. This experiment anticipated later work of Albert Bandura (Bandura & Walters, 1963) on observational learning, whereby conditioning occurs by observing a model in contact with the stimulus, and copying the model results in new behavior. Attempts to extend this research outside the university and into the clinical arena did not begin in earnest until the 1950s. From that point on, interest in applying this work to the treatment of psychological and behavioral disorders led to the development of specifically behavioral treatments.

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Although the focus of the early behaviorists was not exclusively on human learning, the applicability of their animal learning and conditioning experiments to human behavior was considered feasible at the turn of the 20th century following a paradigm shift in psychology, engendered by Darwin’s studies of evolution. Human beings, as more advanced species along the evolutionary trajectory, are subject to many of the same basic contingencies as less complex organisms. The experimental work naturally led to applications of learning theory with humans and to interventions with clinical interventions. Just as B.  F. Skinner articulated two types of conditioning—Pavlovian or classical (respondent) conditioning and operant conditioning—behavioral interventions were developed initially emphasizing each of these types of conditioning. Classical or respondent conditioning derived from the work of Pavlov, Watson, and others. Skinner referred to it as “respondent” because it is the conditioning of responses to a stimulus. Consider the Little Albert experiment where the child was conditioned to respond to white objects with fear after the pairing of such objects with a loud, aversive noise. Operant conditioning considers how the individual and the environment impact each other. The three-term contingency of the operant paradigm is the “ABC” of antecedent, behavior, and consequence. Behavior is determined by its consequences. Under certain circumstances, that is, a specific antecedent (A), a behavior (B) is more likely to occur, or is reinforced, because of the consequence (C), or if the consequence is in some way aversive, the behavior may decrease and we would say it has been punished. Locke’s emphasis on the necessity of experience in learning can also be seen in the writing of the behaviorists, particularly that of Skinner. Skinner’s assertion that behavior is determined by its consequences, rather than by an innate will, is consistent with Locke’s philosophy, as discussed earlier. Philosophers like Hume and Locke had prescribed the behavior of scientists, and behaviorists like Skinner, Moore, and Catania echoed this idea that science is dependent on individuals engaging in the behavior of science (Nuzzolilli & Diller, 2015). The scientist’s behavior is controlled by the same processes as those of the subjects. In 1938, O. H. Mowrer and W. M. Mowrer published an article on a treatment method for enuresis that differed from the many methods used at the time. They refer to “innumerable drugs and hormones, special diets . . . massage, bladder and rectal irrigations” (Mowrer & Mowrer, 1938, p.  436) that were being used at the time to no avail, while they were able to use principles of classical conditioning to help the child develop new habits. Their method came to be known as the bell and pad method, which is still used today. In treatment of adult psychiatric disorders, behavior therapy was also associated with the work of Joseph Wolpe (1958) in South Africa, Hans Eysenck in the United Kingdom, and Ogden Lindsley in the United States (Öst, 2008). These researchers based their work on classical conditioning principles and applied behavior analysis using procedures based on operant principles. The term “behavior modification” was once used to encompass the entire field of applied learning theory (Goldfried & Davison, 1976), although that term is less pre-



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ferred as stereotypical images of manipulation of human behavior (e.g., Stanley Kubrick’s A Clockwork Orange) have cast a negative pall over it. Behavior therapy, however, has been characterized since its first and second decades by diversity of conceptualizations (O’Donohue et al., 2001). According to Goldfried and Davison (1976), there were “several trends” (p. 4) in the early development of behavior therapy. One trend was experimentation on the acquisition and extinction of fear through Pavlovian conditioning. Researchers associated with this trend were Joseph Wolpe and Arnold Lazarus in South Africa, M. B. Shapiro and H. J. Eysenk in the United Kingdom, and Andrew Salter in the United States. Wolpe’s medical school animal experiments led him to extend the strategy used by Cover Jones to anxious patients by pairing deep muscle relaxation with imagining an anxietyevoking situation. Wolpe’s (1958) treatment of reciprocal inhibition—that is, pairing incompatible responses (anxiety and relaxation)—became an early standard behavior therapy procedure and was influential in the development of exposure treatments for anxiety disorders. Pavlov’s study of experimental neurosis appealed to Wolpe, as did the work of Clark Hull that described basic principles based on experimentation with animals that could be applied to humans. Taking a lead from Pavlov, Wolpe embarked on an investigation of the causes and cures for the neuroses (Poppen, 2001). The importance of Wolpe’s work in the development of behavior therapy cannot be overstated. Stanley Rachman (2015) chronicled the development of behavior therapy, articulating the burgeoning work that occurred alongside that of Wolpe’s treatment of anxiety disorders. Rachman noted that it was a behaviorist, Victor Meyer, who first used repeated exposure in the treatment of obsessive-compulsive disorder (OCD), which was, at that time, mostly considered untreatable. This first use of exposure and response prevention resulted in the publication of two case studies from patients treated by Meyer at Maudsley Hospital, and following those publications, others applied the procedure in the treatment of OCD. A second trend in behavior therapy was the use of operant principles applied to human behavior. This early work was more prominent in the United States (Rachman, 2015). Skinner’s research on reinforcement was applied to work with psychiatric inpatients and with institutionalized clients with developmental disabilities. Other scholars reworked psychoanalytic principles from a behaviorist perspective, most notably Dollard and Miller (1950), Andrew Salter (1949), and Charles Ferster (1973). With the exception of Tolman, the early behaviorists did not consider cognition as they eschewed unobservable phenomena as a legitimate focus of study (Bolles, 1979). Skinner’s (1957) formulation of cognition as private “verbal behavior” allowed him to apply learning principles to thinking and language and legitimized the study of behavior that is not observable apart from self-report. The early behaviorists’ insistence on scientific rigor led to a stereotype of behaviorism as lacking in depth and as denying the importance of human experience beyond overt muscle movements. However, the concern of behaviorism has not been to deny that people think or that there is a variety of human emotion but

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rather to ensure that the focus of research be on operationally defined, measurable phenomena. As Skinner (1974) himself stated, “It is often said that a science of behavior . . . neglects the person or self. What it neglects is a vestige of animism, a doctrine which in its crudest form held that the body was moved by one or more indwelling spirits” (p. 184). For Skinner and other behaviorists, it was important to understand the complexity of human behavior without resorting to dualism, designating so-called mental processes as somehow different from physical ones. As Skinner would say, the “world within the skin” followed all of the same principles as the world outside the skin. Behavioral Models The work of Albert Bandura had a major impact on the development of behavior therapy and CBT. Bandura’s research focused on the impact of the social environment on learning, and he took umbrage with the psychodynamic models in vogue in the early 1960s therapy settings. Bandura was intrigued by the impact of direct modification of unwanted behavior on client improvement (Bandura, 2004). While Bandura emphasized the influence of social factors on the performance of observers, his findings still emphasized the importance of consequences on the actor’s behavior in concert with the observed consequences of the modeled behavior. He stated that observed consequences may have different behavioral effects under conditions where the reinforced performers and the performers are members of the same group who are present in the same setting and interacting with the same social agents. Observers who witness other members rewarded for a certain pattern of behavior may temporarily increase similar responding, but if their behavior is consistently ignored they are apt to discontinue the modeled behavior or even respond negatively to the agent’s preferential treatment. (Bandura, 1969, p. 32)

Bandura (1969) also emphasized the impact and importance of selfreinforcement in governing social behavior. He concluded that “there exists a substantial body of evidence that modeling processes play a highly influential role in the transmission of self-reinforcement patterns” (Bandura, 1969, p. 33). During the 1960s, behavior modification and therapy became well established as treatments for a variety of human problems. Examination of the first volume of the Journal of Applied Behavior Analysis provides a good illustration of the breadth of the field. There were articles that articulated the theory and principles of behavioral analysis that became classics in the field (i.e., Ayllon & Azrin, 1968; Baer et al., 1968) as well as articles on work in schools (e.g., Madsen et al., 1968), in psychiatric hospitals (e.g., Ayllon & Azrin, 1968), in the treatment of autism (e.g., Boer, 1968), with developmentally delayed children (e.g. Hopkins, 1968), and in the treatment of phobias (e.g, Leitenberg et al., 1968). The advisory editors included prominent behavior therapists such as Donald Meichenbaum, who was influential in the development of treatment that focused on cognition, which ultimately became known as cognitive behavior modification (Meichenbaum, 1977)—or now CBT.



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Bandura identified several changes in the explanation of human change processes that occurred during the 1960s. First, the analysis of causes shifted “from unconscious psychic dynamics to transactional psychosocial dynamics” (Bandura, 2004, p. 616). There was a shift from categorizing people into psychopathological types and diagnostic labeling to conducting functional analyses of human behavior. Research occurring in the laboratory or in the field replaced analytic interviews as the mechanism for the study of behavior change. Treatment was action oriented rather than insight oriented, and the “modes of treatment were altered in content, locus, and agents of change” (Bandura, 2004, p. 616). The common thread in all the behavior therapies was the commitment to experimental science, and the behaviorist therapists were able to demonstrate that their procedures were efficacious in treating these various human ills. The reliance on empiricism continued as behaviorists became more interested in cognition, and this same requirement for demonstrating outcomes that are supported by rigorous research is a hallmark of CBT. Contemporary clinical behaviorism tends to be separated into behavior therapy or behavior analysis. While the differences are by no means absolutely distinct, behavior therapy treatment developers, researchers, and clinicians apply the principles and protocols to disorders such as anxiety, mood, and some personality disorders and often use procedures based more on classical or respondent conditioning paradigms. Behavior analysts typically work from an operant conditioning paradigm and treat developmental disorders such as autism spectrum disorder or intellectual disabilities. Behaviorism Today Complexities in behaviorism continue today. To a large extent, disagreements over whether cognitive therapy adds anything to behavior therapy that were common in the 1980s (Latimer & Sweet, 1984) have substantially been put to rest. As Emmelkamp (1994) stated, “Most cognitive procedures have clear behavioral techniques in them, and, although less obvious, most behavioral procedures also contain cognitive elements” (p. 379). Even when research demonstrates that a primarily behavioral intervention is of similar or greater efficacy than a primarily cognitive intervention, as was demonstrated in several studies of behavioral activation and cognitive therapy for depression (Dimidjian et al., 2006), efficacy trials do not address theory, and it is possible that behavioral interventions change beliefs, which in turn improve symptoms. The search for mechanisms of change continues, and discussions in the behavioral literature today are more nuanced in the search for what accounts for the efficacy of certain procedures. The use of exposure and response prevention in the treatment of OCD has evolved to incorporate cognitive features, particularly in the treatment of obsessions or mental contamination (Rachman, 2015). Current research on prolonged exposure in the treatment of PTSD serves as a good example.

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For many years, the reduction in fear following exposure therapy was attributed to the process of habituation, or the reduction in physiological arousal within and between treatments of prolonged exposure. Contemporary models of prolonged exposure offer differing explanations of its mechanisms. Emotional processing theory (Foa & Kozak, 1986) suggests that the fear structure includes representations of the feared stimuli, fear responses, and the meaning of the stimuli and responses. When escape and avoidance responses are easily triggered by harmless stimulus events that are erroneously associated with threat, the fear structure becomes pathological (Foa et al., 2007). Emotional processing theory proposes several possible mechanisms. Emotional engagement provides disconfirming evidence for the erroneous interpretation of stimulus events, and habituation dissociates stimulus from response elements, extinguishing the fear response. Repeated imaginal exposure also facilitates reorganization of the trauma narrative. Michelle Craske has proposed the mechanism of fear inhibition learning (Craske et al., 2014) in exposure therapies. According to this model, it is not important for habituation to occur, but rather there should be repeated exposure in the absence of trauma so that a competing association is formed that signals the absence of danger. The reduction in fear is not seen to be as important as the emotional engagement with the exposure exercises without distraction or use of safety behaviors. While emotional processing theory and inhibition learning theory differ in emphasis, they are not completely at odds. Each has important implications for the conduct of prolonged exposure therapy; there is less controversy here and more of a search for clarification of best treatment and empirically supported theory. Perhaps a slightly more divergent thinking from the behavioral analysis stream of CBT has developed roughly over the past 30 years from a perspective that has come to be known as contextualist. A specific treatment, ACT (Hayes et al., 1999), and an explanation of human cognition, relational frame theory (RFT; Hayes et al., 2001), have gained many proponents and have often been referred to as a third wave of the behavioral therapies (the first wave being the behavioral therapies, the second being the cognitive and cognitive behavioral therapies, and the third being contextually based therapies). To some extent, treatments such as DBT (Linehan, 1993) fall into the category of the third wave, although much of DBT makes use of very traditional behavioral interventions. The contextual therapies are defined by a focus on acceptance and mindfulness methods. In ACT, additional methods similar to cognitive distancing (A. T. Beck, 1976), referred to as defusion, are also employed. ACT diverges from traditional CBT by rejecting the conceptualization that cognitions or emotions play a causal role in behavior. ACT is said to be based in contextualism, and Hayes and colleagues (1988) have asserted that behavior analysis in general is contextualist. To the contextualist, the criterion for discovering truth is pragmatic. What is true is what works, what is useful. It is beyond the scope of this chapter to provide a comprehensive account of ACT or to provide a critical analysis of the newer behavior therapies. The point is that behavior therapy has incorporated varied theories and applications from the beginning and continues to do so today. Since adherence to scientific



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principles rather than introspection or theory without science has defined the behavioral therapies, it is logical that ideas will come and go. Some therapeutic strategies will be shown to be more effective than others and will gain popularity. Some theories will more clearly explain human behavior and clinical phenomena. The early behaviorists were charting new ground and worked against predominant ideas in both the basic study of psychological science and, later, the application to clinical problems. That the behavioral and cognitive behavioral researchers and practitioners are continuing to look for greater understanding and to move in unexpected directions is a unifying feature in what often looks like a field of varied, sometimes oppositional views.

CONCLUDING THOUGHTS This chapter provides a panoramic view of the philosophical and historical foundations of CBT in general with particular focus on the separate influences on the cognitive and behavioral models, respectively. As many of us in the CBT field know, the larger umbrella of CBT is a moving target with continued growth in approaches that now attempt to focus on common processes rather than specific diagnostic categories. Thus, we can think of CBT as evolving toward “transdiagnostic approaches”—that is, approaches to treatment and techniques that are not dependent on specific DSM diagnoses but rather focus on processes that may affect many different disorders. Examples of these processes include rumination, avoidance, memory, attention, cognitive processing, and more. The learning and behavioral theories that have informed contemporary CBT were varied, and sometimes contradictory, from the outset. In one way or another, the theories were heavily influenced by philosophical roots of associationism and of Darwinian evolution, which tied the various learning theories together. It is our hope that those of us who focus on the behavioral and learning traditions gain some awareness of the strong theoretical and empirical work that is the foundation of this valuable and effective treatment. Too often psychology may be equated with what has been going on in the last 3 years as opposed to the last 2,400 years. In addition, the cognitive approach has branched out to include cognitive processing therapy, schema-focused therapy, metacognitive therapy, and other integrative and innovative models. Newer wave approaches such as DBT and ACT draw heavily on the Buddhist tradition and that merits its own historical review. We have seen how philosophical approaches to the psyche have developed into psychological models, treatment approaches, and empirical programs of research. Many of the major approaches could merit their own philosophical and historical review—and we welcome those ideas. And it is also possible that we can still reach back into the past and find that the “ancient wisdom” from many centuries ago can still inform us as to which direction we should pursue. Indeed, one can argue that positive psychology is the reemergence of Aristotle in a different form.

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2nd ed.). Cambridge University Press. https://doi.org/10.1017/CBO9780511808517 (Original work published 1782) Kazantzis, N., Beck, J., Clark, D., Dobson, K., Hoffman, S., Leahy, R., & Wong, W. (2014). Clinical round table: The use of Socratic dialogue for guided discovery in cognitive behavior therapy [Workshop]. International Congress of Cognitive Psychotherapy, Hong Kong, China. Kelley, H. H. (1972). Causal schemata and the attribution process. General Learning Press. Kelly, G. A. (1955). The psychology of personal constructs. Norton. Kris, E. (1951). Ego psychology and interpretation in psychoanalytic therapy. Psychoanalytic Quarterly, 20(1), 15–30. https://doi.org/10.1080/21674086.1951.11925828 Kuhn, T. S. (1970). The structure of scientific revolutions. University of Chicago Press. Latimer, P. R., & Sweet, A. A. (1984). Cognitive versus behavioral procedures in cognitive-behavior therapy: A critical review of the evidence. Journal of Behavior Therapy and Experimental Psychiatry, 15(1), 9–22. https://doi.org/10.1016/0005-7916 (84)90116-2 Lazarus, R. S. (1982). Thoughts on the relations between emotion and cognition. American Psychologist, 37(9), 1019–1024. https://doi.org/10.1037/0003-066X.37.9. 1019 Leitenberg, H., Agras, W. S., Thompson, L. E., & Wright, D. E. (1968). Feedback in behavior modification: An experimental analysis in two phobic cases. Journal of Applied Behavior Analysis, 1(2), 131–137. https://doi.org/10.1901/jaba.1968.1–131 Linehan, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. Guilford Press. Linehan, M. M., Bohus, M., & Lynch, T. R. (2007). Dialectical behavior therapy for pervasive emotion dysregulation: Theoretical and practical underpinnings. In J. Gross (Ed.), Handbook of emotion regulation (pp. 581–605). Guilford Press. Locke, J. (1975). An essay concerning human understanding (P. H. Nidditch, Ed.). Oxford University Press. (Original work published 1689) Loftus, E. F. (1979). Eyewitness testimony. Harvard University Press. Madsen, C. H., Jr., Becker, W. C., & Thomas, D. R. (1968). Rules, praise, and ignoring: Elements of elementary classroom control. Journal of Applied Behavior Analysis, 1(2), 139–150. https://doi.org/10.1901/jaba.1968.1-139 Mahler, M. F. (1969). On human symbiosis and the vicissitudes of individuation. International Universities Press. Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. Springer. https://doi.org/10.1007/978-1-4757-9739-8 Miller, G. A. (1956). The magical number seven, plus or minus two: Some limits on our capacity for processing information. Psychological Review, 63(2), 81–97. https://doi. org/10.1037/h0043158 Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis—A method for its study and treatment. American Journal of Orthopsychiatry, 8(3), 436–459. https://doi.org/b9xwrz Nagel, T. (1974). What is it like to be a bat? Philosophical Review, 83(4), 435–450. https:// doi.org/10.2307/2183914 Neisser, U. (2014). Cognitive psychology: Classic edition. Psychology Press. https://doi.org/ 10.4324/9781315736174 (Original work published 1967) Newell, A., & Simon, H. A. (1972). Human problem solving. Prentice Hall. Nuzzolilli, A. E., & Diller, J. W. (2015). How Hume’s philosophy informed radical behaviorism. The Behavior Analyst, 38(1), 115–125. https://doi.org/10.1007/s40614014-0023-0 O’Donohue, W. T., Henderson, D. A., Hayes, S. C., Fisher, J. E., & Hayes, L. J. (2001). Introduction. In W. T. O’Donohue, D. A. Henderson, S. C. Hayes, J. E. Fisher, & L. J. Hayes (Eds.), A history of the behavioral therapies: Founders’ personal histories (pp. 17–40). Context Press.



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Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296–321. https:// doi.org/10.1016/j.brat.2007.12.005 Pavlov, I. P. (1927). Conditional reflexes: An investigation of the physiological activity of the cerebral cortex. Oxford University Press. Piaget, J. (1954). The construction of reality in the child (M. Cook, Trans.). Routledge; Kegan Paul. https://doi.org/10.1037/11168-000 (Original work published 1950) Piaget, J. (1971). Genetic epistemology. Norton. Poppen, R. (2001). Joseph Wolpe: Challenger and champion for behavior therapy. In W. T. O’Donohue, D. A. Henderson, S. C. Hayes, J. E. Fisher, & L. J. Hayes (Eds.), A history of the behavioral therapies: Founders’ personal histories (pp. 73–108). Context Press. Postman, L. (1947). The history and present status of the law of effect. Psychological Bulletin, 44(6), 489–563. https://doi.org/10.1037/h0057716 Powell, R. A., Digdon, N., Harris, B., & Smithson, C. (2014). Correcting the record on Watson, Rayner, and Little Albert: Albert Barger as “psychology’s lost boy.” American Psychologist, 69(6), 600–611. https://doi.org/10.1037/a0036854 Rachman, S. (2015). The evolution of behaviour therapy and cognitive behaviour therapy. Behaviour Research and Therapy, 64, 1–8. https://doi.org/10.1016/j. brat.2014.10.006 Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43(3), 151–160. https://doi.org/10.1037/0003-066X.43.3.151 Rosch, E. H. (1973). Natural categories. Cognitive Psychology, 4(3), 328–350. https://doi. org/10.1016/0010-0285(73)90017-0 Salter, A. (1949). Conditioned reflex therapy, the direct approach to the reconstruction of personality. Creative Age Press. Searle, J. R. (1980). Minds, brains, and programs. Behavioral and Brain Sciences, 3(3), 417–424. https://doi.org/10.1017/S0140525X00005756 Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. W. H. Freeman. Skinner, B. F. (1957). Verbal behavior. Appleton-Century-Crofts. https://doi. org/10.1037/11256-000 Skinner, B. F. (1974). About behaviorism. Alfred Knopf. Sorabji, R. (2000). Emotion and peace of mind: From stoic agitation to Christian temptation. Oxford University Press. Taylor, S. E., & Crocker, J. (1981). Schematic bases of social information processing. In E. T. Higgins, C. P. Herman, & M. Zanna (Eds.), Social cognition: The Ontario symposium on personality and social psychology (Vol. 1, pp. 89–134). Lawrence Erlbaum. Thaler, R. (1992). The winner’s curse: Paradoxes and anomalies of economic life. Princeton University Press. Tolman, E. C. (1948). Cognitive maps in rats and men. Psychological Review, 55(4), 189–208. https://doi.org/10.1037/h0061626 Tulving, E. (2002). Episodic memory: From mind to brain. Annual Review of Psychology, 53, 1–25. https://doi.org/10.1146/annurev.psych.53.100901.135114 Watson, J. B., & Rayner, R. (1920). Conditioned emotional reactions. Journal of Experimental Psychology, 3(1), 1–14. https://doi.org/10.1037/h0069608 Weiner, B. (1974). Achievement motivation and attribution theory. General Learning Press. Wittgenstein, L. (1967). Philosophical investigations (G. E. M. Anscombe, Trans.; 2nd ed.). Blackwell. Wittgenstein, L. (1974). Tractatus logico-philosophicus (D. F. Pears and B. F. McGuinness, Trans.). Routledge; Kegan Paul. (Original work published 1923) Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press. Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35(2), 151–175. https://doi.org/10.1037/0003-066X.35.2.151

2 Theoretical Framework Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann

C

ognitive behavioral therapy (CBT) is a term that is often used to describe a therapeutic intervention derived from the basic principles of Beck’s cognitive theory (Beck, 1967) and traditional behavioral interventions. This use of the term is a common error, however, as CBT is not a single model of therapeutic intervention but a family of interventions (Dobson, 2009) that comprise a number of different therapies aimed at thought processes and behavior. CBTs range from cognitive therapy, which focuses on identifying and modifying dysfunctional thoughts (Beck, 1967), to mindfulness-based cognitive therapy, which focuses on increasing present awareness and relating to experience in an open and nonjudgmental manner (Dobson & Dozois, 2019; Segal et al., 2013). Differences among the various CBTs exist in terms of the degree of focus and importance that is placed on thought and behaviors, as well as the way in which they conceptualize therapy techniques that target these two domains. An example of one such difference can be seen in the realist assumption, which reflects the notions that a “real world” exists that is independent of our perception and that it is possible to misinterpret or misperceive this reality (Dobson, 2013; Dobson & Dobson, 2017). If this assumption were to be considered on a continuum, most CBTs would fall somewhere in the middle. In other words, proponents of CBTs often postulate that there is a “real world” but that the meaning we attach to that world is also important. Therefore, depending on where specific CBTs fall on this continuum, more weight may be placed on

https://doi.org/10.1037/0000218-002 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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restructuring thoughts to be more “realistic,” or more weight may be placed on changing the way in which one relates to the meaning attached to that thought. Taken together, the core theoretical concepts of CBT were conceived from an amalgamation of influences from various theoretical orientations and empirical findings. As a result, it has been argued that CBT lacks clarity as a therapeutic system, as its blending of different models and methods has incorporated theoretical ambiguities and nomenclature with diverse origins and uses (e.g., Mansell, 2008; Mansell & Taylor, 2012). However, advantages of the assimilation of these varied influences are that CBT also incorporates considerable flexibility and encompasses many techniques that can alleviate distress associated with experienced thoughts and behaviors. In fact, despite the differences in specific therapies housed under the cognitive behavioral umbrella, the main tenet of the CBTs can be distilled into the notion that people’s cognitions are critical influences on their emotional state and behavior. Although this tenet may appear to oversimplify what constitutes a CBT, the core consensus between all CBTs is that thought processes, emotions, and behavior are interdependent. This chapter examines the underlying theoretical concepts of CBT in order to offer insight into the theoretical coherence of the CBT family. Specifically, we discuss the assortment of theories that inform early and recent CBT therapies, differences in the way in which cognition is conceptualized, and the shift from diagnostically specific to transdiagnostic CBT modalities.

EARLY THEORETICAL DEVELOPMENTS The CBTs have a blend of different influences that contributed to their theoretical development over time. That said, they were derived from two main theoretical frameworks. Behavior therapy was first developed in the early 1900s as a response to the lack of empirical support for psychological theory and clinical applications (Hayes, 2004). Behavior theory avoided unobservable processes, such as cognition or emotion, and instead focused on associations of observable events, such as behavioral responses to external stimuli. Consistent with this model, behavior therapy focused mainly on principles of learning in order to modify pathological behaviors and distressing emotions (Hayes, 2004; Hupp et al., 2008). Although behavior therapy showed promising results for treatment of less complex pathologies, such as the anxiety disorders, there were significant limits to the treatment of more complex presentations, such as psychotic disorders (Ingram & Siegle, 2010). As a result of these limitations, cognitive theorists attempted to incorporate cognitive mediation into the theoretical models while still preserving the empirical importance founded by behavioral psychologists. Thus, in the 1970s and 1980s, concepts such as vicarious learning (learning by observing others), social modeling (teaching others by modeling or demonstrating desired behaviors), and self-efficacy (the perceived ability to engage in various tasks) were introduced into theory to extend the stricter behavioral models of behavior.



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CBTs resulted from a bidirectional movement that was heavily influenced by an increased importance placed on mediational models of therapy and an understanding of the importance of overt methodology involved in behaviorism (Kendall & Hollon, 2013). The main purpose of CBT was to preserve the efficiencies of behavior modification within a less rigid context and to incorporate cognitive activities in the efforts to produce and enhance therapeutic outcomes (Kendall & Hollon, 2013). One clear example of this extension occurred in the models of depression. Ferster (1974) developed a behavioral model that emphasized diminished social reinforcement (whether by poor social skills, loss of social reinforcers, or increased sensitivity to social punishment) as a key mechanism for the genesis of depression. Building on this model, Lewinsohn and his colleagues (e.g., Lewinsohn et al., 1976) developed a behavioral treatment for depression that included social skills training and increased engagement in positive activities as fundamental components. When the cognitive behavioral model of depression emerged (Beck et al., 1979), it continued to incorporate the idea of increased social engagement, although it also included a focus on the meaning attached to social engagement and the interpretations made by the patient about their increased engagement as important components of the treatment. Thus, although the behavioral activation aspect of behavior therapy for depression was maintained, the CBT approach scaffolded cognitive interventions upon the more elemental process of activation. CBTs also adopted the concept of a therapeutic relationship from classical psychoanalysis. However, as opposed to viewing the therapeutic relationship as the vehicle of change, as was the case in classical psychoanalysis, CBTs postulated a therapeutic relationship as necessary but insufficient to produce therapeutic effects alone (Beck et al., 1979; Kazantzis et al., 2017). The therapeutic relationship is viewed within the CBTs as an environment or context that allows an individual to thrive and move toward the attainment of therapeutic goals (Cronin et al., 2015). Although therapeutic relationships involve listening, expressed empathy, and positive regard, collaboration and working alliance in CBT are also distinct elements of the therapeutic relationship within the CBTs (Cronin et al., 2015; Markin, 2014). Specifically, within CBT, the therapeutic relationship is defined as a collaborative bond and agreement on the goals of therapy and tasks to attain those goals (Bordin, 1979; Cronin et al., 2015). Indeed, the importance of relationships within therapy and their components of collaboration, empathy, and positive regard have all been empirically supported (Castonguay & Beutler, 2006; Norcross & Lambert, 2011). Although therapeutic alliance is not the focus of the current chapter, its importance in the implementation of CBTs can be traced back to its theoretical foundations. Although many specific theories and approaches contributed to the development of modern CBTs, three dominant concepts can be identified. The first postulate that strongly influenced early CBT theory is that cognitive processes (variously termed attitudes, beliefs, expectancies, and thoughts) are central to the understanding of behaviors associated with psychopathology (Kendall &

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Hollon, 2013). Beck’s (1969) cognitive theory and Ellis’s (1962) rational-emotive theory both emphasized the importance of thinking patterns that developed from early experiences and contributed to psychopathology (Mansell & Taylor, 2012). The earliest forms of such therapies included methods that involved the individual testing their beliefs against the “real world.” These methods helped shift cognitive processes to a more evidence-based and realistic perspective. A second influential assumption involved the notion that cognitions and overt behaviors can be shaped using the same laws of learning (Ingram & Siegle, 2010; Kendall & Hollon, 2013). Concepts like Bandura’s (1977) social learning theory and theory of self-efficacy elucidated the relation between cognitive models and behavioral interventions (Ingram & Siegle, 2010; Kendall & Hollon, 2013). Such theories provided a framework for cognitive variables to be conceptualized as observable and testable processes that could be integrated into behavioral paradigms. Clinicians used this idea to apply behavioral strategies, such as functional analysis (i.e., monitoring a target behavior over time and manipulating antecedents and consequences to determine what may predict and influence behavior; Wilson & Murrell, 2002), to cognitive processes (Kendall & Hollon, 2013). The addition of such theoretical understandings of cognition paved the way for clinicians to modify overt therapeutic strategies to work with covert psychopathological factors. The combination of cognitive and behavioral treatment strategies led to the third influential concept in early CBT, which is that both behavioral and environmental change can facilitate cognitive restructuring and subsequent cognitive change (Kendall & Hollon, 2013). This concept specified that there is an association between overt behaviors and covert cognitions, which in turn allowed the hypothesis that cognitive processes operate somewhat outside of behavioral laws and warranted causal status in dysfunction as well as mediation for behavior (Ingram & Siegle, 2010). In short, three fundamental principles arose: (a) cognitions affect behavior, (b) cognition can be monitored and altered, and (c) behavior change may be affected through cognitive change. Despite these influential theoretical origins and principles, recent criticisms have targeted this traditional CBT framework. First, it has been observed that the cognitive components of CBT do not necessarily outperform the behavioral strategies implemented in treatment (e.g., Dimidjian et al., 2006; Longmore & Worrell, 2007). Component analysis studies that have examined the efficacy of each component of therapy often report similar results between those that employ cognitive behavioral strategies and those that employ behavioral strategies (Gaudiano, 2008; Longmore & Worrell, 2007). This finding suggests that cognitive components of CBT are not necessary to invoke change. Along this vein of criticism is also the notion that there is a failure to show predicted mechanisms of action involved in the treatment outcomes of CBT. For example, changes in dysfunctional beliefs do not necessarily affect treatment outcomes (Gaudiano, 2008; Longmore & Worrell, 2007). Second, as the CBTs have at times developed through clinical observations, there is sometimes a lack of coherence between empirical findings of cognitive



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psychology and theoretical concepts (Gaudiano, 2008). This discontinuity raises the question of whether the theoretical component of cognitive change is actually necessary in therapy. Although concerns about the empirical support of cognitive components have been reported, rebuttals to these criticisms indicate that their foundations are based on common misconceptions about mediation models of treatment change (e.g., Hofmann, 2008). Specifically, arguments against these critiques have detailed that (a) component analyses are inadequate to test mediation, (b) changes in cognitions can occur and mediate treatment outcomes without explicit procedures that restructure these cognitions, and (c) a small number of mediation tests exist for treatment change because the statistical techniques to evaluate them have only recently been developed (Hofmann, 2008).

RECENT THEORETICAL DEVELOPMENTS Whereas earlier approaches to CBT focused on the identification and modification of the content of thought processes, more recent developments have tended to focus on the function of thoughts. This shift in therapeutic approach has decreased the use of techniques geared toward examining the evidence that does or does not support a specific idea and thereby changing the substance of the thought, and it has instead encouraged a focus on people’s relationship to their thoughts and the meanings that they attach to their thoughts and more general experience. Thus, contemporary CBTs target the context and function of thoughts, sensations, and emotions rather than targeting their content, validity, or frequency (Hayes et al., 2011). Context and function are targeted through techniques such as increasing awareness or acceptance of thoughts and feelings, increasing cognitive flexibility, increasing flexibility of attention, and distancing oneself from unpleasant thoughts and feelings. Therapies in this domain include but are not limited to mindfulness, acceptance and commitment therapy (ACT), and metacognitive therapy. Both contemporary and traditional CBT models address emotion regulation; however, they teach coping mechanisms for different stages of emotional processing (Hofmann & Asmundson, 2008; Hofmann et al., 2010). Emotion regulation can be implemented successfully in two manners: first by manipulating the evaluation of emotional cues (antecedent focused) and second by manipulating the response or experience of emotions (response focused; e.g., Gross, 1998; Gross & John, 2003). Traditional CBT modalities emphasize antecedent-focused strategies that include situation-specific modification and cognitive restructuring. In contrast, contemporary CBTs have shifted to response-focused therapeutic interventions, which attempt to alter the way in which individuals experience emotions once they have been instigated by teaching methods to increase acceptance of emotional experience and to counter emotional suppression (Hofmann & Asmundson, 2008). Suppression and failure to accept emotional states have been linked to increases in negative affect (Campbell-Sills et al., 2006).

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The response-focused CBT therapies have been described as a “third wave” movement. Proponents of this terminology have argued that such therapies constitute a different class of therapy from traditional CBTs because they adopt a more contextual and experiential approach (Hayes, 2004; Hayes et al., 2006; Hofmann et al., 2010). More specifically, this terminology was adopted because these treatment approaches appeared to represent a set of assumptions and theories that differed from traditional behavioral and CBT approaches (Hayes et al., 2011). However, the term third wave implies that such therapies have replaced more traditional forms of CBT (which presumably went through two previous waves), which has been argued as manifestly untrue. From our perspective, the more recent models are best conceptualized as contemporary members of the family of CBTs, which are both similar to and different from earlier CBT conceptualizations that preceded them, just as those therapies have similar and different approaches from the behavior therapies that preceded them (Wilson et al., 2011). Fundamentally, such therapies are related to CBT by sharing therapeutic principles related to modifying aspects of cognition (e.g., metacognition) in order to decrease emotional distress and problematic behaviors (Hofmann et al., 2010). Further, some theoretical and practical overlap exists between early CBT models and more recent therapeutic developments. Finally, it has been argued that the term third wave has been confusing and has become obsolete because many strategies are now part of modern CBT. Instead, some authors have argued to adopt instead the term process-based therapies (Hayes & Hofmann, 2017). As a result, the current chapter refrains from referring to these recent developments as third wave. Analysis of the theoretical foundations and concepts of contemporary CBT models reveal similarities with traditional CBTs, even as far back as Beck’s earlier work on cognitive therapy (e.g., Beck et al., 1985). Although the focus of cognitive therapy has been primarily on cognitive change, it has long been recognized that this change can be realized through direct cognitive restructuring, behavioral strategies, and acceptance and that resisting, avoiding, or suppressing a negative experience may paradoxically intensify and prolong it (Dozois & Beck, 2011). Thus, acceptance and mindfulness-based approaches fit within the founding cognitive therapy framework. For example, mindfulnessbased interventions are believed to counter experiential avoidance strategies, as they teach an individual to respond reflectively and openly to experiences of distress (Hofmann et al., 2010). Indeed, a change in the relation that a person has to their thought processes may promote a change in the thought itself. Therefore, successful CBTs of all types involve the individual’s acceptance of negative experiences. The primary objective of this principle is to promote acceptance of internal experiences to bring about cognitive change and symptom relief. Paradoxically, accepting distress through methods such as exposure habituates the individual to the uncomfortable experiences and shifts the appraisals of these experiences such that they no longer carry a threating meaning (Dozois & Beck, 2011). Although the goals of exposure for traditional and recent CBT modalities may differ (e.g., reduce arousal vs. increase behavioral



Theoretical Framework  37

flexibility in presence of anxiety; Hayes et al., 2011), both incorporate an element of acceptance into therapy. Another example of similar theoretical principles between traditional and contemporary CBT involve the concept of decentering. Decentering is the ability to observe thoughts and feelings as temporary events rather than true reflections of the self (Fresco et al., 2011; Safran & Segal, 1990). The concept of decentering or distancing oneself from thoughts can be found in traditional CBT modalities, as achieving distance from one’s cognitions is the first step to cognitive restructuring and minimizing suffering (Beck et al., 1985; Dalai Lama & Beck, 2005; Fresco et al., 2011; Herbert and Forman, 2011). Although the concept of decentering can be found in early CBT approaches that emphasize techniques such as the thought record, a difference between contemporary and traditional CBT approaches is the conceptualized mechanisms of change. Specifically, both traditional and contemporary CBT approaches agree that decentering is theoretically involved in successful therapeutic outcomes; however, in traditional CBT, it is believed to be the first step in therapeutic intervention, whereas in contemporary CBT, it is believed to be the factor that produces change (Fresco et al., 2011; Teasdale et al., 2002). Despite this difference in focus between cognitive restructuring and acceptance or distancing, it has been noted that cognitive change can occur even when therapeutic techniques do not explicitly aim to modify maladaptive cognitions. In other words, cognitive restructuring can occur even when this process is not explicitly incorporated into treatment (Hofmann, 2008; Hofmann et al., 2010). Therefore, it could be argued that although contemporary CBT approaches emphasize flexibility of thought and acceptance of experiences, cognitive restructuring may still occur.

APPROACH TO THE CONCEPTUALIZATION OF COGNITION CBT models vary in the extent to which they focus on the structure and process of thought. These two varying dimensions of CBT can best be conceptualized through the influence of Beck and Haigh’s (2014) generic cognitive model (GCM) and Hayes et al.’s (2001) relational frame theory, both discussed below. The GCM broadly postulates that psychological problems and clinical disorders are extensions of normal functioning. Specifically, adaptive functioning involves the utilization of cognitive, affective, and behavioral strategies to help cope with distress or attain goals. When the activation of these adaptive systems becomes disproportionate to life events, the systems are used inappropriately, and they become maladaptive. Maladaptive functioning results from an exaggeration of negative and positive biases found in normal processing. A negative bias is defined as an exaggeration of a threat or challenge, and a positive bias is defined as an exaggeration of a perceived reward. According to the GCM, the way an individual processes information is the mechanism that determines their adaptive or maladaptive functioning. Specifically, when information processing

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provides inaccurate information, cognitions, emotions, and behaviors are activated and engender a maladaptive response. In addition, the GCM suggests that through experience, individuals develop schemas, defined as stable internal representations of ideas or experiences. Schemas directly influence the way that an individual processes information. When a schema is activated, the meaning it holds interacts with cognitive, emotional, and behavioral systems. Schemas control information processing through two interacting subsystems: the automatic processing subsystem and the reflective processing system. The automatic processing subsystem rapidly processes and fits information into crude categories consistent with schemas. In contrast, the reflective processing system processes information deliberately and refines the interpretations of experience. The reflective processing system works with the automatic processing system through reappraisals of initial interpretations. In addition to schemas, the GCM accounts for motivations, such as goals and obligations. These modes represent the consolidation of schemas into belief systems, rules, and concepts, such as self-esteem. They reflect aspects of an individual’s personality through two dimensions: the self-expansive mode and the self-protective mode. The self-expansive mode is primarily concerned with increasing personal value, whereas the self-protective mode is primarily concerned with early detection of danger signals to mobilize when a threat is encountered. An exacerbation of the self-expansive mode is theorized to relate to symptoms of mania, whereas a deficit in this mode can lead to depression. An enhanced self-protective mode can be manifested in either paranoia or anxiety. The components described previously all contribute to a fundamental hypothesis of the GCM, which is that certain beliefs constitute a vulnerability to psychopathology (Beck, 2005). This hypothesis is often referred to as the diathesis– stress model of psychopathology. According to the diathesis–stress model, maladaptive schemas develop early in life in response to adverse experiences and remain dormant until triggered by a later stressful event (Beck, 1967). The schemas related to the self will influence the way in which an individual interprets or experiences events throughout the lifetime (Riskind & Alloy, 2006). In other words, individuals who have underlying maladaptive schemas carry a cognitive vulnerability for psychopathology. More specifically, these schemas, and their associated modes and their effects on information processing systems, can transform normal adaptive reactions into disorders by affecting the way an individual thinks, as well as the meaning and interpretations one derives from experience. Biased beliefs associated with these schemas are postulated to occur on a continuum; when a belief becomes distinctly biased in one direction (i.e., positive or negative), the probability of experiencing psychopathology increases. CBTs that focus on the structure and content of thought develop their treatment approach on the basis of this model. Each component of the model offers a point of intervention that, theoretically, will influence all other components, as all components are interconnected in this model. Content-focused cognitive behavioral therapists can intervene at the level of beliefs, the way information is processed (e.g., attention and memory), and/or behavior. First, belief inter-



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ventions target schemas and motivated goals. This work may include behavioral activation strategies to create obtainable goals, cognitive restructuring, behavioral tests, and/or reality testing in order to identify and evaluate erroneous beliefs. Information processing interventions include the use of thought records to identify biases in attention and cognition and the development of restructuring and reappraisal coping strategies to redirect information processing to function in a more adaptive way. Finally, behavioral interventions include reinforcing prosocial behaviors or relaxation coping strategies, as necessary. In summary, in the GCM, it is theorized that cognition, emotion, and behaviors associated with psychopathology occur when beliefs are significantly distorted. This theory of distorted adaptive functioning shaped content-focused CBTs, which distinguish between adaptive and maladaptive content. This dichotomy provides a concrete outline of what an individual’s thought content should reflect when they adopt and exhibit nonpathological cognitions. In contrast to structural models of cognition and thought content-specific CBTs, relational frame theory (RFT; Hayes et al., 2001) conceptualizes cognition in terms of its relation and meaning to the individual. This theory approaches cognition from a process-related perspective. Specifically, it is argued that factors such as language are instances of a type of operant behavior that is associated with arbitrary relational responding (Hughes & Barnes-Holmes, 2016). This theory postulates that both humans and nonhumans can respond to the physical relation between a stimulus and event (e.g., relate or categorize shapes based on physical similarity), but human behavior can also derive relations between stimuli and events independent from physical characteristics due to socioverbal and abstract abilities (Hughes & Barnes-Holmes, 2016). Language is based on the learned relations among events that form from arbitrary cues. For example, Hayes et al. (2011) provide an example of this phenomenon using a simple nickel and dime. A nickel can be viewed as “larger than” a dime according to physical attributes like size; however, the term “larger than” can also be applied arbitrarily to represent a dime being “larger than” a nickel in terms of its monetary value. When humans interact with their own behavior, the psychological meaning of both the verbal interpretation and the behavior itself can change as a result (Hayes et al., 1996). This bidirectional property of language and behavior is useful and adaptive because it allows humans to change the function of situations and behaviors depending on occasion or context (Hayes et al., 1996, 2011). However, research suggests that any event can acquire a negative function even it is not associated with another aversive event and does not share physical properties (Dymond & Roche, 2009). The ability to associate function and emotion with events that do not share physical properties means that any event may be associated with adversity, as language has the power to manipulate the meaning we derive from any given event (Hayes et al., 2011). Because of their ability for abstraction, humans tend to require a label or cognitive appraisal for their experience (Lazarus, 1982). This appraisal carries implications with respect to how to approach or avoid the associated experiences

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(Hayes et al., 1996). For example, “anxiety” is not only a set of bodily sensations but also a descriptive verbal label that integrates experiences, thoughts, and evaluations (Hayes et al., 1996). If anxiety is labeled as a “bad emotion,” the bidirectionality of language and stimulus can create the belief that the emotion inherently is bad, as opposed to the view that the emotion is perceived as bad (Hayes et al., 1996). Verbal relations can then lead to experiential avoidance (i.e., the unwillingness to focus on private experiences such as body sensations, thoughts, and emotions) that functions as a negatively reinforced behavior (Hayes et al., 1996) and influences psychopathology (Chawla & Ostafin, 2007; Feldner et al., 2003). Using this model as a foundation, practitioners of contemporary CBTs, such as ACT and mindfulness-based interventions, attempt to alter the effect of cognitions by changing the way an individual processes and relates to them, as opposed to directly modifying them. Contemporary CBTs encourage the individual to engage with, bring awareness and attention to, and consider their own experiences in a nonevaluative manner in order to counter avoidance of events and current experiences. In doing so, these methods target the function of psychological events such as thoughts, sensations, and emotions, rather than the content, validity, or frequency of such experiences (Hayes et al., 2011). Changes in the psychological and social context of psychological events are, then, the topic of focus. Contextual and process-oriented targets are diverse and may include aspects of awareness, decentering, acceptance, cognitive flexibility, attention, and readiness to change (Hayes et al., 2011). One example of process-oriented CBT frameworks is mindfulness-based cognitive therapy, which encourages changes in awareness and relationship to thoughts (Segal et al., 2004). A second example is metacognitive therapy, which attempts to modify the way thoughts are experienced and regulated (Wells, 2008). A third example is ACT, which focuses on the way in which language and verbal activity support its use as behavioral regulation (Hayes et al., 1999) and encourages the commitment to make value-based decisions for future behavioral directions. Overall, process-oriented CBT conceptualizations of cognition tend to be transdiagnostic in nature, as they are usually quite broad in their approach and are able to apply techniques flexibly. In addition, process-oriented or contextual CBT approaches tend to include many components and techniques that are utilized in the content-focused approaches described previously (Hayes et al., 2011). However, the purpose for employing these strategies differs in that techniques are often used to allow awareness of processes in order to decrease experiential avoidance and increase behavioral flexibility. This approach to CBT continues to develop (Hayes & Hofmann, 2017, 2018) and will undoubtedly exert an important and continuing influence on the field. It is important to note that whether any given CBT adheres to a GCM model or RFT model, its clinical application to a patient will necessitate a nuanced interpretation. The CBTs require a sophisticated understanding of theory, but its application to an individual’s presentation is equally as essential for proper



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therapeutic engagement. Case conceptualization has been described as a foundation of CBT and the heart of evidence-based practice (Bieling & Kuyken, 2003; Kuyken et al., 2008), as it explains a client’s clinical presentation in a way that helps inform the selection and timing of interventions. Case conceptualization involves the collaboration of the therapist and client to interpret presenting issues with the cognitive behavioral model. Thus, it is a tool that helps describe clinical presentations in a way that is theoretically informed, coherent, and meaningful and that leads to effective interventions (Kuyken et al., 2008). Case conceptualization has several key components (Kuyken, 2006), including the implementation of the cognitive behavioral model to develop a useful descriptive framework of the patient’s presenting problems. Case conceptualization also permits the development of explanatory inferences about etiology and maintenance of presenting problems, and it creates a foundation for informed interventions (Kuyken, 2006). Two primary approaches to case conceptualization have been identified. Clinicians can conceptualize a client’s presenting problems and individualized information into a disorder-specific model, or they can conceptualize on the basis of a generic model (Kuyken et al., 2008). Generic case conceptualization is associated with more nonspecific cognitive theories for emotional disorders and is typically used for more complex or comorbid presentations, as it identifies underlying assumptions or core beliefs that contribute to multiple presenting problems (Kuyken et al., 2008). Both approaches to conceptualization are important to the CBT process and implementation.

DIAGNOSIS-SPECIFIC AND TRANSDIAGNOSTIC THERAPY CBTs employ primarily three different types of treatment techniques to evoke cognitive change (Dobson & Dobson, 2017). These techniques address cognitive process in different ways. One technique involves identifying and changing thoughts as they arise. CBTs that focus predominantly on changing thoughts often employ evidence-based interventions to help evaluate and restructure our understanding of events, feelings, and behaviors. Referring to the realist assumption as a continuum described previously (Dobson, 2013; Dobson & Dobson, 2017), such techniques have their basis in the notion that there is a “real world” with concrete facts and that our thought processes can be changed to align with this real world. A second type of technique involves finding novel, alternative, and more flexible ways to think, to help shift cognitive processes (Dobson & Dobson, 2017). Such techniques are less rigid in their approach to the real world and incorporate the individual’s perspectives, values, and goals to cultivate a more nuanced, complete, and helpful perspective. The third class of techniques involves the examination of the meaning attached to our thoughts (Dobson & Dobson, 2017). This technique is perhaps the most liberal with respect to the realist assumption and identifies the meaning attached to an individual’s perspective rather than the extent to which it truly matches the real world.

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Historically, therapies have adapted these techniques to fit with disorderspecific presentations. Such diagnosis-specific CBTs arose from the contentspecificity hypothesis (Beck, 1967), which postulated that each emotional disorder could be characterized by specific and unique cognitive content related to that disorder (Beck, 2005). For example, the typical maladaptive cognitions associated with anxiety disorders focus on the future possibility of danger or threat, and each specific form of anxiety disorder is characterized by cognitions about danger and/or uncontrollability associated with specific stimuli, situations, or experiences (Hofmann et al., 2010). This disorder-specific tailoring of therapeutic interventions has historically proved to be efficacious (e.g., Butler et al., 2006; Hofmann & Smits, 2008). Although a diagnostically related approach to therapy is empirically supported, many issues can arise. First, many patients present with comorbidities, the presence of which challenges disorder-specific theories of etiology and pathology (Lilienfeld & Treadway, 2016). Comorbidities imply that disorders may consist of common etiological factors. The diagnostic-specific approach is also associated with treatment manuals and more “formulaic” treatments, which may minimize clinical complexity and miss information that would otherwise promote successful treatment outcome (Mansell & Taylor, 2012). Finally, a diagnostic-specific framework is contingent on the current knowledge and validity of the diagnostic system itself. As these systems are, themselves, the subject of ongoing discussion and edits, a treatment framework that relies on diagnosis may incorrectly distinguish categories that are actually variations of broader underlying syndromes (Barlow et al., 2004; Brown et al., 1998). Further, only about 50% to 80% of patients who receive treatment for emotional disorders achieve clinically significant improvement (Barlow et al., 2004), which means that 20% to 50% of individuals do not experience improvement. These results imply that current CBT approaches may not fully address the full range of mechanisms suggested by disorder-specific presentations. Recent developments in the etiological models of mental disorders have shifted focus away from diagnosis-specific interventions and toward transdiagnostic modalities in an effort to rectify the weaknesses evident in diagnosisspecific treatment modalities. Rather than create and implement a specific treatment for each diagnostic disorder, transdiagnostic treatment approaches apply the same underlying treatment principles across mental disorders. Transdiagnostic models decrease the importance placed on disorder-specific symptoms and instead emphasize the underlying mechanisms and processes related to mental disorders in general. In transdiagnostic theoretical frameworks, there is a focus on underlying processes that will reduce comorbid disorders through the use of generalized and flexible treatment approaches that promote coping strategies and treatment principles that can be broadly applied to daily life (McEvoy et al., 2009). Although most current transdiagnostic models and therapies examine the influence of multiple processes on a range of different disorders (Norton & Paulus, 2016), other transdiagnostic models exist that evaluate mechanisms that underlie specific symptoms across diagnostic labels and that



Theoretical Framework  43

examine universal processes that underpin psychopathology (Mansell et al., 2009; Norton & Paulus, 2016). Transdiagnostic therapies have been established with one of two primary approaches (Clark & Taylor, 2009; Norton & Paulus, 2016). The pragmatic approach to transdiagnostic treatment development involves a reliance on clinical intuition, as well as trial and error, and the commensurate consideration of whether a treatment for one disorder may be effective for another (Clark & Taylor, 2009; Norton & Paulus, 2016). For example, a treatment technique found to be effective for one anxiety disorder may be applied to another anxiety disorder to examine whether it can be used across diagnoses. In contrast, the theory-driven approach employs a bottom-up framework to treatment development. This approach involves identification of core processes that underlie several disorders or clinical presentations and then development of treatment modalities on the basis of those processes (Clark & Taylor, 2009; Norton & Paulus, 2016). Transdiagnostic treatment from this perspective focuses on processes across the domains of attention, memory, imagery, thinking, reasoning, and behavior that have been found to commonly maintain distress in people with psychological disorders (Patel et al., 2015). The most recent CBT developments have moved to emphasize underlying cognitive mechanisms and processes rather than symptom presentation (Hayes & Hofmann, 2017, 2018). With recent advances in theory and treatment, fundamental components that can be deployed in the treatment of emotional disorders, broadly speaking, have been developed. Transdiagnostic therapeutic principles have been highlighted by Barlow and colleagues (2004, 2011) and are implemented in a similar context as diagnosis-specific CBT protocols, such as the encouragement of emotional expression through exposure exercises. Specifically, the goal of the therapy is to alter cognitive appraisal that precedes varied emotional disturbance and, in doing so, discourage emotional avoidance and encourage actions not associated with the aversive emotion. These treatment approaches go beyond traditional CBT approaches in that they target cognitive, behavioral, and emotional avoidance tendencies (Barlow et al., 2004; Dobson & Dobson, 2017). The successful provocation of emotions in order to implement treatment components is conceptualized as the mechanism of action in this treatment modality (Barlow et al., 2004). Such treatment components target factors such as the ability to regulate emotions and increased attentional control and flexibility (Hayes et al., 2011). Transdiagnostic treatments target their therapy components toward broad and flexible techniques that can be adapted to a number of different clinical presentations. These treatments have shown similar efficacy to that of diagnosis-specific treatments (Barlow et al., 2017).

SUMMARY AND CONCLUSIONS This chapter has reviewed the theoretical foundations of the cognitive behavioral family of interventions. The CBTs are a diverse group of interventions

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that have developed over the years, drawing upon a wide variety of theoretical principles (Dobson & Dozois, 2019). Despite the diversity among traditional and contemporary CBTs, all maintain that cognitive processes, emotions, and behaviors are interdependent. The conceptual principles of CBT have grown from early to contemporary CBT modalities. Behavior therapy initiated a movement in clinical psychology and psychiatry that moved clinical applications of psychology toward evidence-based and empirical models of therapeutic interventions. The bidirectional movement and amalgamation of behavior and cognitive therapies in the early 1900s allowed for the preservation of the empirical foundations of behavioral interventions, even as it incorporated cognitive activities into similar behavioral laws. This evolution permitted cognition to be modified using similar overt strategies as behavioral interventions and allowed for the development of the three fundamental principles of the traditional CBT models: (a) cognitions affect behavior, (b) cognition can be monitored and altered, and (c) behavior change may be affected through cognitive change. More recent developments within CBTs include an emphasis on context and functional processes associated with psychopathology, as opposed to a focus on cognitive content. Although there has been debate over whether approaches such as mindfulness, ACT, and metacognitive therapy constitute forms of CBTs, their conceptual foundations and therapeutic techniques can be linked and related to the CBT family (Beck, 1967; Hofmann et al., 2010). Differences among specific therapies can be conceptualized according to which stage of emotional processing the therapeutic intervention targets. Earlier CBTs tend to emphasize antecedent-focused strategies to modify unhelpful cognitive content, whereas contemporary CBT models implement response-focused interventions to decrease experiential avoidance and suppression (Hofmann & Asmundson, 2008). Differences in cognition have been identified to play an important role in the way in which CBTs organize their therapeutic techniques and outcome variables. Two approaches to cognition have been conceptualized and implanted into CBTs. According to the GCM (Beck & Haigh, 2014), schemas specific to an individual’s beliefs and goals affect the manner in which they process information. When the ability of an individual to process information becomes distorted, the risk of psychopathology increases, as it interferes with and alters their ability to engage in adaptive thought and emotional and behavioral processes. The GCM’s conceptualization of cognition offers a framework to evaluate whether the content of an individual’s thoughts or behaviors are adaptive or maladaptive, permitting clinicians to apply cognitive and behavioral strategies to “correct” or “adjust” these distortions. In contrast, RFT (Hayes et al., 2001) conceptualizes cognition in terms of its meaning and function. Language and verbal capabilities allow individuals to draw connections and associations between symbolic and arbitrary cues and personal experiences (Hayes et al., 2011; Hughes & Barnes-Holmes, 2016). As a result, CBTs that align with process- or context-oriented conceptualizations of cognition tend to be associated



Theoretical Framework  45

with therapeutic strategies targeting awareness and acceptance of thought, emotions, and behaviors in order to improve behavioral and cognitive flexibility and mitigate distress. The shift from diagnosis-specific to transdiagnostic CBT modalities reflects the shift toward more generic models of psychopathology. Early CBT models postulated that each specific disorder was associated with unique content-specific presentations and cognitive characterizations (Beck, 1967), and therapies were developed and implemented to target specific disorder presentations. However, due to the continuing controversies associated with diagnostic nosology (Lilienfeld & Treadway, 2016), new etiological models of psychological disorders have been theorized that highlight common underlying processes associated with psychopathology in general. Novel treatment approaches attempt to bridge this shift, and transdiagnostic therapies have been created with broad and flexible techniques that can be implemented across many disorder presentations. The transdiagnostic approach to CBT appears to demonstrate efficacy in the treatment of a range of disorders (Farchione et al., 2012; McEvoy et al., 2009; Reinholt & Krogh, 2014). There is a growing scholarly literature devoted to the future of CBT (e.g., Hayes, 2016; Persons, 2016; Thompson-Hollands et al., 2014). Transdiagnostic models and theories are commonly cited as a critical direction for the CBTs. The classification of diagnoses as discrete categories has been shown to decrease validity and undermine common core mechanisms found among disorders (Barlow et al., 2004; Mansell & Taylor, 2012; Thompson-Hollands et al., 2014). CBTs that are refined in the future may emphasize transdiagnostic moderators and mediators, such as temperament or motivation, in order to circumvent some of the perceived limitations of more specific treatment models (Hayes, 2016; Thompson-Hollands et al., 2014). Process-oriented models in CBT (e.g. Hayes & Hofmann, 2017, 2018) may also deemphasize the importance of syndromic classification systems. Consistent with transdiagnostic models of treatment, process-oriented models will encourage research, theory, and treatments related to generic psychopathological mechanisms. This said, transdiagnostic and process-oriented approaches to treatment should be grounded on the recent developments of cognitive, behavioral, emotional, and neuroscience research to optimally identify the mechanisms of psychopathology. These models also must tailor their interventions to the unique presentation of a given patient in order to maximize the fit, utility, and acceptability of therapy (Thompson-Hollands et al., 2014). Future directions in CBT may shift to a more flexible framework that adopts a predominantly process-oriented or transdiagnostic approach but also embodies the foundational importance of case conceptualization at the heart of evidence-based practice. REFERENCES Bandura, A. (1977). Social learning theory. Prentice-Hall. Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35(2), 205–230. https://doi.org/dgqwsf

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Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https:// doi.org/10.1017/S1352465808004815 Lazarus, R. S. (1982). Thoughts on the relations between emotion and cognition. American Psychologist, 37(9), 1019–1024. https://doi.org/10.1037/0003-066X.37.9. 1019 Lewinsohn, P. M., Biglan, A., & Zeiss, A. S. (1976). Behavioral treatment of depression. In P. O. Davidson (Ed.), The behavioral management of anxiety, depression and pain (pp. 91–146). Brunner/Mazel. Lilienfeld, S. O., & Treadway, M. T. (2016). Clashing diagnostic approaches: DSM-ICD versus RDoC. Annual Review of Clinical Psychology, 12, 435–463. https://doi.org/10. 1146/annurev-clinpsy-021815-093122 Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27(2), 173–187. https://doi.org/10. 1016/j.cpr.2006.08.001 Mansell, W. (2008). The seven C’s of CBT: A consideration of the future challenges for cognitive behavior therapy. Behavioural and Cognitive Psychotherapy, 36(6), 641–649. https://doi.org/10.1017/S1352465808004700 Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy, 23(1), 6–19. https://doi.org/10.1891/0889-8391.23.1.6 Mansell, W., & Taylor, J. L. (2012). What is CBT and what isn’t CBT. In W. Dryden & R. Branch (Eds.), The CBT handbook (pp. 5–24). Sage. Markin, R. D. (2014). Toward a common identity for relationally oriented clinicians: A place to hang one’s hat. Psychotherapy: Theory, Research, & Practice, 51(3), 327–333. https://doi.org/10.1037/a0037093 McEvoy, P. M., Nathan, P., & Norton, P. J. (2009). Efficacy of transdiagnostic treatments: A review of published outcome studies and future research directions. Journal of Cognitive Psychotherapy, 23(1), 20–33. https://doi.org/10.1891/0889-8391. 23.1.20 Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy: Theory, Research, & Practice, 48(1), 4–8. https://doi.org/10.1037/ a0022180 Norton, P. J., & Paulus, D. J. (2016). Toward a unified treatment for emotional disorders: Update on the science and practice. Behavior Therapy, 47(6), 854–868. https://doi.org/10.1016/j.beth.2015.07.002 Patel, T., Mansell, W., & Veale, D. (2015). The cognitive behavioral processes questionnaire: A preliminary analysis within student, mixed clinical and community samples and the identification of a core transdiagnostic process. Cognitive Therapy and Research, 39(2), 193–203. https://doi.org/10.1007/s10608-014-9641-9 Persons, J. B. (2016). Science in practice in cognitive behavior therapy. Cognitive and Behavioral Practice, 23(4), 454–458. https://doi.org/10.1016/j.cbpra.2016.01.003 Reinholt, N., & Krogh, J. (2014). Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: A systematic review and meta-analysis of published outcome studies. Cognitive Behaviour Therapy, 43(3), 171–184. https://doi.org/10. 1080/16506073.2014.897367 Riskind, J. H., & Alloy, L. B. (2006). Cognitive vulnerability to emotional disorders: Theory and research design/methodology. In L. B. Alloy & J. H. Riskind (Eds.), Cognitive vulnerability to emotional disorders (pp. 1–29). Erlbaum. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Basic Books. Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In S. C. Hayes, V. M., Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 45–65). Guilford Press.

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Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press. Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275–287. https://doi.org/ 10.1037/0022-006X.70.2.275 Thompson-Hollands, J., Sauer-Zavala, S., & Barlow, D. H. (2014). CBT and the future of personalized treatment: A proposal. Depression and Anxiety, 31(11), 909–911. https://doi.org/10.1002/da.22301 Wells, A. (2008). Metacognitive therapy: Cognition applied to regulating cognition. Behavioural and Cognitive Psychotherapy, 36(6), 651–658. https://doi.org/10.1017/ S1352465808004803 Wilson, K. G., Bordieri, M. J., Flynn, M. K., Lucas, N. N., & Slater, R. M. (2011). Understanding acceptance and commitment therapy in context: A history of similarities and differences with other cognitive behavior therapies. In J. D. Herbert & E. M. Forman (Eds.), Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies (pp. 233–263). John Wiley & Sons. https://doi.org/10.1002/9781118001851.ch10 Wilson, K. G., & Murrell, A. R. (2002). Functional analysis of behavior. In M. Hersen & W. H. Sledge (Eds.), Encyclopedia of psychotherapy (pp. 833–839). Academic Press.

3 The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, Pim Cuijpers, and Claudi L. H. Bockting

D

iagnoses of depressive and anxiety disorders are among the most common and disabling health conditions worldwide (Murray et al., 2012; World Health Organization, 2017). It was once thought that these conditions could only be treated with pharmacological therapies or that they required lengthy and intensive talking cures. The advent and empirical evidence for cognitive behavioral therapies (CBTs) changed this and suggested that brief therapies that were symptom focused and emphasized themes of the present could efficaciously target symptoms of internalizing pathologies (Rush et al., 1977). The development of CBTs can be traced back to the work of Ellis (1962) and Beck (1963), who highlighted the role of biased thinking processes in the onset and maintenance of psychopathology. Consequently, Beck and Ellis developed therapeutic protocols, cognitive therapy (CT) and rational therapy, respectively, that addressed biases in thinking by the use of psychoeducation and logicorational procedures as well as behavioral strategies aimed at changing cognition. With posterity, these therapies have been branded as the “second wave” of CBTs in an attempt to describe historical changes in the field. Beck has twice expanded the theory that underlies CBTs (Beck, 1996; Beck & Haigh, 2014), but the core principles remain much the same. The historical precursors to the CBTs were the behavior theories that ignored or downplayed the role of cognition in influencing behavior, now sometimes referred to as the “first wave” of CBTs. The behavior therapies, which focused on associative and nonassociative learning models, highlighted that overt behavioral changes were the primary goal of therapy. https://doi.org/10.1037/0000218-003 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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There have been at least two attempts to succeed the “traditional” or second wave CBTs, which were focused on changing behaviors as well as altering the content of beliefs, thinking patterns, and other underlying cognitive vulnerabilities. One is the so-called third wave of CBTs, characterized by acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and other less commonly practiced and researched therapies like competitive memory training (Dimidjian et al., 2016). If there is a commonality to these therapies, it is that their stated aim is not to change the content of the person’s thoughts but to change their internal responses and relations to the thoughts. An additional point of commonality among the third-wave CBTs is that they use therapeutic techniques that had hitherto been “reserved for the less empirical wings of clinical intervention and analysis, emphasizing issues as acceptance, mindfulness, cognitive defusion, dialectics, values, spirituality, and relationship” (Hayes, 2004, p. 640). Other therapies are more ambiguously categorized as third-wave therapies, such as behavioral activation (BA) or dialectical behavioral therapy (DBT), the latter of which has more evidence as a treatment for nonsuicidal self-injury or borderline personality disorder than for depression or anxiety. The second advancement in the conceptualizations and treatment of depression and anxiety with CBT concerns the development of transdiagnostic CBT treatments. In the past decades, disorder-specific treatment-CBT protocols have been developed for anxiety disorder, depressive disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). These protocols describe different interventions, although they all share a cognitive behavioral model. Transdiagnostic CBT protocols aim to target the underlying vulnerability to negative affectivity as opposed to addressing symptoms of single disorders. Among the best studied of these is Barlow’s Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders (Barlow, Farchione, SauerZavala, et al., 2017). The UP emphasizes the shared CBT interventions to treat mental health disorders instead of disorder-specific interventions. As its name implies, the UP is a single treatment protocol that applies to depression, the anxiety disorders, OCD, and PTSD. Because the UP is a single protocol that can be used across a range of problems that are frequently comorbid, one of its aims is to be more user friendly for clinicians and patients. The family of CBTs is arguably the best studied group of psychological interventions for anxiety and depression. Hofmann et al. (2012) identified 269 meta-analytic studies examining the efficacy of CBTs for a wide range of mental disorders (e.g., substance use disorders, somatoform disorders), as well as depression and anxiety. They concluded that there was strong support for the efficacy of CBTs for anxiety disorders and mixed support for CBTs for depression, with some studies finding very strong support and other studies suggesting that these effects are overestimated. In addition, they concluded that for somatoform disorders, bulimia, anger control problems, and general stress, there is strong support for the efficacy of CBT. Although CBT for bulimia was considerably more effective than other forms of interventions, less is known for



The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders  53

other eating disorders. For bipolar disorder, the efficacy of CBT was small to medium in comparison with treatment as usual, although the treatment of depressive symptoms within bipolar disorder was well supported. For the treatment of substance use disorders, the effect sizes of CBT ranged from small (for opioid and alcohol dependence) to medium (for treating cannabis and nicotine dependence). For treating schizophrenia and other psychotic disorders, CBT was especially effective in reducing the positive symptoms and secondary outcomes in the psychotic disorders. However, for this population, CBT was less effective than medication and family interventions. For personality disorders, studies showed considerable variation, but there was some evidence for superior efficacy of CBT as compared with other psychosocial treatments. Subsequent meta-analytic reviews have by and large confirmed these findings. For example, CBT appears to be one of the most efficacious treatments available for bulimia, outperforming interpersonal psychotherapy (IPT) as well as other psychosocial interventions (Linardon et al., 2017). Similarly, CBT for psychosis may be especially effective at reducing positive symptoms when compared with nontreatment controls, standardized mean difference (SMD) = −0.29, 95% CI [−0.55, −0.03]; treatment as usual (TAU), SMD = −0.30, 95% CI [−0.45, −0.14]; or supportive therapy, SMD = −0.47, 95% CI [−0.91, −0.03], though the quality of this evidence is relatively low (Bighelli et al., 2020). For the purpose of the current chapter, we provide an updated summary of the state of the evidence of CBTs for emotional disorders, including major depressive disorder and anxiety as well as its historically related disorders, OCD and PTSD, which were only recently removed from the category of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). We focus on these internalizing disorders because they are among the most common and better studied of the DSM-5 disorders.

METHOD Using search terms similar to those of Hofmann et al. (2012), we systematically searched three databases (PubMed, PsycInfo, and Cochrane) for potentially relevant papers that were published in English in peer reviewed journals between fall 2011 and summer 2018. Specifically, we crossed search terms indicating article type (meta-analysis/quantitative review) with terms indicating the type of intervention (CBTs) and the target problems (e.g., depression, OCD). A full search string can be found in Appendix 3.1. In order to be included, papers had to be quantitative reviews (i.e., metaanalyses, not research papers, qualitative reviews, theoretical essays, commentaries, or replies) of various CBTs (C[B]T, BA, ACT, MBCT, exposure) for patients (all ages) with a diagnosis of a depressive and/or anxiety disorder (including OCD and PTSD) that were delivered either individually or in group format. Meta-analyses that did not include an outcome measure of depression/anxiety

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severity were excluded, as were those that focused on purely self-guided or internet-/web-/chat-/text-/email-delivered CBTs. Furthermore, we excluded studies that focused on primary prevention. For meta-analyses with a focus on psychotherapy or psychological interventions in general, we examined the proportion of CBT studies included. If this was at least 90%, or if authors reported subgroup analyses on the CBTs, the manuscript was included. For papers that later were corrected (corrigendum), we included only the corrected version (see Appendix 3.2 for more details). Our initial search yielded 1,281 hits, of which 319 were duplicates and had to be excluded. Of the 962 unique articles that were identified, 851 did not meet our inclusion criteria and were therefore excluded. A total of 111 papers met inclusion criteria and were selected for further review. We asked several experts with long-standing experience in the research field and clinical practice to check the list that was generated and to provide us with additional relevant papers. This led to the addition of eight papers, resulting in a total of 119 papers that were further explored. The full list of references can be found in Appendix 3.3. A selection of these studies is discussed in more detail in the next section. As relevant, we also discuss earlier landmark randomized controlled trials (RCTs), theoretical reviews, and older meta-analyses when we could not find more recent ones. Although our search was focused on meta-analyses studying the efficacy of CBT across age groups, here we focus the discussion on CBT for adult populations.

RESULTS The majority of the data in this section are presented in terms of effect sizes, which characterize the magnitude of the effect under investigation. Table 3.1 presents remission rates for key mental health disorders described in this chapter to help the reader understand the percentage of people who achieve remission following a course of CBT. Major Depressive Disorder Overall Effects Cuijpers and his colleagues have built an online database of clinical trials exploring the efficacy of psychotherapies for depression including CBTs (Cuijpers, van Straten, et al., 2008). Various meta-analytic reviews have been the product of this data set (Cuijpers, Andersson, et al., 2011). By and large, these meta-analyses show that the effects of CBTs for depression are large, g = −0.98, 95% CI [−1.17, −0.80], when contrasted to wait list control conditions (WLCs; Cuijpers, Cristea, et al., 2016). These meta-analyses also support the efficacy of CBT relative to TAU, although the differences tend to be more modest, g = −0.60, 95% CI [−0.75, −0.45]. Meta-analyses have also supported the idea that although CBT for major depressive disorder is efficacious, its effects have been overestimated because of publication bias (Cuijpers, Berking, et al., 2013).



The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders  55

TABLE 3.1. Mean Remission Rates Reported in Studies of Cognitive Behavioral Therapy (CBT) for Depressive and Anxiety Disorders

n

Mean

95% CI

Major depression

17

66%

58%–73%

Generalized anxietyb

3

51%

36%–67%

Social anxietyb

10

40%

30%–51%

Panic or agoraphobiab

13

48%

40%–56%

PTSDb

20

53%

45%–61%

OCDb

6

38%

31%–45%

a

Note. CI = confidence interval, PTSD = posttraumatic stress disorders, OCD = obsessivecompulsive disorder. All rates reported for intent-to-treat (ITT) samples. a Cuijpers, Karyotaki, et al. (2014) definition: not meeting criteria for major depression after therapy. bSpringer et al. (2018) study-specific remission criteria including not meeting diagnostic criteria, good functioning, a score below a threshold, or a combination of criteria.

There are no indications that CBT is more or less efficacious than other psychotherapies or pharmacotherapy (Cuijpers, Andersson, et al., 2011). Fewer comparisons against pill or psychological placebos exist, and, as with the comparisons to TAU, the data suggest a statistically significant but more modest advantage of CBT. Some meta-analyses (e.g., Cuijpers, Cristea, et al., 2016) provide an optimistic estimate of the effects of CBT versus placebo, g = −0.55, 95% CI [−0.81, −0.28], albeit with a small number of studies (n = 5). Other meta-analyses have painted a more modest picture of the relative effects of CBT versus placebo, g = −0.33, 95% CI [−0.50, −0.16], though these effects seem comparable to antidepressant medication (Cuijpers, Turner, et al., 2014). Study features other than the control group appear to inflate the efficacy of CBT. Notably, CBT appears more efficacious than control conditions in lower quality studies (e.g., those that do not adequately generate the randomization sequence, have suboptimal concealed allocations for participants and personnel, handle missing data by using completers analyses; see also risk of bias assessment tool by Higgins & Green, 2008), as well as in studies that are conducted by proponents of CBTs, and studies with higher effect sizes are more likely to get published, thus inflating outcomes (see also Cuijpers, Andersson, et al., 2011). Group formats appear as efficacious as the individual format, though Feng et al. (2012) noted that there are few studies assessing the relapse-prevention effect seen in individual CBT for acute depression. Combining CBT and antidepressants leads to superior outcomes versus providing either treatment as a monotherapy, although the difference is small in magnitude (Tolin, 2017). Interpersonal Psychotherapy Aside from supportive therapy, the psychotherapy that CBT has been most frequently compared with is IPT. In a meta-analysis of 10 RCTs, Zhou et al. (2017) reported a small difference favoring CBT over IPT on the Beck Depression Inventory–II (BDI-II; Beck et al., 1996) but not on the Hamilton Rating Scale for Depression (Hamilton, 1960). This difference of 1.31 BDI-II points

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(SD = 0.12–2.49) falls below most of the conventional thresholds for clinical significance (Button et al., 2015). The authors cautioned against interpreting the findings from these 10 studies, as they were dependent on the outcome measures utilized and run counter to prior findings of meta-analytic summaries showing no differences between CBT and IPT (Cuijpers, Donker, et al., 2016; Cuijpers, Geraedts, et al., 2011; Lemmens et al., 2015). Severe Depression The report from the landmark Treatment for Depression Collaborative Research Program (TDCRP: Elkin et al., 1989) suggested that CBT was equally efficacious as placebo plus clinical management for patients with severe depression, whereas the other treatment conditions (IPT and antidepressants) outperformed CBT and the control. Although the TDCRP has been variously criticized, its findings led to skepticism regarding the use of CBT for this patient subgroup, formally instantiated in specific treatment guidelines suggesting that CBT monotherapy should be reserved for mild to moderate, but not severe, depression. A subsequent trial comparing BA, CBT, placebo, and antidepressants found similar results (Dimidjian et al., 2006). In that study, there were no differences between the four treatment conditions for patients with mild to moderate depression, which was defined as an HRSD ≥ 20. By way of contrast, for patients with severe depression, the outcomes for the BA condition were quite positive. Response rates on the BDI-II, for example, were 76% in BA, 46% in CT, and 49% receiving antidepressants. This finding renewed concerns regarding the efficacy of CBT for severe depression but suggested that BA may be a particularly potent treatment for severe major depressive disorder. However, not all studies suggest skepticism regarding the efficacy of CBT for severe depression. DeRubeis et al. (2005) randomized patients with moderate to severe depression to CBT or antidepressants for 16 weeks in a trial that included an 8-week placebo control. At 8 weeks, response rates in medications (50%) and CBT (43%) groups were both superior to the placebo (25%) group. At the end of treatment, 58% of patients in CBT and 58% of the patients in antidepressants had responded. Furukawa et al. (2017) approached the question of the effects of CBT for severe depression by conducting an individual patient data meta-analysis (IPD-MA). An IPD-MA pools together the individual patient-level data as opposed to the study-level averages, allowing researchers to test for the effect of symptom severity on individual-level outcomes. They added five studies comparing CBT to placebo (n = 509) but failed to find any baseline severity by treatment interaction in predicting outcomes, indicating that the effects of CBT versus placebo do not vary according to baseline severity (Furukawa et al., 2017). Another IPD-MA of 16 studies comparing antidepressant monotherapy to CBT also failed to find a severity by treatment interaction when comparing antidepressants and CBT. This same IPD-MA, however, reported a main effect of antidepressant monotherapy over CBT roughly equivalent to a 1-point dif-



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ference on the HRSD, as well as a nonsignificant trend similarly equivalent to a 1-point difference on the BDI and BDI-II. The authors of the study call into question the clinical significance of the finding of a superiority of antidepressants over CBT. However, the small superiority of antidepressants over CBT is the product of pooling together trials in which the effects of CBT have varied by site (DeRubeis et al., 2005), severity (Dimidjian et al., 2006), and both site and severity (Elkin et al., 1989). This highlights that whereas CBT for depression is efficacious on average, its performance can be highly variable across studies. Overall, there is evidence that CBT for depression is feasible and efficacious for the whole range of severity, although there is also evidence indicating a small superiority of antidepressants over CBT alone. Long-Term Effects Perhaps the most promising finding regarding acute treatment with CBT is that acute treatment has relapse-prevention effects that persist following acute treatment. These effects are noteworthy in light of the high probability of relapse for patients in clinical settings. Cuijpers, Hollon, et al. (2013) reviewed studies in which long-term outcomes of acute-phase CBT were compared with the effects of pharmacotherapy when it was discontinued or continued over the long term. They identified nine studies in which acute-phase CBT was compared with pharmacotherapy delivered acutely but withdrawn at the long-term follow-up. Patients who received acute CBT were less likely to go on to relapse than those who received antidepressant medication and had it discontinued, OR = 2.61, 95% CI [1.58, 4.31]. Further, a trend in the data (based on five studies) suggested that acute CBT was superior to keeping patients on pharmacotherapy, OR = 1.62, 95% CI [0.97, 2.72]. These findings were confirmed by a subsequent meta-analysis including mostly CBT studies, though the protective effect significantly decreased over follow-up time of longer than 6 months (Karyotaki, Smit, de Beurs, et al., 2016). Moreover, another meta-analysis demonstrated that adding psychotherapy to antidepressants resulted in better long-term outcomes as compared with antidepressants alone, OR = 3.02, 95% CI [1.74, 5.25] (Karyotaki, Smit, Holdt Henningsen, et al., 2016). Interestingly, this same meta-analysis did not find that long-term outcomes were superior with combined treatment relative to psychotherapy alone, OR = 1.51, 95% CI [0.79, 2.86]. Most people who seek help for their depression are treated with antidepressants (Olfson & Marcus, 2009). Within this context, preventive cognitive interventions have specifically been developed that start after full or partial recovery/ remission from antidepressants to prevent relapse and recurrence. MBCT and preventive cognitive therapy (PCT) are mostly studied in the past decades (Biesheuvel-Leliefeld et al., 2015, 2017; Bockting et al., 2005, 2009, 2018; Bockting, Smid, et al., 2015; Klein et al., 2018; Teasdale et al., 2000). Both MBCT and PCT consist of eight sessions given in 8 weeks (Bockting, Hollon, et al., 2015). PCT and MBCT are efficacious in preventing relapse and recurrence over follow-ups of at least 1 year and up to 10 years (for meta-analyses, see

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Biesheuvel-Lelieveld et al., 2015; Guidi et al., 2016; Kuyken et al., 2016; Piet & Hougaard, 2011; Vittengl et al., 2007). Results from several RCTs have shown that PCT and MBCT are suitable alternatives for continuation of antidepressants in remitted individuals with multiple previous episodes (Bockting et al., 2018; Kuyken et al., 2008, 2015; Segal et al., 2010). However, a three-arm RCT demonstrated that adding PCT to continuation of antidepressants after recovery resulted in the lowest relapse risk as compared with continuation of antidepressants alone and to PCT alone. The combination of PCT and antidepressants resulted in an additional 41% risk reduction as compared with antidepressants alone (Bockting et al., 2018), whereas no significant risk reduction was found in an RCT comparing adding MBCT to antidepressants and antidepressants alone (Huibers et al., 2015). Continuation of only antidepressant use was not better than PCT for relapse over 2 years. Some meta-analyses have found evidence that the preventive effect of these relapse-prevention interventions is mainly found in individuals with more recurrent depression (defined as more than one or more than two prior episodes; Piet & Hougaard, 2011). Others have failed to find a moderating effect of previous episodes (e.g., Biesheuvel-Lelieveld et al., 2015), including an IPD-MA pooling individual study data of 1,258 patients (Kuyken et al., 2016). The theory of change underlying MBCT for depression proposes that the intervention targets vulnerability to depression relapse and that its effect should be pronounced among those with more prior episodes. Interestingly, the Kuyken et al. (2016) analysis suggested that the superiority of MBCT relative to controls may be pronounced among individuals with greater residual symptoms following acute treatment. Anxiety Disorders Overall, meta-analytic results support the efficacy of CBTs for anxiety, OCD, and PTSD relative to waiting lists and TAU, the control conditions to which they have most frequently been compared. Fewer studies include a pill or psychological placebo-controlled comparison, but these studies also support the efficacy of CBT for anxiety and related disorders (Carpenter et al., 2018). In addition to yielding improvements in symptom-specific measures, CBT seems to lead to improvements in quality of life (Hofmann et al., 2014). Generalized Anxiety Disorder Cuijpers, Sijbrandij, et al. (2014) conducted a meta-analysis of all existing psychotherapies for generalized anxiety disorder (GAD). Most (85%) of the 41 studies included a CBT arm, indicating that CBT is the most widely researched psychological therapy for GAD, but also highlighting the need for more comparative outcome research. Although the data supported the efficacy of CBTs for GAD, most of the studies used a waiting list as a control. There were not enough studies to evaluate the long-term effects of CBT for GAD or its effect relative to other treatments. In the most recently published



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meta-analysis on pill- or psychological placebo-controlled RCTs, only two studies of CBT for GAD were identified (Carpenter et al., 2018). Both supported the efficacy of CBT for GAD, but both were very small studies. Cuijpers, Cristea, et al. (2016) reported large effects of CBT for GAD when compared with waiting list controls, g = −0.85, 95% CI [−0.99, −0.72], or placebos, g = −1.32, 95% CI [−1.81, −0.83], with smaller effects in comparison with TAU, g = −0.45, 95% CI [−0.64, −0.26]. Hanrahan et al. (2013), in a prior review, found somewhat larger effects of CBT versus nontherapeutic (e.g., waiting list) controls, d = −1.81, 95% CI [−2.37, −1.26]. These authors noted that the treatment effect size is higher relative to other meta-analyses and that outcome studies investigating the efficacy of newer forms of CBT may be the explanation for the higher effect size. For example, unlike Cuijpers, Cristea, et al. (2016), they included metacognitive therapy, which is distinct in its addressing of metacognitive beliefs about worry, in their analyses. Although the data support the efficacy of CBT for GAD, more comparative research is needed, particularly with newer forms of CBT. Specific Phobias Meta-analytic estimates from years not covered in the scope of our review suggest that CBT, particularly in vivo exposure, is an evidence-based treatment for specific phobias, outperforming inactive and psychological placebo controls (Wolitzky-Taylor et al., 2008). The effects of exposure relative to a waiting list control are large, d = −1.03, 95% CI [−1.16, −0.91]. We could not locate a newer meta-analytic estimate of the effect of CBT for this target group against placebo (Carpenter et al., 2018), but the meta-analysis by Wolitzky-Taylor et al. (2008) suggested a medium effect, d = −0.48, 95% CI [−0.72, −0.25]. CBT also appears to be superior to relaxation therapy in the treatment of specific phobias, with a small effect-size advantage, d = −0.22, 95% CI [−0.42, −0.03] (Montero-Marin et al., 2018), although the authors noted that these results were sensitive to the number and quality of studies included. One advancing trend in the treatment of specific phobias is the use of virtual reality (VR) as the setting for exposure to feared stimuli. VR may have particular advantages when access to the feared stimuli is expensive or difficult to obtain (e.g., spiders, flying) or as an intermediate step for in vivo exposure. Overall, specific phobia virtual reality exposures are efficacious as compared with WLC (Morina et al., 2015; Opriş et al., 2012), even when just considering improvements on behavioral approach tasks (Morina et al., 2015). Interestingly, in the few studies testing virtual reality exposure against in vivo exposure, there were no significant differences between the modalities in efficacy at termination or follow-up (Morina et al., 2015; Opriş et al., 2012). Social Anxiety Disorder Cuijpers, Cristea, et al. (2016) reported that the effects of CBTs for social anxiety relative to waiting lists were large, g = −1.00, 95% CI [−1.40, −0.61]. The effects of CBT for social anxiety versus TAU, g = −0.47, 95% CI [−0.77, −0.12],

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n = 3, or placebos, g = −0.47, 95% CI [−0.70, −0.24], n = 5, were in the medium range and appeared similar in magnitude, though there were few studies available to make the comparison. When the authors restricted the analyses to studies that met their specific designation of “high quality” and to those that were also compared with TAU or a pill placebo, there were not enough studies available to assess the efficacy of CBT for social anxiety disorder. Other meta-analyses also support the efficacy of CBT for social anxiety when compared with controls (Carpenter et al. 2018), as well as the comparable efficacy of individual CBT versus group-based CBT (Wersebe et al., 2013). Mayo-Wilson et al. (2014) conducted a systematic review and network metaanalysis of psychological and pharmacological treatments for adults with social anxiety disorders, including CBTs. Network meta-analysis differs from traditional meta-analysis in that it provides a quantitative summary of the effects of multiple interventions (e.g., CBT, IPT, antidepressants) across studies making different comparisons (e.g., CBT vs. IPT vs. a waiting list in one study, CBT vs. a waiting list in another study, and IPT vs. antidepressants in another one study). It can provide a summary of the expected difference between treatments directly based on comparisons that are available as well as indirectly based on treatment having a shared comparator (e.g., the comparison of CBT vs. WLC and IPT vs. WLC allows an estimation of the expected difference between CBT vs. IPT). Mayo-Wilson et al. (2014) distinguished between individual CBT (i.e., combining behavioral strategies such as cognitive restructuring and exposure), group CBT, and exposure plus social skills training (i.e., in which the aim was behavioral training devoid of explicit cognitive training). The authors reported that all these CBT interventions were more efficacious than WLC. Of note, individual CBT was the only intervention that also had a greater effect on outcomes than interventions that were classified as psychological placebos, pill placebos, psychodynamic therapy, and “other therapies” (e.g., IPT). Mayo-Wilson et al. found that CBT according to the Clark and Wells (1995) model, which highlights the negative processing of the self with a special focus on self-focused attention, tended to produce the largest effects. Panic Disorder With or Without Agoraphobia In a Cochrane Review, Pompoli et al. (2016) reviewed the effects of psychological therapies for panic with or without agoraphobia on symptomatic remission. More than half of the 54 studies included CBT (n = 32), pure behavior therapy (n = 12), pure cognitive therapy (n = 3), or third-wave CBTs (n = 2). By and large, results supported the efficacy of CBTs for panic disorder relative to WLC. Additionally, the authors found that across 10 studies, the full course of CBT appeared to be more efficacious than pure behavior therapy. The authors noted that more comparisons to other treatments (e.g., psychodynamic therapy) are needed. In another review by the same group, Pompoli et al. (2018) used component network meta-analysis to identify efficacious elements of CBT for panic disorder. Component network meta-analysis is an extension of standard network meta-analysis in which the effect of an intervention (e.g., CBT vs. WLC)



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is assumed to be the sum of different components of the intervention. For example, in some studies, CBT consists of psychoeducation, breathing retraining, cognitive restructuring, interoceptive exposure, and in vivo exposure, whereas in other studies, it is simply done via psychoeducation, interoceptive exposure, and in vivo exposure. Network meta-analysis attempts to elucidate the incremental effect of components by examining differences in outcomes between studies that do and do not include specific components. The results of this meta-analysis suggest that the most efficacious CBT for panic disorder would be one that is delivered face-to-face and with psychoeducation, psychological support, cognitive restructuring, and interoceptive exposure. In their comparison to relaxation therapy, Montero-Marin et al. (2018) found differences between CBT and relaxation therapy only for panic disorder at the long-term follow-up. Thus, despite evidence that CBT for panic disorder is efficacious, including indications that its specific cognitive and behavioral ingredients are efficacious, there is certainly room for improvement in terms of its efficacy relative to treatments that are often intended to be nonspecific. Posttraumatic Stress Disorder CBT for PTSD exists as trauma-focused CBTs and non-trauma-focused CBTs. In the trauma-focused category, the three major CBT treatments for PTSD are prolonged exposure (PE; Foa & Rothbaum, 1998), cognitive processing therapy (CPT; Resick et al., 2002), and trauma-focused CBT (TF-CBT; J. A. Cohen et al., 2006). Questions have been raised regarding whether eye-movement desensitization and reprocessing (EMDR) is best considered as a CBT involving imaginal exposure and cognitive restructuring (Tolin, 2014). However, as it tends not to be classified as such by its proponents, it will not be taken into consideration here. The non-trauma-focused CBTs include stress inoculation training, progressive muscle relaxation, and related treatments that use present-focused behavioral and cognitive principles but do not directly address trauma. Both trauma-focused and non-trauma-focused CBTs have been found to be efficacious when compared with waiting lists and TAU, SMD = −1.62, 95% CI [−2.03, −1.21] (28 studies), and SMD = −1.22, 95% CI [−1.76, −0.69] (4 studies, for trauma-focused and non-trauma focused CBTs respectively; Bisson et al., 2013). Although non-trauma-focused CBTs tend be efficacious following acute treatment, there are indications that trauma-focused CBTs are more efficacious for adult survivors of childhood sexual abuse specifically (Ehring et al., 2014) and in the longer term for patients with chronic PTSD (Bisson et al., 2013). Broadly categorized, CBT treatment for PTSD appears to be efficacious when compared with pill/psychological placebos, OR = −1.85, 95% CI [−2.59, −1.32] (Carpenter et. al, 2018). Efficacy data suggest that CBT for PTSD can generally be delivered in a group format with similar effects as seen in individual format. However, there are some indications that when treatment protocols include in-group exposures, dropout rates tend to be higher (26.4% vs. 18.9% in protocols with and without in-group exposures, respectively, OR = 1.90, 95% CI [1.29, 2.79]; Barrera

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et al., 2013). The composition of the group may also matter, as lower effect sizes tend to be reported in studies that are restricted to men and in studies of combat exposure or childhood sexual abuse relative to other types of traumas (Barrera et al., 2013; Ehring et al., 2014). Obsessive-Compulsive Disorder CBT protocols involving exposure and response prevention with or without cognitive restructuring are the psychosocial interventions that have proved most efficacious in the treatment of OCD. Öst et al. (2015) identified 37 RCTs comparing CBT to WLC, placebo, or one of its components. Large effect sizes were found when comparing CBT to WLC, g = −1.31, 95% CI [−1.55, −1.08], or placebo, g = −1.33, 95% CI [ −1.76, −0.91]. CBT for OCD is such a potent intervention that the existing evidence suggests it is superior to antidepressant medications, and the combination of CBT and medication is superior to medication alone (McGuire et al., 2015; Öst et al., 2015; Romanelli et al., 2014; Sánchez-Meca et al., 2014; Skarphedinsson et al., 2015). Data from follow-up studies suggest that the effects of CBT are long lasting (pooled long-term remission rate of 53%, 95% CI [42%, 65%], mean duration of follow-up 4.9 years; Sharma et al., 2014). A recent meta-analysis of comparative RCTs suggested no differences in outcomes or dropout rates between individual and group CBT for OCD (Pozza & Dèttore, 2017), though patient samples that are characterized as more chronic, severe, or early onset tended to show higher relapse rates. General Issues In addition to examining the efficacy of CBTs for major depression and anxiety, the meta-analytic reviews we identified also considered various other issues germane to characterizing the evidence base supporting the efficacy of CBTs. CBT Versus Other Therapies Meta-analytic reviews that have examined the relative efficacy of CBT versus psychological treatments other than IPT (Baardseth et al., 2013; Tolin, 2014) have addressed a very heated debate within the history of psychology. By and large, there is no consistent evidence that CBT for major depression and anxiety and related disorders reduces symptoms to a greater degree than other therapies. In this contrast between CBT and other therapies, several points are worth noting. For some disorders, such as OCD, CBTs are the only treatments that have been studied, that meet criteria for being empirically supported, and that have been compared against rigorous controls (Lorenzo-Luaces, 2018). Second, in most instances, when meta-analyses find differences between CBTs and other therapies, they tend to favor CBTs, and the effect sizes for CBTs tend to be larger relative to those of other treatments on primary symptom measures (DeRubeis & Lorenzo-Luaces, 2017). Neither of these observations should be taken to imply that other treatments will be found not to be efficacious in the treatment of specific disorders (e.g., psychodynamic therapy for OCD), though



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this of course is an empirical question. CBTs at times outperform supportive therapy and relaxation therapy, especially for OCD and PTSD (Montero-Marin et al., 2018), but the question remains as to whether these findings are better accounted for by the researcher’s allegiance to the therapy in question. Transdiagnostic Therapy The meta-analytic reviews that included transdiagnostic CBT treatments (tCBTs), including David Barlow’s UP, examined their overall efficacy as well as the potential that they were superior to so-called disorder-specific CBT. In one such meta-analysis, Andersen et al. (2016) identified eight RCTs comparing tCBT with various control conditions (primarily WLC) in patients (older than 16 years) who met diagnostic criteria for an anxiety or depressive disorder. All studies included a measure of depression, anxiety, or generic psychological well-being. The authors concluded that tCBT was more efficacious than control conditions, but there were not enough data to perform a meta-analytic estimate of depression and anxiety outcomes. A more recent review of studies comparing tCBT and diagnostic-specific CBT appears to have included more studies because the authors cite an analysis of 83 studies, but only 10 of these were RCTs focused on tCBT (Pearl & Norton, 2017). The authors reported a difference in effect size between tCBT and standard CBT that was statistically significant (p = .008), but an overlap of confidence intervals indicated a lack of clinical significance. It should be noted, however, that this comparison was derived not from comparative outcome studies but from two different meta-analytic estimates. Newby et al. (2015) identified 31 RCTs in their metaanalysis by also including internet-based therapy studies. Their meta-analysis supported the efficacy of tCBT with large effects in anxiety and depression relative to WLC (g = −0.70, 95% CI [−0.84, −0.56] for anxiety, and g = −1.00, 95% CI [−1.30, −0.69] for depression) and attention controls (g = −0.80, 95% CI [−1.08, −0.52] for anxiety and g = −0.69, 95% CI [−0.91, −0.46] for depression), but smaller effects relative to TAU (g = −0.24, 95% CI [−0.43, −0.05] for anxiety and g = −0.57, 95% CI [−0.76, −0.38] for depression). The meta-analysis also presented a subgroup analysis of three studies, suggesting that tCBT may be superior to diagnosis-specific CBT in depression outcomes but not in anxiety outcomes. This same meta-analysis also found superior outcomes for tCBT protocols when compared with diagnosis-specific mindfulness/acceptance protocols. Taken together, these meta-analyses suggest that tCBT is more efficacious than WLC and other control conditions. However, there is little in the way of convincing evidence that tCBT is superior to diagnosis-specific CBT. This is consistent with the findings of recent large RCTs, which fail to support the hypothesis that transdiagnostic treatment is superior to disorder-specific treatment (Barlow, Farchione, Bullis, et al., 2017). Third-Wave Therapies In a Cochrane Review, Churchill et al. (2013) could identify only four small studies of third-wave therapy versus TAU for depression, totaling 224 participants.

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The studies examined different third-wave CBTs, including ACT, competitive memory training, and BA, which was classified as a third-wave therapy by these authors. The authors noted that the data were severely limited by virtue of the fact that there appeared to be an allegiance to the active treatment under investigation, as well as the fact that there was limited evidence about various aspects of the study design. None of the studies had a long-term follow-up. In another Cochrane Review comparing third-wave therapies against other psychological therapies, Hunot et al. (2013) could only identify three studies, totaling 144 eligible participants. Two of these were ACT studies comparing the earliest versions of ACT, comprehensive distancing, to a version of CBT. The third study examined BA, which was classified as a third-wave CBT, to CBT. Overall, no significant differences between the third-wave therapies and CBT were found, risk ratio (RR) of clinical response = 1.14, 95% CI [0.79, 1.64]. This finding was confirmed by another meta-analysis (A-Tjak et al., 2015). Goldberg et al. (2018) conducted a meta-analysis of mindfulness-based interventions (MBIs) for a broad range of problems (e.g., pain, substance use disorders) as well as depression and anxiety. The authors identified 18 studies focused on anxiety and 49 focused on depression. Overall, the results supported the efficacy of MBIs relative to no treatment for anxiety, g = −0.89, 95% CI [−1.17, −0.62], and depression, g = −0.59, 95% CI [−0.73, −0.46], as well as active comparators (e.g., TAU) for depression, g = −0.38, 95% CI [−0.46, −0.12]. MBIs were not superior to active comparators for anxiety, g = 0.15, 95% CI [−0.16, 0.46], or evidence-based treatments for depression, g = −0.01, 95% CI [−0.19, 0.16], and anxiety, g = −0.18, 95% CI [−0.41, 0.60]. Similar effects were reported by Hedman-Lagerlöf et al. (2018), who also conducted a meta-analysis specifically focusing on MBIs. The authors found a total of 19 studies across which MBIs were found to be more efficacious than no treatment, g = −1.07, 95% CI [−1.92, 0.21], and TAU, g = −0.40, 95% CI [−0.61, −0.19], but not in comparison with placebos, g = −0.17, 95% CI [−0.39, 0.05], or other active treatments, g = −0.01, 95% CI [−0.35, 0.33]. The authors judged that there was only one disorder (i.e., hypochondriasis) for which MBIs could be considered probably or possibly efficacious. They contrasted these conclusions to those other meta-analyses (e.g., the one by Goldberg et al., 2018) that lumped together studies focusing on the acute and relapse-prevention phase of treatment and that have not required that samples have psychiatric diagnoses. Thus, the existing data suggest that MBIs are probably more efficacious than no treatment and are probably efficacious for prevention of relapse in recurrent depression, but more data are needed to evaluate their efficacy in the acute phase of treatment when compared with more active treatments. Characterizing the Effects of CBT The effects of CBT are often expressed in relative terms (i.e., as compared with results of other interventions/control conditions). An alternative is to focus on clinically meaningful indices of change. Several meta-analyses



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focused on characterizing the effects of CBTs by using binary measures of improvement, such as symptom remission. The concept of symptom remission implies that the patient is symptom-free or is having very few symptoms, but it has been defined inconsistently across studies. Cuijpers, Karyotaki, Weitz, et al. (2014) reported that, on average, 49%, 95% CI [32%, 66%], of patients are reported as achieving symptom remission in trials of CBT when defined as a score of less than 7 on the HRSD. Around two thirds (66%), 95% CI [58%, 73%], no longer meet criteria for major depression by the end of treatment. By way of contrast, 27%, 95% CI [15%, 43%], of patients with major depression are in remission and 43%, 95% CI [34%, 52%], are diagnosis-free across a range of control groups. Springer et al. (2018) reported that intent-to-treat remission rates following CBT for anxiety disorders were 47.9% posttreatment, 95% CI [43.4%, 52.4%], and 53.5% at follow-up, 95% CI [47.6%, 59.3%]. The authors noted that the highest rates of symptom remission were observed for GAD and PTSD.

DISCUSSION We searched for recently published English-language reviews of meta-analyses of RCTs of CBTs for emotional disorders, including major depressive disorders, anxiety disorders, and the related disorders OCD and PTSD. By and large, the published meta-analytic reviews support the efficacy of CBTs. A consistent theme across the reviews is that the strongest effects of CBTs are evident when they are compared against a WLC. The effects are more modest when CBTs are compared against TAU or placebo, although CBTs still appear to be efficacious in this contrast. Moreover, the number of studies is reduced when considering only the studies that are considered of “high quality.” This should not be taken as a specific indictment against the evidence base for CBT, which is the most widely studied form of therapy (Lorenzo-Luaces, 2018). CBT appears to be more efficacious than relaxation for OCD and PTSD, perhaps also outperforming relaxation over the long term for panic and specific phobias (Montero-Marin et al., 2018). Otherwise, there is no consistent evidence that CBT is superior to other forms of psychotherapy. Despite this, CBTs are the only types of treatments that meet the American Psychological Association Division 12’s category of “strong support” for OCD, panic disorder, social anxiety, specific phobia, and GAD. Further, CBT has enduring effects, and brief sequential relapse-prevention interventions (MBCT and PCT) are efficacious in reducing relapse risk, as has especially been demonstrated for depression. Adding CBT to antidepressant treatment during the acute depressed phase has enduring effects relative to antidepressants alone (Karyotaki, Smit, et al., 2016). Moreover, adding PCT after recovery/remission to continuation of antidepressants reduces relapse risk considerably (Bockting et al., 2018). In their review, Hofmann et al. (2012) failed to identify a meta-analysis focused on specific subpopulations beyond children or the elderly. Similarly,

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our systematic search did not yield a single meta-analysis that focused on specialized subgroups, though we did find a meta-regression analysis on 56 studies that reported race or ethnicity in psychotherapy trials. The analysis included all RCTs in which the effect of psychotherapy, including CBT, for adults with a depressive disorder or depressive symptomatology was compared with a control condition, mainly TAU or WLC. An overall moderate effect size (g = −0.50) in favor of psychotherapy was found, with no moderating effect of ethnicity (Ünlü Ince et al., 2014). Single RCTs of culturally adapted CBT have been published as well for ethnic minorities and low-income samples (Rosselló & Bernal, 1999), as have reviews focused on psychotherapy adapted to ethnic minority populations (Benish et al., 2011; Griner & Smith, 2006). Our inability to find a CBT-specific review in our systematic search reflects the lack of attention that the field has given to special populations, but there is increasing evidence that CBTs can be delivered in low-income and related settings (Arjadi et al., 2018; Bockting et al., 2016; Ünlü Ince et al., 2014). The generalizability of the CBT research base is constrained by geographic limitations and by the entry criteria that studies employ. Studies of CBT for major depression often exclude participants on the basis of symptom severity, substance abuse, psychosis, and suicidality (Lorenzo-Luaces et al., 2018; van der Lem et al., 2012). Studies of psychotherapy for GAD, social anxiety, and PTSD often exclude participants on the basis of comorbid depression, secondary anxiety disorders, substance use, or psychosis (Franco et al., 2016; Hoertel et al., 2012, 2013). Given the increased recognition that mental disorders are highly comorbid and represent a shared vulnerability, more research is needed that utilizes fewer exclusion criteria. For example, it is troubling that more is not known about the efficacy of well-established procedures such as exposure for PTSD or OCD in the context of comorbid conditions like bipolar disorder or alcohol use disorder. Other exclusion criteria appear to influence who can enter a trial but do not appear to reliably relate to outcomes. For example, Hoertel et al. (2013) noted that most studies of panic disorder used current major depressive disorder as an exclusion criterion, even though this variable is not a reliable predictor of outcomes in CBT for panic disorder. We identified only a single meta-analytic review of CBTs delivered in the context of treating comorbid substance use disorders (Roberts et al., 2015). A wealth of data support the efficacy of CBTs when conducted in the context of RCTs, which are considered the gold standard of research designs to test psychotherapy outcomes. Despite this, there is clear evidence that design factors are associated with effect sizes reported across studies. As mentioned throughout the chapter, the control group, publication bias, and study quality significantly affect the reported effect size of CBT (Cuijpers, Cristea, et al., 2016; Cuijpers, Smit, et al., 2010; Driessen et al., 2015), as they likely do for other treatments as well. However, it is important to observe that the choice of the comparison groups is ultimately contingent on the nature of the research question at hand and changes the nature of the conclusions that can be drawn from the results of a study (Freedland et al., 2011; Mohr et al., 2009).



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Increasing Access to CBTs As this updated review reconfirms, CBTs are efficacious for a wide range of depressive and anxiety disorders. A key question concerns how to expand the reach of evidence-based CBT protocols. Kazdin and Blase (2011) noted that individual face-to-face psychotherapy is unlikely to reduce the burden of mental illness because there is scarcity of highly trained mental health providers relative to the large number of individuals who meet criteria for common mental health disorders. Recent high-profile studies have confirmed that CBTs for depression can also be delivered by paraprofessionals (Richards et al., 2016) and lay counselors (Bower et al., 2013). This suggests that one way that the burden of mental illness can be alleviated is by training a large number of paraprofessionals or lay counselors to deliver CBT-type interventions. Another way in which the reach of CBT can be expanded is by delivering it in the format of group psychoeducation to large numbers of patients. For example, White et al. (1992) developed a six-session transdiagnostic CBT protocol for depression and anxiety dubbed “stress control” that can be delivered in groups of six to 100 patients. Stress control has been studied in large research practice networks and benchmarked relative to the findings of guided self-help (Delgadillo et al., 2016). Providing support for its efficacy, Delgadillo et al. reported that 42% of cases that initially scored in the clinical range of anxiety experienced reliable and clinically significant improvement. A similar number of patients experienced clinically significant improvement in depression. There have been other efforts to capitalize on the use of brief CBT groups as a way of making the delivery of treatment more efficient (Mörtberg et al., 2007). Additionally, there is evidence for the efficacy of concentrated CBT treatments (i.e., those that are carried out with more than one session a week), especially in the delivery of CBTs for youth with anxiety (Öst & Ollendick, 2017). Finally, the development of internet-based CBTs (iCBTs) has been among the most promising progresses in mental health treatment of the past several decades. Research suggests that unguided (Karyotaki et al., 2017) and guided (Karyotaki et al., 2018) iCBT can be efficacious relative to control conditions and that guided iCBT can be as efficacious as face-to-face CBT (Andersson et al., 2014). It is likely that in the future, a significant burden of treatment will be delivered via iCBTs. Personalized Medicine Given the lack of strong or consistent evidence that CBT is more efficacious than other forms of treatment, it has been suggested that it may be more promising to focus on identifying subgroups of patients who experience better response with CBTs than other therapies and vice-versa (DeRubeis & Lorenzo-Luaces, 2017). This is broadly consistent with an interest in psychology in the concept of “personalized” or “precision” medicine (Z. D. Cohen & DeRubeis, 2018; DeRubeis et al., 2014). The past several decades have seen growing interest in the topic of personalized medicine in the field of mental health. Relatedly, there is a

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growing interest in the topic of moderators of the efficacy of CBTs and other interventions for depression and anxiety. There is a growing recognition even among proponents of CBT that it may be misguided to argue for the superiority of CBT above and beyond all forms of therapy and that, instead, CBT may be best for individuals who are well suited to this type of treatment (DeRubeis & Lorenzo-Luaces, 2017; Lorenzo-Luaces et al., 2017). This, in turn, suggests the existence of individuals who are ill-suited for CBT and who would be better served by other forms of therapy. Cuijpers, Ebert, et al. (2016) conducted a meta-analysis of the efficacy of psychotherapy across patient subgroups (e.g., older adults, patients with cancer) to determine whether there was enough evidence to personalize recommendations to CBT or other treatments based on patient characteristics. They found preliminary evidence that CBTs for depressive symptoms may be superior to other therapies among college students, older adults, and those with substance use problems. These authors also concluded that most studies were underpowered (Cuijpers, Reynolds, et al., 2012). Various data-analytic techniques, including meta-analytic techniques, have been developed to answer the question of optimal treatment selection that rely on the idea of combining moderator variables (DeRubeis et al., 2014; Kraemer, 2013). Huibers et al. (2015) used the approach suggested by DeRubeis et al. (2014) in a comparison of CBT versus IPT for depression and identified five predictors (i.e., gender, employment status, anxiety, personality disorder, and quality of life) and six moderators (i.e., somatic complaints, cognitive problems, paranoid symptoms, interpersonal self-sacrificing, attributional style, and number of life events) of treatment outcomes. These variables were subsequently combined in an algorithm that produced a measure of the predicted advantage in one therapy compared with the other, the so-called personalized advantage index (PAI). Patients who had better outcomes in IPT rather than CBT were more likely to have cognitive problems, whereas patients who experienced better outcomes in CBT rather than IPT had somatic complaints, paranoid symptoms, a self-sacrificing style, a more negative attributional style, and a higher number of life events pretreatment. Researchers have also turned to genetics (Bockting et al., 2013), intensive within-person data collection (Fisher & Boswell, 2016; Rubel et al., 2018), and neuroimaging (Drysdale et al., 2017; Dunlop & Mayberg, 2014) to facilitate personalized medicine. Mechanisms It is common to observe that despite consistent support for the efficacy of CBT, research has provided only little confirmation about the mechanisms through which CBTs lead to symptom change (Cuijpers et al., 2019; Kazdin, 2007). In addition to verifying basic theories, such knowledge is expected to enhance treatment elements and techniques that are crucial for therapeutic change, thereby optimizing treatment outcomes. According to the cognitive behavioral model, interventions (e.g., psychoeducational, cognitive, behavioral) aimed at altering the function, content, and



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structure of biased patterns of thinking will lead to symptom change. The idea that cognitive change accounts for therapeutic change is a popular hypothesis. Dozens of studies have examined the role of cognitive processes, such as automatic thoughts, dysfunctional attitudes, attributional style, and other cognitive distortions both in CBTs and in other psychological interventions (see overview papers of, e.g., Cristea et al., 2015; Garrat et al., 2007; Kazantzis et al., 2018; Lemmens et al., 2016; Lorenzo-Luaces et al., 2015; Spinhoven et al., 2018). Meta-analyses generally support the effects of CBT on variables that are hypothesized to be mechanistically related to outcomes. Unfortunately, only a few studies have included efforts to detect the direction of causality. Studies that have attempted to disentangle the direction of causality are supportive of the CBT model, which is also consistent with basic research (see Lemmens et al., 2016; Lorenzo-Luaces et al., 2015). However, more research is needed. As a result, it remains unclear whether changes in cognitions precede or follow from changes in depression and anxiety during treatment. More knowledge about the mechanisms of change in CBTs could lead to improved outcomes in existing treatment components.

CONCLUSION Given the wealth of evidence supporting the efficacy of CBTs, a central question that emerges from efforts to evaluate the evidence base is how to evaluate the overlapping data for CBTs. A number of authors have used the technique of network meta-analysis as a way of integrating evidence across studies (MayoWilson et al., 2014; Pompoli et al., 2016, 2018). Regardless of the way in which one chooses to evaluate the evidence for CBTs, the data are clear. CBTs are the most commonly studied psychotherapies for depression, anxiety, and related disorders. They are efficacious, and although their mechanisms of change have not been clearly elucidated, their theories of change comport with basic science (Hofmann et al., 2013). We expect that the coming decades will see a greater interest in efforts to disseminate CBT as an individual treatment and to deliver it in novel formats that have a greater capacity to reduce the public health burden of mental disorders. Moreover, there will likely be continued interest in efforts to personalize the delivery of CBTs and elucidate their mechanisms of change.

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treatments for pediatric obsessive-compulsive disorder: A meta-analysis. Journal of Anxiety Disorders, 28(1), 31–44. https://doi.org/10.1016/j.janxdis.2013.10.007 Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., & Levitan, R. D. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256–1264. https://doi. org/10.1001/archgenpsychiatry.2010.168 Sharma, E., Thennarasu, K., & Reddy, Y. C. (2014). Long-term outcome of obsessive-compulsive disorder in adults: A meta-analysis. Journal of Clinical Psychiatry, 75(9), 1019–1027. https://doi.org/10.4088/JCP.13r08849 Skarphedinsson, G., Hanssen-Bauer, K., Kornør, H., Heiervang, E. R., Landrø, N. I., Axelsdottir, B., Biedilæ, S., & Ivarsson, T. (2015). Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A systematic review of effect estimates across comparisons. Nordic Journal of Psychiatry, 69(2), 81–92. https://doi.org/10.3109/08039488.2014.941395 Spinhoven, P., Klein, N., Kennis, M., Cramer, A. O. J., Siegle, G., Cuijpers, P., Ormel, J., Hollon, S. D., & Bockting, C. L. (2018). The effects of cognitive-behavior therapy for depression on repetitive negative thinking: A meta-analysis. Behaviour Research and Therapy, 106, 71–85. https://doi.org/10.1016/j.brat.2018.04.002 Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical Psychology Review, 61, 1–8. https://doi.org/10. 1016/j.cpr.2018.03.002 Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615–623. https://doi.org/10.1037/0022-006X.68.4.615 Tolin, D. F. (2014). Beating a dead dodo bird: Looking at signal vs. noise in cognitivebehavioral therapy for anxiety disorders. Clinical Psychology: Science and Practice, 21(4), 351–362. https://doi.org/10.1111/cpsp.12080 Tolin, D. F. (2017). Can cognitive-behavioral therapy for anxiety and depression be improved with pharmacotherapy? A meta-analysis. Psychiatric Clinics of North America, 40(4), 715–738. https://doi.org/10.1016/j.psc.2017.08.007 Ünlü Ince, B., Riper, H., van ’t Hof, E., & Cuijpers, P. (2014). The effects of psychotherapy on depression among racial-ethnic minority groups: A metaregression analysis. Psychiatric Services, 65(5), 612–617. https://doi.org/10.1176/appi.ps.201300165 van der Lem, R., de Wever, W. W., van der Wee, N. J., van Veen, T., Cuijpers, P., & Zitman, F. G. (2012). The generalizability of psychotherapy efficacy trials in major depressive disorder: An analysis of the influence of patient selection in efficacy trials on symptom outcome in daily practice. BMC Psychiatry, 12, 192. https://doi.org/10. 1186/1471-244X-12-192 Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B. (2007). Reducing relapse and recurrence in unipolar depression: A comparative meta-analysis of cognitivebehavioral therapy’s effects. Journal of Consulting and Clinical Psychology, 75(3), 475– 488. https://doi.org/10.1037/0022-006X.75.3.475 White, J., Keenan, M., & Brooks, N. (1992). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 20(2), 97–113. https://doi.org/10.1017/S014134730001689X Wersebe, H., Sijbrandij, M., & Cuijpers, P. (2013). Psychological group-treatments of social anxiety disorder: A meta-analysis. PLOS ONE, 8(11), e79034. https://doi.org/ 10.1371/journal.pone.0079034 Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021–1037. https://doi.org/10.1016/j.cpr.2008.02.007

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World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. Zhou, S.-G., Hou, Y.-F., Liu, D., & Zhang, X.-Y. (2017). Effect of cognitive behavioral therapy versus interpersonal psychotherapy in patients with major depressive disorder: A meta-analysis of randomized controlled trials. Chinese Medical Journal, 130(23), 2844–2851. https://doi.org/10.4103/0366-6999.219149

APPENDIX 3.1: KEY-TERM SCHEME FOR DATABASE SEARCH (meta-analysis OR “meta analysis” OR “quantitative review”) AND (CBT OR BT OR cognitive-behav* OR “cognitive therapy” OR BA OR “behavioral activation” OR “behavioural activation”) AND (depress* OR anxiety OR dysthym* OR panic OR OCD OR PTSD OR “obsessive-compulsive” OR trauma OR “posttraumatic stress disorder”)

APPENDIX 3.2: OVERVIEW OF INCLUSION AND EXCLUSION CRITERIA Publication type Language Article type Intervention

Target group

Included (peer reviewed) journal articles English Meta-analysis/ Quantitative Review Cognitive-behavioral therapy (CBT), cognitive therapy (CT), behavioral activation (BA), acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), exposure (delivered individually or in group format) Patients (all ages) with a diagnosis of depression or anxiety disorder (including PTSD and OCD).

Excluded Books, book chapters, dissertations, dissertation abstracts, posters Every other language Systematic literature reviews, research papers, commentaries, replies Other interventions, studies focusing on purely self-guided and internet/web/ chat/text/email CBTs (except when internet was the medium to deliver traditional CBT, e.g., CBTs via Skype. Note: For meta-analyses with a focus on “psychotherapy” or “psychological interventions” in general, we examined the proportion of studies that examined CBTs. If this was > 90% (or if authors included subgroup analyses on CBTs), the paper was included. Meta-analyses focusing on symptoms (instead of diagnoses), meta-analyses that focused on (effects of CBT for) other diagnoses (on depression/ anxiety). Note: We included meta-analyses that examined effects of CBT for depression/anxiety in specific populations (e.g., effects of CBT for depression in people with autism; double diagnosis), as well as those that examined effects of CBT for depression on anxiety (and vice versa).



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Outcome

Other

Depression/anxiety severity Meta-analyses focusing on other outcomes than depression/anxiety (e.g., dropout, predictors, moderators, components, cost-effectiveness, well-being, quality of life, self-harm, suicidality, perfectionism) Meta-analyses focusing on Meta-analyses focusing on primary prevention of relapse, prevention meta-analyses focusing on effects of continuation treatment. Note: For papers that later were corrected, we included only the corrected version.

APPENDIX 3.3: LIST OF SELECTED PAPERS (N = 119) 1

Andersen, P., Toner, P., Bland, M., & McMillan, D. (2016). Effectiveness of transdiagnostic cognitive behaviour therapy for anxiety and depression in adults: A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 44(6), 673–690.

2

Baardseth, T. P., Goldberg, S. B., Pace, B. T., Wislocki, A. P., Frost, N. D., Siddiqui, J. R., Lindemann, A. M., Kivlighan, D. M., III, Laska, K. M., Del Re, A. C., Minami, T., & Wampold, B. E. (2013). Cognitive-behavioral therapy versus other therapies: Redux. Clinical Psychology Review, 33(3), 395–405.

3

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. Journal of Anxiety Disorders, 39, 44–64.

4

Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33(1), 24–32.

5

Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews. https://doi.org/10. 1002/14651858

6

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624.

7

Calati, R., Pedrini, L., Alighieri, S., Alvarez, M. I., Desideri, L., Durante, D., Favero, F., Iero, L., Magnani, G., Polmonari, A., Raggini, R., Raimondi, E., Riboni, V., Scaduto, M. C., Serretti, A., & De Girolamo, G. (2011). Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis. Acta Neuropsychiatrica, 23(6), 263–271.

8

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514.

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9

Chan, A. T., Sun, G. Y., Tam, W. W., Tsoi, K. K., & Wong, S. Y. (2017). The effectiveness of group-based behavioral activation in the treatment of depression: An updated meta-analysis of randomized controlled trial. Journal of Affective Disorders, 208, 345–354.

10

Chen, L., Zhang, G., Hu, M., & Liang, X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: Systematic review and meta-analysis. Journal of Nervous and Mental Disease, 203(6), 443–451.

11

Churchill, R., Moore, T. H., Furukawa, T. A., Caldwell, D. M., Davies, P., Jones, H., Shinohara, K., Imai, H., Lewis, G., & Hunot, V. (2013). “Third wave” cognitive and behavioural therapies versus treatment as usual for depression. Cochrane Database of Systematic Reviews. https://doi.org/ 10.1002/14651858.CD008705.pub2

12

Crowe, K., & McKay, D. (2017). Efficacy of cognitive-behavioral therapy for childhood anxiety and depression. Journal of Anxiety Disorders, 49, 76–87.

13

Cuijpers, P., Andersson, G., Donker, T., & van Straten, A. (2011). Psychological treatment of depression: Results of a series of meta-analyses. Nordic Journal of Psychiatry, 65(6), 354–364.

14

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry, 58(7), 376–385.

15*

Cuijpers, P., Cristea I. A., Ebert, D. D., Koot, H. M., Auerbach, R. P., Bruffaerts, R., & Kessler, R. C. (2016). Psychological treatment of depression in college students: A meta-analysis. Depression and Anxiety, 33(5), 400–414.

16

Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), 245–258.

17

Cuijpers, P., Cristea, I. A., Weitz, E., Gentili, C., & Berking, M. (2016). The effects of cognitive and behavioural therapies for anxiety disorders on depression: A meta-analysis. Psychological Medicine, 46(16), 3451–3462.

18*

Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. American Journal of Psychiatry, 173(7), 680–687.

19

Cuijpers, P., Gentili, C., Banos, R. M., Garcia-Campayo, J., Botella, C., & Cristea, I. A. (2016). Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis. Journal of Anxiety Disorders, 43, 79–89.

20

Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open, 3(4), e002542.

21

Cuijpers, P., Karyotaki, E., Pot, A. M., Park, M., & Reynolds, C. F., III. (2014). Managing depression in older age: Psychological interventions. Maturitas, 79(2), 160–169.

22*

Cuijpers, P., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2018). Who benefits from psychotherapies for adult depression? A meta-analytic update of the evidence. Cognitive Behaviour Therapy, 47(2), 91–106.



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23*

Cuijpers, P., Karyotaki, E., Reijnders, M., Purgato, M., & Barbui, C. (2018). Psychotherapies for depression in low- and middle-income countries: A meta-analysis. World Psychiatry, 17(1), 90–101.

24

Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A metaanalysis. Clinical Psychology Review, 34(2), 130–140.

25*

Cuijpers, P., Turner, E. H., Mohr, D. C., Hofmann, S. G., Andersson. G., Berking, M., & Coyne, J. (2014). Comparison of psychotherapies for adult depression to pill placebo control groups: A meta-analysis. Psychological Medicine, 44(4), 685–695.

26

Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128–141.

27

DiMauro, J. (2014). Exposure therapy for posttraumatic stress disorder: A metaanalysis. Military Psychology, 26(2), 120–130.

28

Dorrepaal, E., Thomaes, K., Hoogendoorn, A. W., Veltman, D. J., Draijer, N., & van Balkom, A. J. (2014). Evidence-based treatment for adult women with child abuse-related complex PTSD: A quantitative review. European Journal of Psychotraumatology, 5, 23613.

29

Ebrahim, S., & Bance, S. (2012). Correcting and interpreting the effect of cognitive therapy versus exposure in anxiety disorders. BMC Psychiatry, 12, 202.

30

Ehring, T., Welboren, R., Morina, N., Wicherts, J. M., Freitag, J., & Emmelkamp, P. M. (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34(8), 645–657.

31

Ewing, D. L., Monsen, J. J., Thompson, E. J., Cartwright-Hatton, S., & Field, A. (2015). A meta-analysis of transdiagnostic cognitive behavioural therapy in the treatment of child and young person anxiety disorders. Behavioural and Cognitive Psychotherapy, 43(5), 562–577.

32

Feng, C. Y., Chu, H., Chen, C. H., Chang, Y. S., Chen, T. H., Chou, Y. H., Chang, Y. C., & Chou, K. R. (2012). The effect of cognitive behavioral group therapy for depression: A meta-analysis 2000–2010. Worldviews on Evidence-Based Nursing, 9(1), 2–17.

33

Furukawa, T. A., Weitz, E. S., Tanaka, S., Hollon, S. D., Hofmann, S. G., Andersson, G., Twisk, J., DeRubeis, R. J., Dimidjian, S., Hegerl, U., Mergl, R., Jarrett, R. B., Vittengl, J. R., Watanabe, N., & Cuijpers, P. (2017). Initial severity of depression and efficacy of cognitive–behavioural therapy: Individual-participant data meta-analysis of pill-placebo-controlled trials. British Journal of Psychiatry, 210(3), 190–196.

34

Galante, J., Iribarren, S. J., & Pearce, P. F. (2013). Effects of mindfulness-based cognitive therapy on mental disorders: A systematic review and metaanalysis of randomised controlled trials. Journal of Research in Nursing, 18(2), 133–155.

35

Gerger, H., Munder, T., Gemperli, A., Nüesch, E., Trelle, S., Jüni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis: Relative effectiveness of psychological interventions for adults with post-traumatic stress disorder. Psychological Medicine, 44(15), 3151–3164.

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36

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52–60.

37

Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Cognitive behavioral therapy for depression in older people: A meta-analysis and metaregression of randomized controlled trials. Journal of the American Geriatrics Society, 60(10), 1817–1830.

38

Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Efficacy of cognitive behavioral therapy for anxiety disorders in older people: A meta-analysis and meta-regression of randomized controlled trials. Journal of the American Geriatrics Society, 60(2), 218–229.

39

Hacker, T., Stone, P., & MacBeth, A. (2016). Acceptance and commitment therapy—Do we know enough? Cumulative and sequential meta-analyses of randomized controlled trials. Journal of Affective Disorders, 190, 551–565.

40

Hall, J., Kellett, S., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of cognitive behavioral therapy for generalized anxiety disorder in older adults: Systematic review, meta-analysis, and meta-regression. American Journal of Geriatric Psychiatry, 24(11), 1063–1073.

41

Hanrahan, F., Field, A. P., Jones, F. W., & Davey, G. C. (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33(1), 120–132.

42

Hans, E., & Hiller, W. (2013). A meta-analysis of nonrandomized effectiveness studies on outpatient cognitive behavioral therapy for adult anxiety disorders. Clinical Psychology Review, 33(8), 954–964.

43

Hans, E., & Hiller, W. (2013). Effectiveness of and dropout from outpatient cognitive behavioral therapy for adult unipolar depression: A metaanalysis of nonrandomized effectiveness studies. Journal of Consulting and Clinical Psychology, 81(1), 75–88.

44

Hedman-Lagerlöf, M., Hedman-Lagerlöf, E., & Öst, L. G. (2018). The empirical support for mindfulness-based interventions for common psychiatric disorders: A systematic review and meta-analysis. Psychological Medicine, 48(13), 2116–2129.

45

Hetrick, S. E., Cox, G. R., Witt, K. G., Bir, J. J., & Merry, S. N. (2016). Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews. https://doi.org/10. 1002/14651858.CD003380.pub4

46

Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder–Is it all in the homework then? European Review of Applied Psychology, 62(4), 253–260.

47

Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect of cognitivebehavioral therapy for anxiety disorders on quality of life: A meta-analysis. Journal of Consulting and Clinical Psychology, 82(3), 375–391.

48

Honyashiki, M., Furukawa, T. A., Noma, H., Tanaka, S., Chen, P., Ichikawa, K., Ono, M., Churchill, R., Hunot, V., & Caldwell, D. M. (2014). Specificity of CBT for depression: A contribution from multiple treatments metaanalyses. Cognitive Therapy and Research, 38(3), 249–260.

49

Huang, F. F., Li, Z. J., Han, H. Y., Xiong, H. F., Ma, Y. (2013). Cognitive behavioral therapy combined with pharmacotherapy for obsessive compulsive disorder: A meta-analysis. Chinese Mental Health Journal, 27(9), 643–649.



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50

Hunot, V., Moore, T. H., Caldwell, D. M., Furukawa, T. A., Davies, P., Jones, H., Honyashiki, M., Chen, P., Lewis, G., & Churchill, R. (2013). “Third wave” cognitive and behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews. https://doi. org/10.1002/14651858.CD008704.pub2

51

Jakobsen, J. C., Hansen, J. L., Simonsen, S., Simonsen, E., & Gluud, C. (2012). Effects of cognitive therapy versus interpersonal psychotherapy in patients with major depressive disorder: A systematic review of randomized clinical trials with meta-analyses and trial sequential analyses. Psychological Medicine, 42(7), 1343–1357.

52

Jakobsen, J. C., Hansen, J. L., Storebø, O. J., Simonsen, E., & Gluud, C. (2011). The effects of cognitive therapy versus “no intervention” for major depressive disorder. PLOS ONE, 6(12), e28299.

53

Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747–768.

54

Johnsen, T. J., & Thimm, J. C. (2018). A meta-analysis of group cognitive– behavioral therapy as an antidepressive treatment: Are we getting better? Canadian Psychology, 59(1), 15.

55

Jonsson, H., Kristensen, M., & Arendt, M. (2015). Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Journal of Obsessive-Compulsive and Related Disorders, 6, 83–96.

56*

Karyotaki, E., Smit, Y., de Beurs, D. P., Henningsen, K. H., Robays, J., Huibers, M. J. H., Weitz, E., & Cuijpers, P. (2016). The long-term efficacy of acute phase psychotherapy for depression: A meta-analysis of randomized trials. Depression and Anxiety, 33(5), 370–383.

57*

Karyotaki, E., Smit, Y., Holdt-Henningsen, K., Huibers, M. J. H., Robayse, J., de Beurs, D., & Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders, 194(1), 144–152.

58

Kishita, N., & Laidlaw, K. (2017). Cognitive behaviour therapy for generalized anxiety disorder: Is CBT equally efficacious in adults of working age and older adults? Clinical Psychology Review, 52, 124–136.

59

Kliem, S., & Kröger, C. (2013). Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling. Behaviour Research and Therapy, 51(11), 753–761.

60

Lenz, A. S., & Hollenbaugh, K. M. (2015). Meta-analysis of trauma-focused cognitive behavioral therapy for treating PTSD and co-occurring depression among children and adolescents. Counseling Outcome Research and Evaluation, 6(1), 18–32.

61

Ma, D., Zhang, Z., Zhang, X., & Li, L. (2014). Comparative efficacy, acceptability, and safety of medicinal, cognitive-behavioral therapy, and placebo treatments for acute major depressive disorder in children and adolescents: A multiple-treatments meta-analysis. Current Medical Research and Opinion, 30(6), 971–995.

62

Martin, F., & Oliver, T. (2018). Behavioral activation for children and adolescents: A systematic review of progress and promise. European Child & Adolescent Psychiatry, 28(4), 427–441.

63

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network metaanalysis. Lancet Psychiatry, 1(5), 368–376.

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4 Empirical Status of Mechanisms of Change Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, Amy Wenzel, and Jasper A. J. Smits

C

ognitive behavioral therapy (CBT) is an established first-line intervention for psychological disorders. Numerous randomized controlled trials (RCTs) and meta-analyses indicate that CBT outperforms wait-list and placebo conditions and evidences comparable efficacy to other efficacious interventions such as pharmacotherapies (Cuijpers et al., 2010; Hofmann & Smits, 2008). In addition, more recent efforts reveal that CBT can also exert positive effects when delivered via the internet as opposed to in person, thus showing promise for widespread dissemination (Cuijpers et al., 2017). As is true for any intervention for any indication, the response to CBT has been highly variable within and across trials. In fact, a sizeable group of patients who enter these trials leaves treatment prematurely or completes the intervention without experiencing meaningful symptom reduction. This observation highlights the importance of studying mechanisms of change, that is, why and how changes occur. When we know how an intervention exerts its effects, we are in a better position to improve upon the treatment. Identifying key mechanisms of change can guide the development of augmentation strategies—adding pre-, in-, or postsession actions that can engage these core targets of therapeutic change. Moreover, identifying mechanisms of change can aid the development of treatment algorithms—optimizing outcomes by matching interventions with personal characteristics at different stages of the disorder and treatment. For mechanisms of change to be identified and substantiated by evidence, research needs to fulfill certain criteria. Kazdin (2007) proposed that

https://doi.org/10.1037/0000218-004 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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identifying a mediator is a first step in understanding treatment mechanisms. A mediator is a variable that accounts for at least part of the effect of an independent variable (e.g., treatment received) on a dependent variable (e.g., anxiety symptom severity). This means that studies need to demonstrate that a treatment, like CBT, causes variation in the variable (i.e., the proposed mechanism, often measured by a task or questionnaire) and that this variable, in turn, causes symptom reduction (mostly assessed using a questionnaire or structured clinical interview). Research should also examine the specificity of the association between the proposed mediator and symptom reduction. That is, studies should demonstrate that this mediator, specifically, accounts for the change in symptoms and not other plausible variables. Furthermore, examining the temporality of change, or when the proposed mediator affect symptoms change during treatment, is also important to guide clinical innovations. Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Identifying a mediator is, thus, a first step in structurally evaluating mechanisms of change. As outlined by Kazdin (2007), research on mechanisms of change in CBT needs to (a) identify possible mechanisms based on theory and/ or correlational or preclinical research, (b) (experimentally) manipulate the mechanistic processes, (c) execute RCTs measuring multiple possible mechanisms in all or most sessions (to address the aspects of specificity and temporality), and (d) ultimately disseminate the gained knowledge to use in CBT practice. In this chapter, we provide a narrative review of studies examining putative mechanisms of action of CBT for depression and anxiety disorders, and we also briefly address research in other mental health disorders later in the chapter. Although we recognize that there are likely multiple mechanisms of action operating at multiple levels (e.g., psychological, biological), we have focused our review in this chapter on core behavioral (e.g., fear extinction, avoidance) and cognitive (e.g., cognitive reappraisal, cognitive bias) mechanisms of action as tested by self-report measures or behavioral measures. Because sustainable treatment effects should be reflected by changes in the brain, specifically in areas related to proposed mechanisms of change, researchers have started relating brain activation in areas related to such processes with CBT outcome (see review by Clark & Beck, 2010; Månsson et al., 2016). Some relevant neurocognitive research will, therefore, be discussed as well. We illustrate how mechanistic research can guide treatment development and finish by offering some directions for research in this important area.

LEARNING MECHANISMS In essence, CBT is a learning therapy. In CBT we encourage patients to learn to think or act differently. Is this learning of new thoughts or behavior cardinal to change in symptoms? If so, what should patients learn, and how do we facili-



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tate this learning? In the following section, we focus on learning as a mechanism of change in CBT. We first address fear conditioning and extinction as a model for exposure therapy for the treatment of anxiety and related disorders, which is the best investigated mechanism of action of CBT (Kazdin, 2009). Next and related, we address avoidance learning. Then, we discuss generalization of learning experiences outside the context of cognitive behavioral treatment. Last, we discuss the exciting new field of enhancers of memory and learning essential to therapeutic change. This novel line of research aims at improving CBT outcome by (pharmacologically) enhancing the learning mechanisms thought to be crucial during CBT. Fear Extinction: Learning New Associations Between Stimuli The fear conditioning and extinction model has proved to be a valuable model to study anxiety disorders and their treatment (Craske et al., 2008; Kindt, 2014; Scheveneels et al., 2016). In classical (Pavlovian) fear conditioning, fear is acquired via the coupling of a neutral stimulus (conditioned stimulus [CS]), such as a tone, with an aversive stimulus (unconditioned stimulus [US]), such as a mild electric shock (see Figure 4.1). After several pairings of the CS with the US, the presentation of the previously innocuous stimulus alone will elicit the fear response. The extinction of fear results from repeated presentations of the CS without the occurrence of the US. It is easy to see the relevance of this classical conditioning paradigm to the development and treatment of anxiety disorders. For instance, Mr. G. has social anxiety disorder (SAD). His anxiety may originate from a conditioning experience wherein he felt humiliated (US) during an oral presentation (CS) he gave in high school. Ever since, whenever he gives a presentation, he anticipates humiliation and experiences intense FIGURE 4.1. Representation of Experimental Fear Acquisition and Extinction

b.

a. Extinction CS/noUS

CBT-Exposure CS/noUS

Fear

Fear

Acquisition CS/US

Time

Time

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fear. During CBT, his therapist aims to extinguish this excessive fear by encouraging him to repeatedly engage in speech exposures without experiencing a negative consequence like humiliation. Progress in the basic science of learning and memory has taught us that extinction learning does not lead to erasure of the fear associations; extinction learning is a form of new learning (e.g. Bouton, 1993). That is, during extinction an inhibitory association between the CS and the nonappearance of the US is learned (i.e., CS/no US association), often referred to as inhibitory learning. Importantly, it is believed that the original CS/US association is unaffected by extinction learning and thus remains intact. This idea is supported by observations that extinguished fears easily return (see for review Vervliet et al., 2013). In the fear literature, three different phenomena are used to describe the return of fear. Spontaneous recovery refers to finding that merely by the passing of time fear responses to the extinguished CS can recover (Quirk, 2002). Reinstatement refers to the observation that when presentations of the US occur without prior warning (e.g., after fear extinction, the mild electric shock is given without forewarning), fear responses to the extinguished CS can return (Rescorla & Heth, 1975). Renewal refers to the observation that fear responses to the CS return when testing of extinction learning takes place in a different context from extinction training (e.g., in animal studies, when extinction training was done in Cage A and subsequent testing in Cage B; Bouton, 2002). These phenomena may help us understand the clinical counterpart of the return of fear, or relapse. For example, Mr. G. experiences a marked reduction in anxiety symptoms following a course of CBT for his SAD. However, he may experience a relapse if he must give a presentation at work several months after treatment completion (i.e., spontaneous recovery), if he experiences anxiety symptoms during periods of high workload and stress (i.e., reinstatement), or if he has practiced presentations at his own workplace but now must give a presentation for a different company (i.e., renewal). Studies on return of fear have taught us that “fear extinction is relatively easy to ‘learn’, but difficult to ‘remember’” (Vervliet et al., 2013, p. 215). Translated to CBT mechanisms, this suggests that CBT sessions should be set up to strengthen the inhibitory association (in order for this association to inhibit the threat-related association) to reduce the risk for relapse. Suggestions have been made on how this might be done, such as by conducting exposure sessions over various contexts (e.g., giving speeches at work and during town hall meetings) or by spreading sessions over longer periods of time (Craske et al., 2014). However, whether these interventions indeed lead to better CBT outcomes over the long term still needs to be determined (Jacoby & Abramowitz, 2016). Fear conditioning studies have demonstrated that people at risk for anxiety disorders and those who have already developed an anxiety disorder exhibit impaired fear and extinction learning (for review, see Duits et al., 2015; Lissek et al., 2005). Although in the previous paragraph a conditioning paradigm with one conditioning stimulus (CS; see also Table 4.1) was used to explain the



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TABLE 4.1. Overview of Abbreviations and Terms Used in the Fear Conditioning

Literature Example Explanation Experimental Clinical A stimulus that Electric shock Panic attack US generates a fear response A neutral stimulus Red rectangle Shopping mall CS that predicts the occurrence of the US Conditioned A neutral stimulus Red rectangle Shopping mall CS+ stimulus, that predicts the danger cue occurrence of the US in a discriminative conditioning paradigm Conditioned A neutral stimulus Blue circle CS− stimulus, that predicts the safety cue nonoccurrence of the US in a discriminative conditioning paradigm Fear Learned association The person has A person CS/US acquisition between the learned that the associates association conditioned red rectangle going to the stimulus and the predicts an shopping mall aversive outcome electric shock, with a panic and they attack and respond with experiences fear when fear when presented with going to the the red rectangle shopping mall Fear Learned association The person has A person has CS/no US extinction between the learned that the learned that association nonoccurrence of red rectangle no going to a the US followlonger predicts shopping mall ing the CS the shock, and does not they no longer necessarily lead respond with to aversive fear when outcome, and presented with they no longer the red rectangle fear shopping malls Generalization A stimulus that The person has A person fears GS stimulus resembles the CS learned that the supermarkets and elicits similar red rectangle as well as responses predicts the shopping malls shock, and they respond with fear to a red square A stimulus that is A yellow star is An accompanying Inhibitory CS Inhibitory condipresented presented next person in the tioned alongside the CS to the red shopping mall stimulus and predicts the rectangle nonoccurrence of the US Abbreviation

Term Unconditioned stimulus Conditioned stimulus

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model (i.e., single cue conditioning), in most fear conditioning studies, a paradigm with two conditioning stimuli is used (i.e., differential conditioning). In these paradigms, people are presented with (a) a stimulus that predicts the US, referred to as the CS+ or danger cue, and (b) a stimulus that never predicts the occurrence of the US, referred to as the CS− or safety cue. For instance, people see intermittently a red rectangle and a blue circle on a computer screen. The red rectangle (CS+) is followed by the electric shock (US), whereas the blue circle (CS−) is never followed by the electric shock. After several pairings, people learn that the CS+ predicts danger, whereas the CS− predicts safety. Patients with anxiety disorders, however, lack discrimination between these danger and safety cues and respond fearfully to both stimuli. This may reflect an overgeneralization of fear to neutral stimuli. Alternatively, this may indicate an incapacity to inhibit fear responses in a threatrelated context (i.e., the conditioning context). Moreover, during the extinction phase of the experiment, or the phase wherein the US no longer occurs, patients with anxiety disorders show elevated fear responses to the CS+ in comparison to those without anxiety disorders. In other words, they are slower to learn that the stimulus that was previously predictive of danger now no longer predicts an aversive outcome. This finding is highly relevant to CBT’s mechanism of action. During CBT, patients with anxiety disorders need to learn that contact with their feared stimulus does not lead to a hazardous outcome, but, apparently, they have difficulty acquiring this new association and keep expecting an aversive outcome. It is important to note that these impairments were found in groups of individuals (with different anxiety disorders and posttraumatic stress disorder [PTSD]) in comparison to healthy (nondisordered) individuals and that many open questions remain. Are there individual differences in patients with regard to fear learning? Further, are these deficits related to treatment response? We review here the existing evidence to answer these questions. In light of the facts that patients are marked by deficits with respect to safety and extinction learning and that these learning processes are implicated as mechanisms of change that are particularly responsible for outcomes in CBT, the question arises whether these learning deficits hamper CBT efficacy. Remarkably, empirical studies aimed at investigating this question are sparse (Scheveneels et al., 2016). Some studies have assessed extinction learning before CBT treatment and related this to treatment outcome. Specifically, these studies investigated brain activation during extinction learning. The neural bases of extinction are well understood (Kindt, 2014; LeDoux, 2000; Rauch et al., 2006). Decades of research in both animals and humans have demonstrated that the amygdala is critically involved in extinction learning, although a broader network of brain areas is also implied to play a crucial role (including the anterior cingulate cortex [ACC], hippocampus, insula, and ventromedial prefrontal cortex [vmPFC]). Activations and interactions in this so-called fear network during fear conditioning can be related to CBT outcome. In a recent study, Ball et al. (2017) tested whether individual differences in extinction



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learning were predictive of exposure outcome for public speaking anxiety. Better extinction learning (as expressed by less negative CS ratings following the extinction phase of the experiment) and brain activation during extinction learning (including greater activation in the vmPFC and less activation in the amygdala) prior to treatment were indeed predictive of lower anxiety symptoms 2 weeks following the exposure session. Similarly, Hahn et al. (2015) were able to predict, by whole brain activation during fear conditioning and extinction prior to treatment, who responded to 12 sessions of CBT for the treatment of panic disorder and agoraphobia (with high sensitivity, 92%). In line, Lueken et al. (2013) demonstrated that, compared with CBT responders, CBT nonresponders displayed enhanced activation of threat-related brain systems (i.e., the ACC, hippocampus, and amygdala) in response to safety cues during an extinction task pretreatment. Together, these findings comport well with the cross-sectional studies demonstrating deficient safety and extinction learning in anxiety disordered individuals (Duits et al., 2015), and they add to the literature by suggesting that these deficits in safety and extinction learning hamper CBT effectiveness. Another way to gain more insight into fear learning as a mechanism of change in CBT is by examining changes in extinction learning following (successful) CBT treatment. If extinction deficits are trait factors of those with anxiety disorders, one would expect to find that someone’s performance on an extinction learning task would not be affected by CBT. Essentially, personality traits are thought to be relatively stable over time. Alternatively, CBT may improve someone’s extinction learning capacity. Indeed, Duits et al. (2016) found no differences in extinction learning between those treated with CBT for their anxiety disorder and nonanxious controls, suggesting that any preexisting extinction deficits had been resolved following CBT. Another indication that CBT affects extinction learning capacity comes from a study by Schienle et al. (2007), who compared changes in brain activation between a group of people with spider phobia who received one session of exposure therapy and a control group. Those who had received exposure showed more pre-to-post increase in the activation of the orbitofrontal cortex (OFC), an area that is implicated in extinction learning and specifically thought to be related to the learning of the CS/no US association. Similarly, Kircher et al. (2013) demonstrated that, as compared with nonpatient controls, patients who had received CBT for their panic disorder had better connectivity between cerebral regions (inferior frontal gyrus [IFG]) and fear-related areas (i.e., amygdala, insula, ACC) during a fear conditioning task, suggesting that CBT improves emotional control. Taken together, these studies suggest that patients with anxiety disorders are marked by extinction deficits and those with more deficits profit less from CBT but also that these learning deficits are reversible and can change following successful CBT. Clearly, more work needs to be done to unravel the association between fear learning and CBT outcome. Are “bad performers” able to profit from CBT under certain conditions or will they never learn? Do they need longer sessions, more sessions, explicit contingency

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learning, or cognitive enhancement? Linking the paradigms of the experimental fear conditioning literature with CBT effectiveness research has opened interesting new avenues to study the mechanisms of action of CBT and might ultimately guide interventions to improve CBT efficacy. For example, poor performance on a fear conditioning experiment before treatment may lead to the prescription of longer or more exposure exercises or pharmacotherapy (see also the section on pharmacological enhancement below). Importantly, there is currently no well-established way to assess extinction learning during CBT sessions. Measuring extinction learning over the course of treatment would provide crucial information on the temporal association between extinction learning and symptom change in CBT. Some have used change in subjective fear levels during and across CBT sessions (i.e., fear habituation) as an index of extinction learning (Berry et al., 2009; de Kleine et al., 2015; Smits, Rosenfield, Otto, Powers, et al. 2013). But, although the reduction of fear may point to extinction learning, fear habituation is not equivalent to extinction learning. Fear habituation in itself may be an indicator of change, but the empirical evidence that fear habituation mediates exposure therapy outcome is unstable (for review, see Craske et al., 2008, 2014) To summarize, linking the empirical evidence for extinction learning as a mechanism of action to Kazdin’s mediation criteria, (a) there is strong theoretical and preclinical work that supports extinction learning as a crucial mechanism of change in CBT, (b) extinction learning appears to improve following CBT, and (c) whether extinction learning during CBT sessions drives CBT’s efficacy requires further study. Avoidance Learning Avoidance is behavior that is carried out to protect oneself from confrontations with feared danger (see for review Krypotos et al., 2015). When dangers are real, avoidance can help prevent harmful outcomes. However, when fears are irrational and there is no real danger, avoidance is unnecessary. Importantly, avoidance precludes learning opportunities to see that fears are irrational. Persistent avoidance behavior in response to “false alarms” is, therefore, not only a hallmark of anxiety disorders but also an important maintaining factor. In the section that follows, we focus on the influence of avoidance on change mechanisms during CBT. Theoretical Accounts of Avoidance Remarkably, the fear conditioning and extinction learning research has mostly focused on fear (i.e., physiological arousal, freezing, or subjective fear) and not as much on avoidance behavior. However, avoidance behavior is a cardinal symptom of all anxiety disorders, underscoring the need to understand what role avoidance plays in the origin and maintenance of anxiety problems. Here, we discuss the empirical evidence for the impact of avoidance on extinction learning, in both experimental fear conditioning and clinical studies.



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In the two-factor theory, Mowrer (1951) proposed that fear is first acquired via the coupling of a conditioned stimulus with an aversive outcome (classical conditioning; first factor) and, next, that avoidance behavior is reinforced by reduction of this learned fear (instrumental learning; second factor). Thus, a patient experiences a panic attack (US) in a supermarket (CS) and becomes fearful of supermarkets (CS/US association). Next, avoiding the supermarket is reinforced by the reduction of fear. According to this theory, fear is the motor of avoidance behavior, and the reduction of fear reinforces avoidance behavior. But this model has been criticized, as it has been repeatedly shown that avoidance behavior can persist following fear extinction, suggesting that fear is not necessary for avoidance behavior (Bravo-Rivera et al., 2014; Solomon et al., 1953; Vervliet & Indekeu, 2015). Most recently, LeDoux et al. (2017) proposed that avoidance behavior follows not only from classical conditioning and instrumental learning but also from habitual learning. Habitual learning refers to the process whereby after many repetitions, actions become habits, which are highly persistent and insensitive to outcome. In this case, for a person who avoids the supermarket repetitively over a period of years, their avoidance may become habitual. Clinically, this is highly relevant, as habitual responses tend to resist extinction (see LeDoux et al., 2017). With regard to the mechanisms of change associated with CBT, the idea that avoidance might result from different processes suggests that different therapeutic strategies may be required to reduce avoidance behavior. The Impact of Avoidance on Fear Learning Aiming to teach patients that their fears are irrational, CBT programs for anxiety disorders encourage patients to have contact with feared stimuli without engaging in avoidance behaviors. Here, it is worth noting that these avoidance behaviors—also termed “safety behaviors”—can range from high-cost actions (e.g., not going out of the house or to work) that hinder normal life functioning to more subtle or low-cost behaviors. For example, a patient with panic disorder and agoraphobia may still visit crowded stores, but only when accompanied by a trusted partner. Theoretically, these safety behaviors are conditioned inhibitors of the fear response because they predict the absence of the US. These safety signals are thought to be detrimental to extinction learning, a phenomenon called protection from extinction. Protection from extinction refers to the finding that when the CS is presented in conjunction with an inhibitory CS (i.e., a predictor of the nonoccurrence of the US) during extinction, the CS again elicits the fear reaction when presented without the inhibitory CS at a later time point (Lovibond et al., 2009; see Table 4.1 for examples). Clinical studies have demonstrated the unfavorable effect of safety behaviors on CBT efficacy. Exposure with explicit instructions to reduce safety behaviors proved more efficacious than exposure without such instructions (Salkovskis et al., 1999; Wells et al., 1998). A study wherein the use of safety behaviors was experimentally manipulated demonstrated that people with claustrophobia who were allowed to use safety behaviors during in vivo exposure reported

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more fear at posttreatment and follow-up compared with those who could not use safety behaviors but were encouraged to focus on threat reevaluation (Sloan & Telch, 2002). Moreover, in a further refinement of this study design, Powers et al. (2004) demonstrated that it is not the use of safety behaviors per se but rather the availability of safety strategies that interferes with exposure efficacy. Clinically, this implies that to effectively treat anxiety disordered patients with exposure, patients should be encouraged not only to not use safety strategies (e.g., taking an anxiety pill) but also to limit the availability of the safety aid (e.g., carrying the pill). It should be noted that several studies failed to find detrimental effects of safety behavior on exposure efficacy (Deacon et al., 2010; Hood et al., 2010; Olatunji et al., 2013; Rachman et al., 2011; Sy et al., 2011). An alternative view on safety behavior is that it may help patients engage in exposure therapy and, thereby, promote the acceptability of treatment. Clearly, more work is warranted here to obtain a more thorough perspective about the specific conditions under which safety behaviors are either helpful or detrimental. For now, it is unclear the extent to which safety behaviors hinder (or help) the learning (i.e., extinction learning) thought to be crucial for CBT mechanisms. Avoidance in Depression In contrast to the anxiety disorders, less is known about avoidance behavior in those with depressive disorders. Whereas avoidance in anxiety specifically relates to the avoidance of a circumscribed threat event, avoidance in depression has been qualified as a problem-solving style, coping strategy, or personality trait (Ottenbreit & Dobson, 2004). Ferster (1973) suggested a central role for avoidance in depression. He posited that depressed individuals tend to avoid or escape situations that are considered to be unpleasant. Frequent avoidance would lead to decreased opportunities for positively reinforced behavior and social interactions and, thereby, promote apathy and inaction. Behavioral activation (BA) has its basis in Ferster’s functional analysis of depression and aims to reduce avoidance behavior (Lewinsohn et al., 1976). In BA, patients are taught coping and problem-solving skills to overcome avoidance and increase their activities in order to increase the likelihood of response-contingent positive reinforcement from their environment (Jacobson et al., 2001). BA has proven to be as efficacious as cognitive therapy in the treatment of depression (Cuijpers et al., 2007), some studies even showing superior efficacy (Dimidjian et al., 2006). What is more, a dismantling study of CBT for depression by Jacobson et al. (1996) showed that BA alone was as efficacious as BA combined with cognitive therapy in both reducing depressive symptoms and altering negative thinking, suggesting that exposure to reinforcing contingencies might be an important change mechanism in treatment for depression. However, determining whether the reduction of avoidance behavior (and thereby the increase of positively reinforcing activities) is indeed the mechanism of action of BA requires further study (Manos et al., 2010).



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Generalization of Fear Learning Fear learning is not limited to the specific instances in which conditioning has occurred. For example, stimuli that have not been associated with the aversive event but that resemble the CS can come to elicit the fear response as well. This resemblance between the CS and the associated stimulus can be either perceptual or symbolic. For instance, someone who experienced a panic attack (US) in a shopping mall (CS) can come to fear other shopping contexts (e.g., grocery stores), all crowded spaces (e.g., fairs or festivals), or situations that share no perceptual similarities to shopping malls but are related to the feared object on a conceptual level (e.g., train rides, which can also foster feelings of entrapment; for an overview, see Dymond et al., 2015). In clinical care, it is not always possible or fruitful to get an idea of the conditioning history, as the route from the original conditioning experience to current fear may be quite complex. In experimental paradigms, generalization is examined by presenting participants with stimuli that in more or lesser degree resemble the CS, called generalization stimuli (GSs), and it is then assessed whether these generalization stimuli elicit the fear response. Patients with anxiety disorders have been shown to display an overgeneralization of fear when compared with healthy controls; that is, they show fear responses to GSs that show less perceptual resemblance to the CS (Lissek et al., 2010, 2014). Aside from the acquisition of fear, overgeneralization might influence the extinction of fear. Until now, studies investigating generalization effects on extinction are sparse, although these studies would obviously be of great clinical relevance. In clinical care, it is often not possible or ethical to expose a patient to the original CS (for instance, in PTSD), and there is no other option than to expose to resembling stimuli. The experimental studies that have examined generalization in extinction provide a somewhat gloomy picture. Whereas extinction of the original CS transfers to related stimuli, the opposite appears not to be true, as extinction of a GS does not affect fear of the CS (Boddez et al., 2012; Vervliet et al., 2005; Vervoort et al., 2014). This pattern of results suggests that CBT might be most effective when exposure exercises include exposure to the original CS, but again, this is often not possible. Recently, it was shown that verbal information about the typicality of the CS as predictor of the US (e.g., the stimulus “Labrador” is typical for all danger stimuli “dogs”) could reduce the return of fear following extinction (Scheveneels et al., 2017). It has been suggested that people perceive the omission of the US during extinction as “an exception to the rule” (Bouton, 2002; Scheveneels et al., 2017). Explicitly labeling a stimulus as a typical exemplar of a certain category (and thus not an exception) might, thus, enhance learning and optimize outcome. Whether this suggestion indeed holds in clinical care requires further study. There are no clinical studies examining the effect of exposure to the original CS versus exposure to GSs. Some work has been done on stimulus variation, with the idea that extinction to multiple GSs might enhance retention of learning experiences. Indeed, there are some indications that variation of stimuli

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during exposure leads to better outcome as compared with constant stimulus presentation (Lang & Craske, 2000; Rowe & Craske, 1998), but more work should be done to allow clinical recommendations. In sum, although fear acquisition is easily generalized across stimuli and contexts, extinction of fear does not easily transfer. This provides a challenge for the efficacy of CBT, especially in the long term (i.e., after treatment completion). However, more work is warranted to examine whether generalization of extinction learning across stimuli and contexts mediates CBT outcome and, if so, the way in which generalization of extinction learning can be facilitated. Pharmacological Enhancers of Extinction Learning Over the last decade, researchers have attempted to boost therapeutic effects for anxiety and related disorders by combining CBT with pharmacological strategies thought to enhance memory and learning processes underlying CBT efficacy. In the previous paragraphs, we reviewed the evidence for extinction learning as a mechanism of action of CBT. Animal studies have shown that several pharmacological agents can facilitate extinction learning. That is, administration of such a drug leads to faster learning or better retention of learning experiences. Translating this paradigm to the clinic, researchers have given pharmacological agents in conjunction with a CBT session. If extinction learning is indeed a crucial mechanism of action of CBT, one would expect to find that those who receive a drug that improves extinction learning would improve faster or more over treatment than those who receive a placebo. Relating this field of research to Kazdin’s (2007) criteria for research on mechanisms of change, we see that theoretical and preclinical knowledge about a mechanism of action of CBT (i.e., extinction learning; Criterion 1) is used for experimental manipulation (i.e., pharmacological augmentation; Criterion 2) and tested in RCTs (i.e., comparing the effects of CBT plus pharmacological agent versus CBT plus pill placebo on symptom change; Criterion 3). The first drug that was examined within this paradigm was D-cycloserine (DCS), a partial agonist of the NMDA receptor that is thought to enhance the consolidation of extinction learning. Whereas the first human studies demonstrated that those who received DCS prior to CBT sessions had better treatment outcomes than those who received placebo (Hofmann et al., 2006; Ressler et al., 2004), subsequent studies have reported weaker or null findings (see meta-analysis by Mataix-Cols et al., 2017). Thus, whereas early work (in animals and humans) generated strong evidence that DCS enhances extinction memory consolidation and that this learning and memory process is likely implicated in CBT efficacy, it is unclear whether DCS given in conjunction with exposure therapy leads to superior therapy outcomes. Importantly, ongoing research has shown that the efficacy of DCS is influenced by different patient and treatment characteristics. For instance, some found that DCS effects are dependent on the success of the exposure session (Smits, Rosenfield, Otto, Marques, et al., 2013; Smits, Rosenfield, Otto, Powers, et al., 2013). This makes



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sense, as DCS is thought to enhance the consolidation of extinction learning. Thus, initially, this line of research was aimed at improving CBT outcome by augmentation of an identified mechanism of action—extinction learning. Accumulative science has pointed to moderators of DCS enhancement effects. Apparently, DCS does not augment CBT efficacy for all patients under all conditions. Future studies should investigate these moderators and mediators and identify for whom and when DCS might improve CBT efficacy. DCS is the most studied drug within this paradigm, but the effects of several agents thought to enhance extinction learning have been tested in clinical trials. For instance, yohimbine (Meyerbroeker et al., 2012; Powers et al., 2009; Smits et al., 2014), methylene blue (Telch et al., 2014), oxytocin (Acheson et al., 2015; Guastella et al., 2009), and hydrocortisone (de Quervain et al., 2011; Soravia et al., 2006, 2014; Yehuda et al., 2015) have all been given in conjunction with exposure sessions, with the aim of boosting extinction learning during these sessions and, thereby, improving treatment effects. Of note, the effects of these drugs may not be restricted to extinction enhancement but might involve other mechanisms of action underlying CBT. For instance, hydrocortisone (cortisol) is known to reduce emotional memory retrieval (de Quervain et al., 2009), and oxytocin promotes social learning (Guastella et al., 2008). Thus, these agents might boost CBT effects via different mechanisms. Future studies will shed more light on the mechanisms of action of these drugs and enlighten the promises and limitations of different enhancement strategies.

COGNITIVE MECHANISMS Challenges are part of our lives; however, the way we think about them influences how well we will cope, which in turn will have consequences for our mental health. The same trigger, such as losing a job, can, in this way, lead to a psychological disorder, such as a depressive episode, or to a positive change in life. If the loss triggers self-devaluation and hopelessness (e.g., “I failed; this is catastrophic”), a phase of negativity and eventually even depression might follow. For someone else, losing a job opens new possibilities and is regarded as a positive change. In this manner, the way in which we think about a possible event—as a new beginning, or another failure—influences how well we do. Importantly, the way we process information, rather automatically and often involuntarily, also can further or hinder change. What we attend to and how we evaluate information can have dramatic consequences. Unfortunately, automatic processes such as these are not easily influenced. In this next section, we review processes that have been studied as mechanisms of change for CBT, starting with the emotion regulation strategy of cognitive reappraisal and moving to more automatic processes such as modification of cognitive biases, distancing from repetitive thinking, and adoption of more positive mental imagery. We also briefly discuss change in brain processes as a possible correlate of change in CBT mechanisms.

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Cognitive Reappraisal Cognitive reappraisal is fundamental to CBT. According to the theory that underlies CBT (Beck, 2008; Beck & Haigh, 2014), people who struggle with mental health disorders often view their life circumstances in an inaccurate and/or unhelpful manner. An important focus of CBT, then, is to help patients craft more accurate and helpful interpretations and views of these circumstances, which is expected to soften negative emotional reactions. This is a form of cognitive reappraisal that in turn is a very important and well-researched form of emotion regulation (Gross & Thompson, 2007). According to the appraisal theory, the way a person thinks about or appraises the meaning of their experiences influences their emotional responses (Frijda, 1986; Lazarus, 1991). The notion that emotions partly depend on the way a person thinks about events means that the capacity of a person to alter their way of thinking is important for emotional well-being (Gross, 2001). Research shows that successful cognitive reappraisal is effective in reducing negative emotions. For example, in Arimitsu and Hofmann’s (2017) study, over 200 healthy individuals performed a writing assignment in which they used one CBT strategy to change self-critical thinking about a past event. Participants completed either a cognitive reappraisal exercise or an exercise focused on another CBT strategy, such as responsibility reattribution (i.e., helping the patient step back and consider different factors that contributed to the occurrence of an event), self-deflection (i.e., inviting the patient to focus on their positive characteristics in reinterpreting events), or self-compassion (i.e., inviting the patient to approach their feelings and thoughts in a caring and accepting way), or were given no instructions as a control condition. Results indicated that cognitive reappraisal, together with self-compassion, was associated with lower levels of negative emotions, compared with the responsibility reattribution and control conditions. Relatedly, other studies comparing different emotion regulation methods that are used in CBT with patients have found cognitive reappraisal to be a particularly effective emotion regulation strategy for disorders such as depression, anxiety, and addiction and more effective than suppression of negative or unwanted thoughts (Beadman et al., 2015; Moscovitch et al., 2012). Cognitive reappraisal has been studied as a CBT working mechanism mainly in (social) anxiety. In general, anxious individuals are less effective than nonanxious individuals in deploying cognitive reappraisal (Goldin et al., 2009). Also, cognitions about reappraisal itself may play a role in CBT. For example, socially anxious individuals believe that they are not effective in applying this emotion regulation strategy (Goldin et al., 2009). Goldin et al. (2012) found that, in SAD patients, 16 sessions of individual CBT improved patients’ belief that they can successfully employ cognitive reappraisal. The change in cognitive reappraisal mediated the effect of CBT on anxiety symptoms, providing some indication for the role of cognitive reappraisal in CBT efficacy. Also, research shows that early acquisition of cognitive reappraisal skills during CBT predicts subsequent symptom reduction in patients with SAD (Moscovitch et



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al., 2012), providing additional evidence for its mechanistic role in CBT. In this study, SAD patients underwent 12 sessions of group CBT, and cognitive reappraisal and emotion suppression strategies were measured pre-, mid-, and posttreatment. CBT responders had a higher level of cognitive reappraisal skills by midtreatment compared with nonresponders, but responders did not differ from nonresponders in their use of emotion suppression strategies throughout the course of treatment. Another study randomized SAD patients over 16 sessions of CBT or a wait-list condition (Brozovich et al., 2015). Researchers measured social anxiety symptom severity, cognitive reappraisal, and rumination (a possible mechanism of change we discuss in detail later), not only at the beginning, the middle, and the end of treatment but also weekly during the course of CBT. Rumination, but not cognitive reappraisal, was related to symptom change over the course of CBT. Finally, examining modification of underlying beliefs rather than situation-specific thoughts, Gregory et al. (2018) demonstrated that change in maladaptive self-beliefs predicted reduction in social anxiety at the end of treatment, implying that successful modification of unhelpful beliefs is a key mechanism of action in the successful cognitive behavioral treatment of SAD. Cognitive reappraisal as a mechanism of change in CBT for SAD has also been examined in various subtypes of CBT (broadly speaking). Kocovski et al. (2015) examined cognitive reappraisal and mindfulness and acceptance as mechanisms of change in patients with SAD who were randomly assigned to traditional group CBT or mindfulness and acceptance-based group therapy. Cognitive reappraisal mediated symptom change in traditional group CBT, such that self-reported use of cognitive reappraisal, had a greater impact on social anxiety symptoms and on the rate of change in social anxiety symptoms in traditional group CBT than in the mindfulness and acceptance group. Interestingly, mindfulness mediated treatment and ultimate symptom change in both groups. A review by Smits et al. (2012) focused on a specific form of cognitive reappraisal as mechanism of change in CBT for anxiety, namely threat reappraisal. Anxious individuals tend to overestimate the likelihood and negative consequences of harm. During threat reappraisal, these faulty appraisals are modified by crafting accurate and helpful interpretations and ideas about the (consequences) of the expected harm. In the review, studies on threat reappraisal in CBT in anxiety disordered patients were included only if they had a longitudinal design (i.e., multiple assessments over time) and if they investigated threat reappraisal as a mediating factor in the association between CBT and clinical outcome. Approximately half of the studies found evidence for mediation, and threat reappraisal seems to be related to anxiety symptom improvement with CBT (though one study found that threat reappraisal mediated the relationship between CBT and depressive symptoms; Bryant et al., 2001). However, only a few studies met the criteria set forth in the introduction of this chapter that are necessary to conclusively demonstrate that threat reappraisal causes symptom improvement in CBT. A subsequent review (Powers et al., 2017) reported that,

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of 25 studies examining the threat reappraisal mediation hypothesis, 13 of 14 that examined statistical mediation demonstrated evidence for mediation, and six of seven studies that examined causality demonstrated that threat appraisal resulted in a reduction in anxiety. To conclude, change in cognitive reappraisal, including threat reappraisal, has been examined as a mediator on several occasions (see criteria put forward by Kazdin, 2007), and the evidence for their mechanistic role in CBT is mixed but promising. One goal of CBT is for patients to leave treatment with an enhanced sense of self-efficacy, or the belief that they can effect positive changes in their lives (Bandura, 1977). Thus, it is possible that patients improve in CBT in part because they acquire belief that they are able to embrace the strategies that they are being taught and make a positive difference in their lives, such that they have modified their thoughts about their own coping abilities. In fact, in a study of patients with panic disorder, it was found that within-session change in selfefficacy, but not within-session change in catastrophic misinterpretations (which would be modified using cognitive reappraisal), was associated with reductions in anxiety at the end of treatment (Fentz et al., 2013; see also Hoffart, 1995, for similar results). An increase in self-efficacy has also been implicated as a mechanism of change in SAD, as it would suggest that CBT helps socially anxious patients acquire confidence that they will be able to make their desired impression on others (Hofmann, 2000). Although the vast majority of the empirical literature, as reviewed above, focuses on cognitive reappraisal as a mechanism of change in the successful cognitive behavioral treatment of anxiety and related disorders, cognitive reappraisal is also a hallmark feature of CBT for depression. Surprisingly, empirical evidence for the causal influence of cognitive change on symptom change has been mixed (Longmore & Worrell, 2007). Several studies failed to demonstrate a temporal relation between reduction in unhelpful thinking and treatment outcome (e.g., Burns & Spangler, 2001), and one study reported that reduction in depression occurred before, not after, a reduction in unhelpful thinking (Stice et al., 2010). However, other studies have found that cognitive change precedes symptom improvement in CBT but not in a distinctly different approach to treatment, pharmacotherapy (e.g., DeRubeis et al., 1990), though this result was not replicated when cognitive therapy was compared with BA (Jacobson et al., 1996). In a recent study, Schmidt et al. (2019) demonstrated in a sample of 126 depressed patients receiving CBT that self-reported immediate cognitive change at the end of the session was associated with symptom change at the end of treatment, an association that was explained by selfreported sustained cognitive change, or lasting cognitive change that was endorsed at the start of each subsequent session. Although this literature is complicated, it is generally concluded that cognitive change contributes to symptom change in depression, regardless of exactly how it is achieved (LorenzoLuaces et al., 2015). In sum, a robust literature is accumulating that has examined the role of cognitive reappraisal as a mechanism of change in CBT for the two most common categories of emotional disorders—anxiety-related disor-



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ders and depression. According to theory, the modification of inaccurate and unhelpful cognition plays a central role in facilitating successful treatment of these emotional disorders, and research generally shows that patients who complete CBT for these conditions demonstrate a greater ability to use cognitive reappraisal skills, a greater belief in their ability to use cognitive reappraisal skills, lower levels of dysfunctional cognitions, higher levels of self-efficacy, and less maladaptive underlying beliefs. In many instances, assessments of these constructs midway through treatment predict ultimate outcome. However, the pattern of results supporting cognitive mediation in anxiety-related disorders is stronger than it is for depression, and preliminary evidence suggests that other mechanisms of change (e.g., reduction in ruminative processes, mindfulness) also account for variance in treatment outcome. Cognitive Biases One way in which CBT aims to decrease symptom severity is to modify dysfunctional beliefs. Dysfunctional beliefs about the self, the world, and the future are often based on stressful (early childhood) experiences and result in negative mental schemas (Beck, 2008). CBT teaches patients to change their dysfunctional processing style and adopt a healthier, more positive processing style. This is done in an overt way, that is, through talking explicitly about the dysfunctional beliefs, as is often done in cognitive reappraisal. However, dysfunctional beliefs not only are expressed though negative thoughts but also influence the way information is processed automatically. Such a schema-based automatic processing style is called a cognitive bias (Beck, 2008; Beck & Haigh, 2014). Based on Beck’s theory, change in cognitive biases is a proposed mechanism in CBT. Emotions bias our cognitive processing; they give a special weight to information that is congruent with how we feel. For example, anxiety ensures that we attend to threat, whereas sadness or depression ensures that we pause and take more time to reflect. Biased processing is observed across different cognitive domains, of which attention, interpretation, and memory are most frequently studied, in relation to mental health problems. Important to note is that healthy (or rather, nondisordered) individuals show a processing style toward the preferential processing of positive information (Cummins & Nistico, 2002; Gotlib & Joormann, 2010; Mathews & MacLeod, 2005). Specifically, healthy individuals tend to attend more to positive relative to negative information and are more likely to interpret ambiguous events and stimuli in a positive way (Mathews & MacLeod, 2005). Healthy individuals also remember positive information better than negative information (Matt et al., 1992). This means that neither healthy nor disordered individuals are “correct” and that we all are characterized by cognitive biases. Instead, it makes clear that cognitive biases are ubiquitous and that some are just less beneficial to our mental health than others. Different mental disorders are characterized by either facilitated attention to and/or difficulties with disengaging from relevant stimuli, such as alcohol-related

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cues in alcohol addiction, high-caloric food in eating disorders, angry faces in SAD, and negative self-descriptions in depression (Faunce, 2002; Field & Cox, 2008; Gotlib & Joormann, 2010; Mathews & MacLeod, 2005; Van Bockstaele et al., 2014; van Hemel-Ruiter et al., 2016). Consider, again, Mr. G., who has SAD. He has always been self-conscious and shy, but his symptoms have deteriorated because of recent stress. When Mr. G. enters the meeting room at work, his anxiety spikes. As a result, he avoids making eye contact, but he scans the facial expressions of the people around him. His attention is drawn quickly and automatically to expressions of anger and disapproval, causing him to appraise the situation as unpleasant and possibly harmful. By focusing solely on those negative facial expressions, he is likely to remember uncomfortable encounters especially well, which in turn reinforces his avoidance behavior. This example illustrates anxiety-related attention, interpretation, and memory biases in a daily-life setting and how they tend to be interrelated (Everaert et al., 2012). The causal relation between biases and mental problems has been researched most in depression and anxiety (see reviews by De Raedt & Koster, 2010; Van Bockstaele et al., 2014), though there is tentative evidence that biases may be global markers for psychopathology and thus present in a wide range of disorders in addition to anxiety and depression (Vrijsen et al., 2017). Attention and interpretation bias in anxiety have been most frequently studied as mechanisms of change in CBT. For example, a study in highly anxious adolescents showed that attentional bias for threat decreased after CBT (Hadwin & Richards, 2016). A study in patients with SAD compared CBT responders (i.e., with decrease in symptoms) with nonresponders (i.e., with no change in symptoms) and found that only responders showed a decrease in attentional bias for disorder-specific social threat words (Lundh & Öst, 2001). Mediation of attentional bias change on the effect of CBT on symptoms was not examined. Waters et al. (2008) assessed both attentional bias and interpretation bias before and after CBT in clinically anxious children (including children with SAD and generalized anxiety disorder [GAD]) and found that negative interpretation bias but not attentional bias decreased during CBT. Mediation was again not examined. Finally, Davis et al. (2016) examined whether observed improvements in attentional bias mediated CBT effects on social anxiety symptoms in SAD patients, but they showed that these changes did not mediate symptom improvement. Taken together, attentional bias as a CBT mechanism of change has only very sparsely been evaluated according the Kazdin (2007) criteria, and the evidence available does not indicate it as a mechanism of change. Change in interpretation of ambiguous information has also been studied as a mechanism of change for CBT, although also only in a few studies. For example, negative interpretation bias decreased after four sessions of computerized CBT in a sample of individuals with high social anxiety (Bowler et al., 2012). Importantly, this change in bias mediated the effect of CBT on symptoms. In a moderately socially anxious adolescent sample, no difference between individuals receiving CBT and individuals receiving no treatment was found on



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interpretation bias reduction from baseline to the 2-year follow-up (de Hullu et al., 2017). Mediation was, however, not examined. In their review on attentional and interpretation bias change after CBT in anxious children, Ege and Reinholdt-Dunne (2016) concluded that, in children, the evidence regarding the effect of CBT on attentional bias is mixed, and there is limited empirical evidence to indicate that CBT changes interpretation bias. This partially contrasts with more recent evidence of interpretation bias, as well as perceived control, as a strong mechanism of change in anxious children (Pereira et al., 2018). As with attentional bias, structural examination of interpretation bias as a CBT mechanism of change is very limited, and, hence, we cannot conclude whether attentional bias and interpretation bias are mechanisms of change in CBT. So far, memory bias has received even less attention in research on CBT mechanisms of change. A study in depressed patients showed that negative recall bias decreased over the course of CBT but that this change did not mediate a CBT treatment effect in depressed patients (Quilty et al., 2014). There is also some evidence from research in bipolar patients showing that negative memory bias decreased after CBT (Docteur et al., 2013). However, mediation was not studied. No evidence for memory bias as CBT mechanism of change exists. In addition to biased attention, interpretation, and recall of emotional information, automatic negative implicit associations have been studied in relation to CBT outcomes. Implicit associations are also a form of processing bias, as people have either relatively more positive or more negative associations with disorder-related versus neutral words. For example, individuals with GAD show stronger negative than positive associations with worry-related and neutral words on a computer task (Reinecke, Rinck, et al., 2013). In a sample of patients with GAD, negative worry-related associations became more positive after 15 weeks of CBT, and patients showed fewer worry-related intrusive thoughts after CBT (Reinecke, Hoyer, et al., 2013; Reinecke, Rinck, et al., 2013). CBT effects on implicit associations have also been found in individuals with high spider anxiety (Reinecke et al., 2012), such that implicit threat associations were lower after CBT. Implicit associations were also examined in the socially anxious adolescent sample discussed previously (de Hullu et al., 2017) but did not change from before CBT to 2 years after CBT. Importantly, mediation was not examined in any of these studies. Thus, although implicit association may change in some anxiety patients, evidence for implicit associations as a mechanism of change in CBT does not exist at this point. Change in bias has been studied more structurally in relation to antidepressant treatment. This means that mediation was examined and bias was assessed, not only before and at the end of treatment but also multiple times during treatment, thus conforming to the recommendations put forward by Kazdin (2007). From pharmacological treatment studies, we know that change in bias may precede symptom change during treatment (Harmer & Cowen, 2013). Serotonergic antidepressants may change the brain’s reactivity to emotional

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stimuli, encouraging a relatively more positive attentional bias (Browning et al., 2010) and, in turn, contributing to symptom reduction. Studies that show support for bias modification as a mechanism of change for CBT are limited at this time, mostly because of a lack of adequately designed studies for testing this putative change mechanism. On the basis of Beck’s cognitive theory of depression, change in biases is expected to precede symptom change during CBT, in line with the pharmacological studies. Overall, cognitive processing seems to become less negatively biased after CBT. But because (a) most studies do not include mediational analyses on the role of change in bias on symptom change during CBT and (b) there are no studies, as far as we know, measuring bias during the course of CBT, we currently cannot either accept or reject cognitive biases as CBT mechanisms of change. What studies are needed that can yield data that would allow us to fully conclude whether changes in cognitive biases can be considered mechanisms of change? Considering the criteria put forward by Kazdin (2007), again, we need RCTs in which not only bias but also other hypothesized mechanisms of change are measured after every (couple of) session(s) and mediation of symptom change during CBT by bias change is analyzed. This will inform us about the temporality (i.e., when does change occur?) and specificity (i.e., is symptom change related to bias specifically?) of biases as mechanisms of change. Important to note here is that we are now clustering evidence on biases in different cognitive domains (e.g., attention, interpretation, memory, associations) on the basis of different measurements used (e.g., reaction time tasks, explicit verbal tasks), and for different stimulus types (e.g., disorder-specific or more general stimuli, pictures, words). Although we assume that all tasks used measure the same underlying construct of cognitive bias, we currently do not know to what extent the variation in measurement affects the (generalizability of the) results. Moreover, the research on change in cognitive biases as a mechanism of CBT needs to be extended to include the study of disorders beyond anxiety and depression, such as eating disorders and addiction. The question of whether cognitive biases are mechanisms of change remains unanswered until we have sufficient high-quality evidence. Repetitive Negative Thinking: Rumination and Worry Negative repetitive thinking patterns are prominent in many mental disorders, rumination being the best researched of those patterns. According to cognitive theory, negative cognitive schemas (Beck, 2008) drive this negative and preservative processing style. While ruminating, an event is retrieved from memory and the causes and consequences are repeatedly processed without engaging in active problem solving (Nolen-Hoeksema et al., 2008). Worry is a similar activity, but the focus instead is on future negative events. Individuals use repetitive negative thinking to cope with emotional distress, which maintains this unhealthy cognitive style. Many patients are concerned about the negative consequences of their repetitive negative thoughts, which results in even more



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distress and contributes to psychopathology. Both rumination and worry are experienced as excessive and uncontrollable. Rumination and worry have been most frequently linked to depression and anxiety, respectively. However, both are also well researched as more global risk factors for mental problems (Ehring & Watkins, 2008; Harvey et al., 2004), such as eating disorders, substance abuse, suicidal ideation, and depression/anxiety comorbidity (Gibb et al., 2012; Miranda & Nolen-Hoeksema, 2007; Nolen-Hoeksema, 2000; Nolen-Hoeksema et al., 2007). A special form of rumination linked to SAD is postevent processing (Clark & Wells, 1995). Socially anxious individuals tend to extensively review past embarrassing or stressful events. Socially anxious individuals are likely to have experienced anxious feelings and heightened self-focus during the event, and these negative feelings are likely to be a prominent part of the memory. Moreover, reviewing a past event and evaluating it as negative will likely trigger memories of other instances of perceived social failure, contributing to the negative impact of postevent processing. Consider, once again, Mr. G., who has SAD. He feels anxious and down, but he still manages to go to work. At work, he gave what many viewed as a good presentation. Despite this feedback, Mr. G. has difficulty letting go of the thought that he responded badly to a question. He is unable to stop thinking about how this could happen and what the others now might think. Ruminating over this incident does not change what happened, nor will it help him perform better the next time. It simply increases his emotional distress. Changes in rumination and worry are proposed as mechanisms of change in CBT and have been related to CBT outcomes. For example, a study of SAD found that negative rumination decreases after 12 weeks of CBT (Abbott & Rapee, 2004). However, mediation of the treatment effect by change in rumination was not examined, and all SAD patients received CBT, meaning that treatment effects cannot be attributed to CBT with certainty. As presented previously in the section on cognitive reappraisal, Brozovich et al. (2015) measured social anxiety symptom severity, rumination, and cognitive reappraisal weekly during the course of CBT and found rumination to be associated with weekly changes in social anxiety. Change in worry has been mostly studied in GAD patients as a mechanism of change in CBT. In one study focusing on individual response trajectories, seven GAD patients completed a daily questionnaire, including items assessing symptoms and worry during 10 to 12 weeks of CBT (Bosley et al., 2018). All patients showed improvement in (controllability of) worry over the course of CBT. However, the authors did not relate change in worry to symptom change. Another study found that early decreases in worry (after the first month of CBT) predicted treatment response not only immediately after 10 sessions of CBT but also 1 year after the end of treatment (Bradford et al., 2011). Moreover, the magnitude of early reduction in worry predicted symptom decrease from posttreatment to 1 year later. Lemmens et al. (2016) reviewed studies examining, among other constructs, rumination and worry as mechanisms of

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change in various forms of psychotherapy including CBT and concluded that (a) rumination and worry are associated with depressive symptom change in the majority of studies, but (b) few studies conducted mediation analyses, and the results on the role of rumination and worry in symptom change are mixed. They furthermore posited, “Research aimed at identifying the active ingredients of psychotherapy for depression would benefit from a further refinement of research methods to disentangle mechanisms of change” (Lemmens et al., 2016, p. 105). This is, indeed, the conclusion that can be drawn when reviewing literature on rumination and worry as mechanisms of change in CBT, as change in both seem related to symptom change, but thorough and structural (see criteria put forward by Kazdin, 2007) examination of worry and rumination as mechanisms of change (starting with mediation analyses) is largely lacking. Mindfulness-based cognitive therapy (MBCT; Teasdale et al., 1995) combines mindfulness with elements of CBT such as activation and psychoeducation. As with CBT, MBCT is based on the assumption that patients with mental disorders differ from healthy individuals in cognitive processing (Ma & Teasdale, 2004; Teasdale et al., 1995). Reduction in rumination is a proposed mechanism of change of MBCT, as for CBT. To illustrate, one study compared MBCT with CBT in depressed patients and found that both treatments affect rumination to the same extent and that posttreatment rumination was related to posttreatment depressive symptom levels for both treatment types (Manicavasagar et al., 2012). Mediation of treatment effect by rumination change was, however, not studied. Gu et al. (2015) conducted a meta-analysis of mediation studies on the mechanisms of change in MBCT for depression, anxiety, stress, and overall psychopathology. They included six studies on rumination and/or worry and found moderate consistent evidence for rumination and worry as mediators for clinical outcomes. Taken together, and in contrast to traditional CBT, the evidence for change in rumination and worry as a mechanism of change in MBCT is rather consistent and based on several mediation studies. Experimental research on the central role of rumination in depression instigated a new translational approach to CBT specifically targeting ruminative thinking called rumination-focused CBT (Watkins, 2009). In this form of CBT, patients learn to switch from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises, and behavioral experiments. This means that rumination is explicitly implemented as a mechanism of change. So far, this novel approach to CBT has been tested in remitted depressed patients and appears efficacious in improving residual depressive and comorbid symptoms (Watkins et al., 2007, 2011). Moreover, research shows that change in rumination mediates treatment outcome in one study comparing treatment as usual plus rumination-focused CBT to treatment as usual alone (Watkins et al., 2011). Although compelling, the clinical effects and mechanisms of change of this novel form of CBT need to be studied further. Taken together, the theoretical background of CBT and some experimental work indicates that decreases in rumination and worry are related to CBT efficacy.



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Emotional Mental Imagery Mental imagery has received much attention in psychological research, and the adoption of more positive mental imagery has been proposed as a mechanism of change in CBT. Mental imagery refers to the “perceptional experience in the absence of sensory input” (Ji et al., 2016, p. 703) and is often described as “seeing with the mind’s eye” and “hearing with the mind’s ear” (Kosslyn et al., 2001, p.  635). A mental imagery representation of an emotionally charged stimulus activates a network of related information that largely mimics the actual experience of encountering this stimulus. Imagery interventions in CBT are based on the idea that emotional mental imagery has a strong effect on emotional processing. Consider again Mr. G., who has SAD. Mr. G forgot his keys in the meeting room at work. Thinking about going back to the workplace prompts upsetting mental images—Mr. G. sees the meeting room with his mind’s eye (i.e., perceptual information), and he also feels how uncomfortable and anxiety provoking it is to be in the meeting room (i.e., affective information). Even his muscles react involuntarily by tensing up. Hence, the imagined confrontation with the stimulus (i.e., the meeting room) evokes emotional responses in a similar fashion to the actual interaction with the stimulus on a perceptual, semantic, affective (Moulton & Kosslyn, 2009), and even physiological level (for an overview, see Ji et al., 2016). Negative imagery contributes to the development and maintenance of anxiety disorders such as SAD and PTSD (Clark & Wells, 1995; Ehlers & Clark, 2000) and is also present in depression (e.g., Holmes et al., 2007). Specifically, as proposed in the model by Clark and Wells (1995), when in a feared or overall negative situation, anxious and depressed patients experience excessive negative images of themselves. They erroneously base their conclusions about constructs like their own performance or own worth on these images. Negative images tend to represent abstracted core ideas about how patients think about themselves. Emotional mental imagery might, thus, be a strong target for treatment because it impacts emotional response even more so than verbal processing, which is a central target of CBT (Ji et al., 2016). As presented in the section on learning mechanisms, exposure is a CBT technique often used to treat anxiety disorders such as SAD, obsessivecompulsive disorder (OCD), GAD, and PTSD (see Holmes & Mathews, 2010; Ji et al., 2016), as well as depression (Hayes, 2015). Imaginal exposure occurs when the patient vividly imagines the feared situation and its consequences and does not avoid the subsequent experience of anxiety. Mental imagery is used to evoke emotions during imaginal exposure, and this affective response is also a requirement for imaginal exposure to yield effects on symptomatology. Emotional mental imagery is, hence, a key element of exposure therapy and is therefore proposed to be a mechanism of change. Although far from being part of standard CBT for depression, imaginal exposure may also reduce intrusive memories in depression (see, for example, a case study by Kandris & Moulds, 2008).

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Imagery rescripting is another imagery-based CBT technique that is increasing in popularity among cognitive behavioral therapists. In imagery rescripting, the patient and therapist find an alternative, more positive outcome for an intrusive image or memory. Subsequently, the patient is prompted to focus on the content of the image or memory and rehearse imagining the previously generated alternative outcome. Imagery rescripting has been proved effective in lowering symptom levels, especially when combined with exposure or classic CBT in the treatment of PTSD, anxiety, depression, OCD, and personality disorders (see Ji et al., 2016; Veale et al., 2015), and it may even work as stand-alone treatment (see, for evidence in depression, Brewin et al., 2009). As for imaginal exposure, emotional mental imagery is a key component of this technique but has not been explicitly studied as a mechanism of change so far. The role of emotional imagery in emotional problems and related psychopathology is evident. To date, emotional mental imagery is used as a treatment target in anxiety (and sometimes depression), but research (e.g., mediation studies) directly examining emotional mental imagery as a mechanism of change seems to be lacking. Nevertheless, we think imagery is a possible mechanism worth mentioning because it will likely continue to attract attention in the clinical research field in the coming years.

MECHANISMS OF CHANGE IN OTHER MENTAL HEALTH DISORDERS As is evident in this chapter, the majority of theoretical inquiry and empirical research on mechanisms of change has focused on anxiety disorders and depression. Thus, the potential candidates to serve as mechanisms of change that have primarily been subjected to empirical scrutiny are generally those that are in line with cognitive behavioral theories of anxiety-related disorders and depression. Clearly, there is a great need to extend consideration of processes of change to other types of mental health disorders. In this section, we present examples of research on the mechanisms of change associated with CBT of other mental health disorders. Perhaps the most complicated mental health disorder that has been subjected to mechanism-of-change analyses is alcohol use disorder, as the extant research shows that purported mechanisms of change typically only apply to subsets of the samples under consideration. For example, Roos et al. (2017) demonstrated that self-reported coping (e.g., finding alternative activities, seeking social support, using stimulus control techniques, thinking about the benefits of changing drinking habits) at the end of treatment mediated the positive effects of CBT in patients with high (but not low or moderate) baseline dependence severity. Although this study highlights the importance of the acquisition of a wide array of coping skills, its limitation is that self-reported coping skill was not measured at various intervals throughout the course of treatment. Hallgren et al. (2019) found that abstinence status at the time of treatment commencement is important, with those already abstinent when treatment



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started reporting higher levels of self-efficacy and use of coping skills throughout treatment and those committing to abstinence at some point during the course of treatment reporting improvements on these variables the same week. In a relatively recent review, Magill et al. (2015) highlighted that methodological limitations (e.g., inadequate measurement of coping skills) might explain the lack of compelling data supporting the acquisition of coping skills as a mechanism of change for alcohol and drug use disorders in research conducted through the mid-2000s. More recent research has indeed supported the notion that increased coping skills mediate the relation between specific CBTs and outcomes for gambling (Petry et al., 2007), alcohol use disorder (Witkiewitz et al., 2012), and drug use disorder (Kiluk et al., 2010). In the realm of eating disorders, Dingemans et al. (2007) examined mediators of outcome in CBT for binge-eating disorder. Results indicated that a reduction in self-reported weight concerns, a cognitive variable, mediated the outcome (i.e., abstinence of binge eating) posttreatment. However, patients generally demonstrated a rapid response to treatment, with a significant reduction in binge-eating episodes in the first half of treatment before mediators were measured midtreatment. Thus, we cannot conclude that reduction in weight concerns caused response to treatment that was measured after treatment had ended. Research has very recently ventured into the territory of examining potential mediators involved in CBT for psychosis. Mehl et al. (2018) considered various relevant cognitive factors that could serve as mediators in the successful reduction of delusions, such as a change in reasoning biases, changes in self-schemas, and improvements in self-esteem. Variables were measured only pretreatment and posttreatment, so conclusions about temporal changes in putative mediators could not be made. Regardless, the only cognitive variable that showed a reduction in treatment was implicit associations associated with self-esteem, and none of these variables demonstrated a mediating effect on strength of delusions posttreatment. This research clearly suggests that more critical examination into the mechanisms of change in CBT for psychosis is warranted.

CONCLUSIONS AND FUTURE DIRECTIONS In this chapter, we reviewed evidence for mechanisms of change in CBT. Fear extinction and avoidance learning are regarded as important learning mechanisms, and cognitive processes such as cognitive reappraisal, cognitive biases, repetitive negative thinking, and mental imagery all are central to theoretical accounts guiding CBT. Although the empirical literature on mechanisms of change of CBT has grown, the quality and quantity of evidence supporting theory is limited at this time. Indeed, there is considerable heterogeneity in the quality of research on mechanisms of change (Kazdin, 2007, 2009; Maxwell & Cole, 2007). Although most proposed mechanisms are related to symptom

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improvement in CBT, there are few studies that meet the criteria to conclude that the mechanism indeed causes symptom improvement in CBT (see Kazdin, 2007, 2009) and that it is not reflecting a nonspecific therapeutic change mechanism. Considering the research criteria and phases identified by Kazdin (2007) and described at the beginning of this chapter, we can conclude the following. First, mechanisms are, in fact, generally selected based on theory or previous correlational or preclinical research. Most mechanistic processes have been manipulated, and RCTs measuring the different mechanisms discussed in this chapter have been conducted. The main caveat in current literature seems to be the execution of mediation studies, as well as studies measuring the proposed mechanistic process together with other processes in multiple CBT sessions. This means that, for the future, it will be important to do RCTs specifically designed to examine the specificity and temporality of mechanisms of change and then to disseminate this knowledge to CBT practice. Mechanisms of change may differ between disorders, just as there is variation in (key) risk factors for different disorders. Focusing on the examination of certain mechanisms (e.g., extinction learning) in certain disorders (e.g., anxiety) makes sense. However, to be able to draw conclusions about the general and disorder-specific mechanisms of change in CBT, future research should include a broader range of disorders. Related to this is the weakness that comorbidity as well as severity of current and past disorders is often ignored in this line of research. It seems plausible that mechanisms of change differ depending on differences in comorbid disorders, severity, and psychiatric past. In addition to addressing these weaknesses, future research in this area may focus more on experimental approaches that directly target putative mechanisms of change (e.g., blocking, augmenting). Some examples of ongoing research in this area include the work on cognitive enhancers described above (Mataix-Cols et al., 2017), as well as research on the effects of neurostimulation, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), on treatment response (De Raedt et al., 2015) and research on exercise augmentation (e.g., Powers et al., 2015). The large variation in measurements (e.g., from implicit computer tasks to self-report questionnaires) may be a methodological limitation that helps explain the lack of compelling evidence for certain mechanisms of change in CBT. As a field, we are clustering different modes of measurement together and assuming we are all measuring the same aspect of a certain mechanism. It is striking that within the clinical research field, “cognition” is measured as a change in content, a change in self-reported skill or usage of a certain cognitive technique, or one’s belief in the ability to apply this cognitive technique. Comparing measurements and creating uniformity in the measurements used should be a goal of future research on mechanisms of change of CBT. We encourage future researchers to compare different types of mechanisms of change within the same sample to determine their relative explanatory power. In one example, Chu et al. (2015) examined the mediational power of



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youth coping (both cognitive and behavioral strategies), therapist interventions (both cognitive reappraisal and exposure), and youth-interfering behaviors (e.g., avoidance, escape, compulsions) in a trial of exposure with response prevention for youth with OCD. Results from this study indicated that all three clusters of variables were important in understanding treatment outcome, having great clinical importance for therapist behavior during exposure and interventions and education provided to clients. Of additional note in this study is that the mediating variables were coded observationally, which is an advantage over self-report measures because it establishes actual behaviors that are contributing to change, rather than patient or therapist perceptions of such behaviors. In another innovative study examining mechanisms, Hayes-Skelton and Marando-Blanck (2019) determined that a reduction in anticipatory processing preceded improvements in decentering in group CBT for social anxiety. In other words, both variables served as mediators of change, but an important temporal order emerged that has implications for the way in which interventions are delivered. These studies raise awareness of the value of comprehensive investigation of mediators of change within the same study and using multiple approaches to measurement. Clearly, much work remains to be completed before we have an understanding of the mechanisms of change associated with CBT that is on par with our understanding of CBT’s efficacy and effectiveness. We encourage researchers to frequently collect data relevant to the broad array of possible mechanisms of change, including those that are cognitive, metacognitive, emotional, and behavioral in nature. We also encourage researchers to distinguish the specific mechanisms of action associated with the lower order distinctive variants of CBT, including cognitive therapy (e.g., Schmidt et al., 2019), schema therapy (e.g., Renner et al., 2018), exposure with response prevention (e.g., Chu et al., 2015), and BA (Jacobson et al., 1996). Of course, it would be ideal for research to demonstrate that different mechanisms of change are at work in distinctively different approaches to treatment, such as CBT and interpersonal psychotherapy, but thus far, there is little empirical support for the notion that different processes are at work in treatments associated with different theoretical frameworks (Lemmens et al., 2017). Understanding the workings of these experimental manipulations can inform us about what changes in whom during CBT. Hence, such research can provide valuable information on CBT mechanisms of change.

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after extinction. Behaviour Research and Therapy, 43(3), 357–371. https://doi.org/10. 1016/j.brat.2004.02.005 Vervoort, E., Vervliet, B., Bennett, M., & Baeyens, F. (2014). Generalization of human fear acquisition and extinction within a novel arbitrary stimulus category. PLOS ONE, 9(5), e96569. https://doi.org/10.1371/journal.pone.0096569 Vrijsen, J. N., van Amen, C. T., Koekkoek, B., van Oostrom, I., Schene, A. H., & Tendolkar, I. (2017). Childhood trauma and negative memory bias as shared risk factors for psychopathology and comorbidity in a naturalistic psychiatric patient sample. Brain and Behavior, 7(6), e00693. https://doi.org/10.1002/brb3.693 Waters, A. M., Wharton, T. A., Zimmer-Gembeck, M. J., & Craske, M. G. (2008). Threat-based cognitive biases in anxious children: Comparison with non-anxious children before and after cognitive behavioural treatment. Behaviour Research and Therapy, 46(3), 358–374. https://doi.org/10.1016/j.brat.2008.01.002 Watkins, E. R. (2009). Depressive rumination: Investigating mechanisms to improve cognitive behavioural treatments. Cognitive Behaviour Therapy, 38(Suppl. 1), 8–14. https://doi.org/10.1080/16506070902980695 Watkins, E. R., Mullan, E., Wingrove, J., Rimes, K., Steiner, H., Bathurst, N., Eastman, R., & Scott, J. (2011). Rumination-focused cognitive-behavioural therapy for residual depression: Phase II randomised controlled trial. British Journal of Psychiatry, 199(4), 317–322. https://doi.org/10.1192/bjp.bp.110.090282 Watkins, E. R., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., Kennell-Webb, S., Moulds, M., & Malliaris, Y. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45(9), 2144–2154. https://doi.org/10.1016/j.brat.2006.09.018 Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1998). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 29(3), 357–370. https://doi.org/10.1016/S00057894(98)80037-3 Witkiewitz, K., Donovan, D. M., & Hartzler, B. (2012). Drink refusal training as part of a combined behavioral intervention: Effectiveness and mechanisms of change. Journal of Consulting and Clinical Psychology, 80(3), 440–449. https://doi.org/10.1037/ a0026996 Yehuda, R., Bierer, L. M., Pratchett, L. C., Lehrner, A., Koch, E. C., Van Manen, J. A., Flory, J. D., Makotkine, I., & Hildebrandt, T. (2015). Cortisol augmentation of a psychological treatment for warfighters with posttraumatic stress disorder: Randomized trial showing improved treatment retention and outcome. Psychoneuroendocrinology, 51, 589–597. https://doi.org/10.1016/j.psyneuen.2014.08.004

5 Cognitive Case Formulation Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler

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his chapter provides an overview of cognitive case formulation, its purpose, and key areas of patient assessment that contribute to it. We then review the extant empirical evidence for cognitive case formulation and share our thoughts about its potential role in the newer cognitive behavioral therapy (CBT) treatments. A complete guide to developing and using cognitive case formulation is beyond the scope of this chapter; there are several excellent resources available that address this topic more fully (e.g., Eells, 2007; Persons, 2008). Here, we focus on the definition of case formulation and then move on to the broader topics of function and utility.

WHAT IS CASE FORMULATION? Case formulation is a tool that therapists use to assist them in treating patients. Specifically, “case formulation is a hypothesis about the causes, precipitants and maintaining influences of a person’s psychological, interpersonal and behavioral problems” (Eells, 2007, p. 4). In other words, case formulation involves both describing a patient’s current problems and developing hypotheses about factors contributing to the onset and maintenance of these problems. These hypotheses have a basis in theory, and they influence intervention decisions. Case formulations tend to comprise the following elements, regardless of theoretical perspective: (a) a description of the presenting problem(s), (b) distal causal factors, (c) proximal precipitating factors, (d) factors maintaining the https://doi.org/10.1037/0000218-005 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  131 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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problem(s), (e) coping strengths and challenges, and (f) implications for treatment (Bieling & Kuyken, 2003). In describing these factors, the formulation helps the clinician consider hypotheses about the ways in which the factors interact to bring the patient to the current moment and suggest interventions that will be particularly helpful for the patient. Cognitive case formulation uses cognitive theory to explain the patient’s systems of beliefs, behaviors, and thoughts. Different models of cognitive case formulation emphasize different components of the formulation (i.e., behaviors, thoughts, underlying beliefs) and use different methods and frameworks in constructing the formulation. These differences can lead to a very distinct “look and feel,” and many practitioners will develop a preference for one model over another. There are several commonly cited models of cognitive behavioral case formulation, including those developed by Nezu et al. (2004), Persons (2008), J. S. Beck (2011), and Kuyken et al. (2008). We briefly describe these four models next. Nezu et al. (2004) identified the practitioner as a problem solver and an expert in recognizing the patient’s particular approach to challenging life circumstances. A problem-solving strategy is used to work toward identified goals. In this model, CBT case formulation helps the clinician to identify the patient’s problems; identify the variables involved in the problems presented; and build a treatment plan clarifying treatment targets, goals, and objectives. A key point of this model is its “problem orientation” (Nezu et al., 2004, p. 14), grounded on two methodological approaches. The first one refers to the multiple causality framework (Shadish, 1993). When applied to the context of clinical assessment, the multiple causality framework advocates a multiplicity of factors (e.g., biological, psychological, social) contributing to the symptom, leading to a variety of treatment strategies in CBT. The second approach refers to the systems perspective, according to which the factors mentioned previously interact reciprocally. This approach can, potentially, help the therapist to identify a variety of clinical targets for the treatment and increase the likelihood of a successful outcome (Nezu et al., 2004). On the basis of empirical evidence regarding mechanisms, underlying symptoms, and disorders, Persons’s (2008) model emphasizes adapting this evidence to the situations of individual patients. The main goal of a case formulation is to guide a treatment. Persons noted that evidence-based treatments and practices for psychiatric disorders and psychological problems represent an important achievement; unfortunately, in many circumstances these protocols do not provide the needed guidance to the clinician, such as with patients who have comorbidities, a history of treatment failure, or nonadherence to the treatment (Persons, 2008). The structure of a complete case formulation, according to the author, consists of four main components: (a) a clear description of “the patient’s symptoms, disorders and problems” (Persons, 2008, p. 5); (b) the formulation of hypotheses to explain the “mechanisms” involved with problems and disorders; (c) hypotheses about the recent “precipitants” of problems and disorders; and (d) an investigation of the “origins” of the mechanisms (Persons, 2008, p. 5). Persons argued that a strong formulation needs to be internally coherent. This characteristic will help the clinician in understanding the



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relation that exists among different problems and in developing an efficient treatment plan. The development of a case formulation starts with a nomothetic (general) formulation that is ideally translated into an idiographic (individualized) formulation that supports the therapist’s clinical decision making. A case formulation is developed at three nested levels, each one guiding different aspects of a treatment: case, disorder or problem, and symptom (Persons, 2008). Case formulation in CBT results from a principle-driven approach to treatment, providing the necessary flexibility to address the various difficulties encountered by the therapist. Within this framework, the therapeutic relationship is seen both as a pillar for the development of the treatment and as “an assessment and intervention tool itself” (Persons, 2008, p. 13). Judith S. Beck (2011) described the way in which the cognitive case formulation brings to life the basic constructs of CBT for each individual patient. In this context, the case formulation is a continuous process that helps the clinician conceptualize the patient’s difficulties and problems in cognitive terms. The case formulation not only describes problems and their cognitive origins; it is at the same time a “road map” (J. S. Beck, 2011, p. 39) that guides the therapist toward the achievement of the goals discussed with the patient by selecting treatment strategies that target specific problematic emotions, thoughts, and behaviors. According to J. S. Beck (2011), “if the conceptualization is on target, patients confirm that it ‘feels right’—they agree that the picture the therapist presents truly resonates with them” (p. 40). In this model, and consistent with the cognitive model, different levels of cognition are considered, from automatic thoughts in reaction to “here and now” situations, to deeper conditional assumptions, and finally the deeper level of core beliefs or schemas. In addition, this model highlights features of the patient’s history that may have given rise to maladaptive core beliefs and makes note of maladaptive compensatory strategies. The conceptualization (used here in a way that is synonymous with the concept of formulation) is a fluid and continuous process that begins at the first contact with the patient. All interpretations must be based on the data collected from the patient as therapy progresses. The discovery of new data can lead the clinician to modify the conceptualization, testing the hypotheses at various phases to confirm, disconfirm, or refine them (J. S. Beck, 2011). A case example using this model is below.1 Finally, Kuyken et al. (2008) proposed a model that emphasizes the developing nature of conceptualization in CBT as well as the essential contribution of collaborative empiricism. According to the authors, conceptualization is seen as a process that evolves over time, starting from a descriptive level and evolving toward higher, more complex, models of explanation, such as targeting how the symptomatology of a disorder is maintained. The authors used the metaphor of the crucible to introduce their model, according to which the case conceptualization encompasses three elements: (a) theoretical and empirical foundations of CBT, (b) the patient’s experience and strengths, and (c) collaborative empiricism. Some basic principles are seen to guide the formulation. Clinical examples are disguised to protect patient confidentiality.

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The first principle refers to the stratification and evolution of the case conceptualization, namely that conceptualization evolves over time, as new information becomes available to the therapist. The evolution of a formulation, according to this model, follows a typical pattern, moving from an initial descriptive level toward an increasingly explanatory level as therapy progresses. The second principle refers to the adoption of collaborative empiricism, a systematic process based on mutual collaboration between the therapist and the patient. As noted by Kuyken et al. (2008), collaborative empiricism relates to the utilization of a solid theoretical approach in CBT on one side, supported by an empirical method of observation and investigation with each patient on the other side. The third principle focuses on the inclusion of the patient’s strengths and resiliency within the conceptualization. In this context, a strength-focused approach helps the patient in two directions, relieving the distress and building on positive abilities at the same time (Kuyken et al., 2008). Sample Case and Partial Formulation Case Description Emma is a 56-year-old cisgender White Canadian woman with major depression (recurrent, moderate). Her Beck Depression Inventory–II (BDI-II) score at treatment initiation is 33. Emma works as a nurse. She has three grown sons and is not currently married. Emma has two bachelor’s degrees, in English literature and in nursing. She stayed home with her children when they were young, and she pursued her degrees in her 30s and 40s. In addition to this episode, Emma has had one other clearly defined episode of depression, nearly 20 years ago when her first husband announced that he was “in love with another woman.” During the subsequent separation and divorce, she drank heavily and was quite depressed for over a year. Although her depression eventually abated, she abused alcohol for 10 years before seeking rehabilitation (her only experience as an inpatient). At the time of the assessment, she had not had a drink in 5 years. Emma was married for a second time 10 years ago, and 4 years thereafter, her husband died of cancer. Although she found this to be extremely upsetting, she did not become depressed after his death. Within a year, she was dating again and felt that her grief had resolved. With regard to history, Emma acknowledged that her mother was affectively unstable (possibly borderline). Emma recalled never quite knowing which of her “mothers” she would find at home and trying to alter her own behavior to gain her mother’s approval. Emma’s recent episode of depression was related to a relationship. She had been seeing a man named Mark for close to a year. Although she found, initially, that he was “dynamic, bright, and challenging,” another side of him emerged over the course of the first months of the relationship. She found that he became controlling and angry when she did not do as he wished and was manipulative much of the time. Emma described ambivalence about the relationship, acknowledging that he was not a “healthy choice” for her and that his



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behavior was not acceptable. Nonetheless, she was reluctant to end the relationship, fearing she would be lonely and have regrets. When asked to describe specific events that she experienced as difficult and distressing, she described a recent incident with Mark. She was returning his phone call when he began to berate her for taking too long to get back to him. She felt extremely hurt and sad, and she wondered what she had done wrong and whether there was any hope for making things right. When they met up again, she decided to wear an outfit that he had given her as a gift even though it was not to her taste. At that date, he criticized her for wearing something she was not confident about and insisted that she change outfits. Partial Initial Formulation According to J. S. Beck’s model, two important factors to identify would be Emma’s conditional beliefs and her core beliefs. From the above description, we might hypothesize that Emma has conditional beliefs such as “If someone important to me is mad at me, I must have done something wrong” and, conversely, “If I do everything right, I will be loved.” The therapist might also hypothesize that Emma’s core beliefs relate to her own inadequacy or inherent flawedness and to the importance of pleasing others. The clinician might also be on the lookout for core beliefs related to Emma’s history of alcohol use disorder, such as “I can’t cope with negative emotions on my own” or “Bad feelings are unbearable.” These are but two aspects of the case formulation, and it is important to note that they are just hypotheses on the part of the clinician. As Emma shares more about her history and her distress, the therapist may adjust these hypotheses on their own, perhaps in response to data gained through cognitive restructuring. At some point the hypothesized beliefs should be shared with Emma for her feedback. If they appear to be accurate and relevant, the beliefs should be targeted in treatment, through, for example, discussions of the basis of individuals’ worth (perhaps using Socratic questioning) and examination of evidence for her inability to cope effectively. Comparison of Models All of these models have something to offer; indeed, the work on formulation (much like in a therapy case) is unlikely to be “finished” in some perfected way. Each has interesting aspects; for example, J. S. Beck’s model is particularly “diagrammatic” in its form, and the Kuyken model specifically highlights strengths. Indeed, much more could be written comparing each of these approaches, particularly their differences. However, in this chapter we focus more on the “generic” cognitive behavioral formulation rather than analyze subtleties. These approaches have a great deal in common. Each is structured, directive, and diagrammatic, especially as compared with the conceptualization frameworks of other theoretical orientations. In practice, cognitive behavioral therapists may use eclectic and less formal approaches to formulation, based on

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concepts from the models reviewed here and, perhaps, those of other theoretical perspectives. Just how common it is for cognitive behavioral therapists to use formulation is difficult to ascertain, given the diversity of formulation methods, health disciplines, settings, and patient populations. In addition, of course, there are multiple cognitive formulation models, and none has been demonstrated to be superior to the others. Indeed, data are lacking as to the costs and benefits of engaging in a formal and structured case formulation process, and without such data, it may be difficult to justify the time required to do so. Therefore, clinicians may be more likely to choose less formal approaches to formulation, prioritizing efficiency and relying in part on clinical judgement. It seems as though formulation tends to be taught later in training, perhaps as an “advanced” aspect of CBT. In addition, instruction in formulation also seems to emphasize challenging cases. Research data about practitioners’ training would be particularly meaningful if we consider that case formulation, despite the proliferation of various manuals and methods, is a core skill in psychotherapy that relies largely on a clinician’s judgment (Kendjelic & Eells, 2007). Zivor et al. (2013) considered not only the impact of training for case formulation for a specific anxiety disorder (obsessive-compulsive disorder [OCD]) but also the relation between the level of expertise in case formulation and the perception of self-competence in clinicians. The study confirmed other results according to which clinicians tend to overestimate their competence. In particular, less competent clinicians in case formulation are also less able to recognize the lower quality of their formulation. As observed by the authors, the perception of competency in CBT formulation tends to be lower than the perception of overall competency in CBT, confirming that formulation is indeed likely to be an advanced skill in CBT (Zivor et al., 2013). Another relevant gap in research relates to the investigation of which critical ingredients cognitive behavioral therapists consider important to conceptualization in CBT and what practices are implemented in their actual clinical practice. The training background might influence a therapist’s decision to endorse practices related to the consultation of theory or evidence-based practices relevant to the problems presented by the patient, as hypothesized by Huisman and Kangas (2018). These practices are rated as significantly more important by clinical psychologists and clinicians with more experience when compared with general psychologists. However, the authors noted that the level of experience did not seem to play a role in the implementation of these practices. Huisman and Kangas suggested that training programs should address the difficulties of less experienced clinicians in using external sources related to evidence-based practices in case formulation. Returning to the issue of patient complexity, the value of formal approaches to formulation may be particularly salient for cases that go beyond standard protocols. Arguably, the clearest marker of such complexity is comorbidity, where multiple diagnoses seem to apply and no single protocol or manual will offer a comprehensive treatment plan. Clinical experience would also tell us that not even multiple diagnostic categories applied to the same person, par-



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ticularly when there are personality factors and more acute symptoms, fully reflect what the person is struggling with or suggest clear treatment goals. In such cases, the cost-benefit analysis seems clearer: The benefits of better organizing the clinical information seem likely to outweigh the cost of the time needed to develop the formulation. In other words, “Three most important things for a difficult case? Formulate, formulate, formulate!” (origin unknown). Below, we examine this notion, specifically with respect to the context, content, and validity of cognitive formulation.

WHAT ARE THE ROLE AND FUNCTION OF CASE FORMULATION? Case formulation functions primarily as a way of mapping broad theories onto individual patients’ situations to inform the selection of treatment interventions. As such, it requires clinicians to remain up-to-date with respect to developments in cognitive theories, particularly as they relate to factors influencing the development and maintenance of psychological difficulties. This thorough understanding of current cognitive theory provides the foundation of a solid formulation. In addition, the capacity to conduct a thorough and culturally responsive assessment and to extrapolate critical information is essential to obtain a high-quality case formulation. Finally, a good formulation should inform treatment planning, grounded in empirically supported treatments, and point to important variables to be evaluated throughout treatment to evaluate treatment effectiveness. Thus, some of the main elements of a good quality case formulation—that is, to ensure both quality inputs and outputs—are • a thorough and current understanding of cognitive theory; • competent, comprehensive, and culturally responsive assessment, including (when possible) standardized scales; • implementation of evidence-based practices (i.e., empirically supported treatments for the relevant problems); • capacity to monitor the progression of treatment quantitatively and qualitatively and make adjustments as new information arises; and • the ultimate arbiter of success: the patient’s progress. Case formulation aims to provide substantial guidance as therapy progresses, when a higher effort is required for therapists in integrating the information to formulate more complex and comprehensive inferences. An evidence-based case formulation offers critical guidance in these cases through the integration of three major components in evidence-based practice in psychology: (a) research, (b) expertise, and (c) patient characteristics (Eells, 2016). Schulte and Eifert (2002) argued that therapists tend to deviate from manuals “too soon, too often, and occasionally for the wrong reason” (p. 312). A case formulation

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aligned to the criteria mentioned above might provide the necessary support for better clinical decision making, especially when decisions are required under time pressure and in situations where there is high uncertainty. Case formulation has many potential benefits, although research examining these benefits is in its infancy. Research supporting manualized CBT, on the other hand, is abundant (A. T. Beck & Dozois, 2011; Chambless & Ollendick, 2001; Leichsenring et al., 2006). This discrepancy could lead practitioners to question whether they should in fact engage in case formulation. Certainly, manuals can be applied without case formulation. We argue, however, that there are many strong theoretical reasons to use case formulation in the context of manualized treatments. First, a case formulation requires therapists to attend to the many factors that may contribute to the onset or maintenance of a patient’s difficulties, potentially yielding a richer and more comprehensive description and understanding of the presenting problems, for both therapist and patient. This enhanced understanding may result in a stronger therapeutic relationship, based on a shared understanding and on increased therapist empathy for the patient. A comprehensive, systematic formulation that sheds light on key factors contributing to a patient’s difficulties and considers them within the patient’s cultural context(s) also helps guide the therapist toward interventions that address these factors. In addition, when difficult situations arise that are not accounted for by a manualized treatment, case formulation can help a therapist determine how to proceed. Formulation should, ideally, help the therapist understand the obstacles and challenges that occur in treatment and suggest alternative approaches for navigating these situations. Treatment protocols generally specify what the therapist should do in treatment; formulation can help predict or understand how the patient might react to these interventions. One of the most common situations that clinicians face that is not always addressed by treatment protocols is comorbidity. Often patients have more than one presenting problem, and therapists need to determine how best to address each, choosing interventions to address one problem or another or perhaps addressing multiple problems at once. Formulation can inform these decisions, identifying which problems may be most pressing and which factors may contribute to the most significant difficulties. Case formulation can be helpful in organizing a team of treatment providers. The formulation may help clarify overall goals of treatment and the role of each treatment provider in addressing these goals. Having a formulation may help providers collaborate more effectively, avoid redundancy, and ensure that their interventions are consistent or, at least, not working in contradictory ways. Case formulation may be of particular value when there is no empirically supported treatment available for the patient’s disorder or when the problem is not a diagnosable disorder (e.g., perfectionism). In such cases, formulation can help guide treatment decisions. Indeed, even when a manualized treatment does exist, therapists need to make many clinical decisions throughout treatment. For example, although sets of dysfunctional cognitions have been identi-



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fied for many psychological disorders, determining just which thoughts are present and which are causing the most problems for a given patient remains up to the clinician and patient to determine. Case formulation may help address these questions. Formulation may also help clinicians understand reasons for nonadherence to treatment. In some cases, formulation may help clinicians predict when nonadherence is likely and may even help clinicians to avoid that outcome— perhaps because it prioritizes the particular patient over a particular protocol (Persons, 2008). A culturally responsive formulation may help the therapist realize when a treatment developed on or for one type of patient of one particular background may not be appropriate to apply to a member of a different group. Finally, case formulation can help clinicians choose an alternative intervention if a given protocol is not resulting in the desired outcomes. In summary, case formulations can complement treatment manuals by filling in the framework provided by the manual and guiding the decisions clinicians must make when tailoring the treatment to a given patient. Ultimately, a case formulation approach to treatment should lead to enhanced outcomes for patients. Case formulation can be conceptualized as existing on a continuum: At one end of the spectrum is an entirely nomothetic approach, where the same treatment protocol would be used for all patients, and at the other, a tailored approach. In some straightforward cases, a manual on its own may be sufficient to deliver high-quality CBT. Some relatively straightforward problems can be addressed with a highly structured, standardized treatment, and some group interventions are highly manualized, following a set “curriculum.” Such interventions do not tend to require formal case conceptualization, and overall, group interventions in CBT have a solid evidence base (Bieling et al., 2009). However, as argued previously, even when using a manualized treatment, there is a role for case formulation in guiding decisions, whether such formulation is formal or not. Clinicians tend to anticipate how patients might react, in terms of cognitions and behaviors, to different interventions or what they might present in a given session, and the ability to make these predictions suggests that the clinician holds at least an implicit formulation. In a way, explicit case formulation is just a more formal version of what clinicians are already doing, and it stands to reason that formalizing this process might result in more efficient treatment, improved therapeutic alliances, and improved adherence to treatment. Similarly, it follows logically that case formulation would be increasingly useful as the complexity of a case increases. This question is, of course, an empirical one, and to date we do not have the data to support the claim. Indeed, research on the dissemination of CBT suggests that manualized CBT treatments can be delivered effectively by community therapists who, theoretically, have less experience with CBT case formulation, whether implicit or formal. However, inferences about the utility of case formulation from this research are indirect at best; research is needed that directly evaluates the utility of CBT case formulation, especially in complex cases. Such research would need to

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consider a variety of different patient populations and settings and a variety of CBT formulation approaches.

OPTIMIZING CASE FORMULATION THROUGH ASSESSMENT As previously noted, there are several components that compose a case formulation, which correspond to these tasks for therapists2: 1. Create a problem list. 2. Generate hypotheses about causal mechanisms. 3. Uncover the origins and precipitants of mechanisms. 4. Connect hypotheses and inferences in one cohesive explanation of the patient’s problems. 5. Determine implications for treatment and continue to refine the formulation over the course of treatment. Each of these components can be approached in a variety of ways, as discussed below. Developing a Problem List The problem list should be comprehensive. Symptoms from Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition [DSM-5]; American Psychiatric Association, 2013) diagnoses should certainly be included, but a case formulation should go beyond symptoms and consider multiple domains, including interpersonal functioning, medical problems, and access to treatment, among other factors. The problem list should be tailored to the individual patient and should take into consideration the patient’s cultural identities. Clinical interviews may be used to arrive at a diagnosis that is derived from the DSM-5 or International Classification of Diseases (ICD); other measures should assess cultural factors, quality of life, and the patient’s functioning more broadly. Finally, and in keeping with the scientific approach inherent in CBT, objective, specific symptom measures for known problems should be used. The selection of such assessment tools should be driven by the patient’s presenting problems. Therapists should search the literature periodically for reliable and valid psychometric tools to aid in formulation and may also be guided by other resources and compilations of measures (e.g., Antony & Barlow, 2011; Antony et al., 2001; Corcoran & Fischer, 2013; Hunsley & Mash, 2018; Nezu et al., 2000). Seeking information in these ways allows therapists to develop hypotheses based on objective information and helps them become aware of disconfirming evidence. Clinical psychologists will likely be comfortable using such tools, although members of other professional groups may not feel as comfortable. List inspired by Bieling and Kuyken (2003).

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Nonetheless, CBT has such a strong tradition of objective assessment that using reliable and valid measures remains an important gold standard to which the field, as a whole, should be committed. In that spirit, we would suggest using structured clinical interviews such as the Structured Clinical Interview for DSM Diagnosis (SCID; First, 1997, 2014) and the Mini-International Neuropsychiatric Interview (MINI; Rogers et al., 2009; Sheehan et al., 1998, 2010) to at least aid in developing the problem list at a sophisticated level. The patient’s cultural context(s) should be explicitly assessed, perhaps using the Cultural Formulation Interview for DSM-5 (American Psychiatric Association, 2013); the Culturally Informed Functional Assessment (Tanaka-Matsumi et al., 1996), which provides guidance specifically for culturally informed cognitive behavioral assessment; or the Jones Intentional Multicultural Interview Schedule (Jones, 2009), which assesses the constructs in the ADDRESSING framework (Hays, 2008): age/generational influences, developmental or other disability, religion and spiritual orientation, ethnic and racial identity, socioeconomic status, sexual orientation, Indigenous heritage, national origin, and gender. In addition, we recommend tools that assess functional impairments and broad symptom inventories to help understand what is the “most” important issue (presumably individual scales with the highest scores), as well as to what extent, and how these difficulties compare with norms in the population. For this we suggest the Short Form 36 (SF-36) Health Survey Version 2 (Ware et al., 2000) and the Symptom Checklist-90-Revised (Derogatis & Unger, 2010). Self-report measures for specific symptoms might include the Beck Depression Inventory–II (A. T. Beck et al., 1996) and the Penn State Worry Questionnaire (Meyer et al., 1990; Zlomke, 2009), as appropriate to the patient’s problem areas. In addition (and with the patient’s permission), reports from other health care providers and collateral information from sources, such as family members, can be extremely valuable, particularly in more complex cases. Clinicians should take care to consider the impact that culture might have on patients’ reactions to information gleaned from any of these sources. Reinforcing an observation made previously, much of the assessment strategy will be determined by the patient’s presenting problems, so in addition to any “omnibus” measures, specific symptoms might require modifications to the instruments used. As important as such objective measures are, they should always be accompanied by patient-centered questions about what patients are struggling with the most; what outcomes would reflect success in therapy; and what changes they seek in themselves, their situations, or their lives. A patient’s cultural contexts and identities should be considered throughout the formulation and treatment processes and are perhaps especially important here. Issues that are brought up in both the answers to these more open-ended questions and the data from the objective measurement tools are likely the most important areas be addressed (see Haynes et al., 2009, for a step-by-step guide to the development and evaluation of idiographic assessment tools).

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Developing Mechanism Hypotheses One of the most useful and important aspects of case formulation is the generation of hypotheses about psychological, biological, and/or sociocultural mechanisms that may be causing or maintaining the problems on the patient’s problem list. Strategies for developing these hypotheses include (a) referring to a theory associated with a specific disorder and an empirically supported treatment or (b) referring to a broader psychological theory (e.g., learning theory or the cognitive model; Persons, 2008). Either way, the therapist starts with the theory that fits the patient and their problems the best and then seeks information about how this theory may apply to the individual patient. In the context of cognitive case formulation, the assessment should address the patient’s automatic thoughts, underlying assumptions, and core beliefs. The theory chosen may inform which exact tools are used in this assessment process, and, again, there is likely to be a combination of “objective” tools and clinical inferences made by the practitioner. Two commonly used self-report scales that may be useful in generating hypotheses about cognitive mechanisms are the Dysfunctional Attitudes Scale (Weissman, 1979a, 1979b) and the Young Schema Questionnaire – Short Form (Young & Brown, 1998), followed by a more recent version, the Young Schema Questionnaire – Short Form 3 (Young, 2005). These measures aim to (a) examine a level of cognition that is “deeper” than inventories that measure negative thoughts and (b) give some insight into the patient’s likely problematic beliefs. Of course, it is also true that such beliefs are highly idiosyncratic, as it is far easier to assess and map out symptoms and functional impairments of an anxiety or mood disorder than it is to objectively assess the beliefs that give rise to such difficulties. Therefore, it is often helpful to probe for unhelpful thoughts in stressful situations and/or beliefs about the self, the world, and others. Further information about potential cognitive mechanisms may also be gleaned by having patients self-monitor their thoughts and behaviors. Uncovering Origins and Precipitants of Potential Mechanisms Next, the therapist attempts to determine where the patient learned or acquired the mechanisms that may have caused their symptoms as well as any recent stressors that may have activated their current problems. Information regarding the distal causes of the patient’s problems often comes from a clinical interview and any historical information available, such as the patient’s descriptions of their early upbringing, their relationships with caretakers, any significant childhood events (e.g., trauma, neglect), and family history of psychiatric illness. Here again, cultural considerations are critical, including understanding how psychiatric illness is understood in the patient’s culture(s). The clinician’s task here is to relate the patient’s presenting problems to their early life experiences, taking care that the interview does not become overwhelming. Therefore, the interview should not comprise a complete biographical overview but rather should focus on particular people, experiences, and cultural influences



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that led the patient to interpret their experiences in a way that might contribute to their current problems. Objective measures are less likely to be useful for gathering this kind of historical information, and a great deal of clinical discernment is called for. A clinical interview is also the main source of information about the proximal precipitants of a patient’s current problems; indeed, most clinicians ask patients about recent stressors during an initial assessment. In addition, a survey that lists common stressful life events may help identify precipitants. Often, precipitating life events are particularly relevant to a patient’s maladaptive beliefs (e.g., job loss for a patient who believes that they are worthless). The events identified as the main cause of the problem or difficulty can be analyzed along two dimensions: qualitative and quantitative (Kuyken & Dudley, 2013). In particular, focusing on the qualitative dimension provides the therapist an opportunity to consider the personal meaning of the event, thereby addressing the individual’s particular vulnerability to stress. This is probably one of the most important aspects of case formulation, and it provides a contrast between the formulation process and the diagnostic process, making explicit that human suffering is an individual comprehensible response to intolerable circumstances.

Developing a Cohesive Explanation, Determining Treatment Implications, and Continuing to Refine the Formulation The process of connecting these hypotheses and inferences in one cohesive explanation—and of determining treatment implications—requires the therapist to integrate the information collected with cognitive behavioral theories and evidence-based treatments. One note of caution: Although multiple sources of information are valuable, and we would recommend at least some reliable and valid assessment tools be used in most formulation work, the use of too many such measures can have its own unintended consequences. First using a very large battery of measures can produce enough variables that integration with more subjective patient reports becomes a challenge, especially when measures produce inconsistent results. Second, in some settings, a series of scores on inventories can too easily become a substitute for true formulation, which requires the patient’s real-world experiences and problems to be considered. Once the initial formulation is drafted, a critical step is discussion with the patient, both to educate and to receive feedback on the formulation. In this discussion, it is important to keep the patient’s cultural values and perspectives in mind, as well as the therapist’s cultural vantage point and potential biases, as these may lead to gaps in understanding of the patient’s problems and experiences. Over the course of treatment, self-report measures of symptoms may be used for assessment but are also no substitute for qualitative feedback from the patient. Other sources of information include patient self-monitoring of daily activities, responses to exposure practice, and subjective ratings of distress. Sources of feedback such as these not only monitor treatment progress but also

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provide continuing evidence for (or against) the hypothesized mechanisms of the patient’s problems. The formulation should thus be continually revisited to incorporate this new information, revising hypotheses as appropriate. In addition, therapists may opt to evaluate cognitive vulnerabilities and other hypotheses directly and explicitly to enhance these aspects of the formulation and to guide, in an ongoing way, the selection of appropriate interventions, ultimately leading to more effective treatment.

RESEARCH EVIDENCE FOR THE UTILITY OF CASE FORMULATION Case formulation, across theoretical orientations, is believed to be beneficial (e.g., Binder, 2004; Hersen & Porzelius, 2002), but there is limited research supporting these claims (Eells et al., 2011). In considering the utility of cognitive case formulation, we should evaluate the formulations’ reliability and validity, in addition to their potential impact on treatment (Bieling & Kuyken, 2003). Below we review some of the research that has been conducted. Reliability and Validity of Case Formulation Reliability for some aspects of the case formulation may be higher than for others. For example, it appears that clinicians are more likely to agree on the more concrete aspects of the formulation (e.g., the problem list) than on the more hypothetical aspects (e.g., underlying beliefs; Bieling & Kuyken, 2003). In addition, on the basis of the limited research available, it seems that both the reliability (Kuyken et al., 2005) and the quality of case formulation may increase with training (Kendjelic & Eells, 2007). In order to evaluate the quality of case formulation, Kuyken et al. (2005) used a rating scale previously developed to specifically address this aspect: the Quality of Cognitive Case Formulation Rating Scale (Fothergill & Kuyken, 2002). The reliability of case formulation was assessed with a different method, examining the percentage of agreement among participants (Kuyken et al., 2005). Kendjelic and Eells (2007) utilized the Case Formulation Content Coding Method (CFCCM; Eells et al., 1995, 1998, 2005) to code the formulations and rate their quality by using specific scales embedded in the instrument. Measures of quality are assessed through different Likert-type scales from 1 to 5, addressing the overall quality as well as other constructs, such as complexity and degree of inference. It may also be the case that expert therapists develop formulations of higher quality (Eells et al., 2011), which is consistent with the idea that more training may improve formulation. As reported by Eells et al. (2005), experts produced formulations that were more comprehensive, better elaborated, more precise in terms of language articulation and specificity, more complex and coherent, and more likely to be characterized by the inclusion of a systematic formulation process, as compared with nonexperts. Experts’ formulations also showed better goodness of fit to the treatment plan. It is difficult to evaluate the validity of



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case formulations with respect to the accuracy of the inferences contained in it; without any information about the “true” mechanisms and causes of patients’ problems, some types of validity, in particular, are hard to assess. One proposed method for validating case formulations emphasizes the importance of understanding the patient’s idiosyncratic cognitive schema (ICS), a construct used to explain the way in which assumptions, attitudes, and beliefs contribute to the generation of automatic thoughts (Mumma, 2004). During the first stage, a dynamic factor analysis is used to test the convergent and discriminant validity of the ICS. In the second stage, these hypotheses about beliefs are tested on their ability to predict symptoms and distress. Moreover, during this second stage, convergent and discriminant validity are further examined, “assessing structural relationships between the daily ICS scores and the daily scores of theoretically (or conceptually) important constructs (the psychological distress scales)” (Mumma, 2004, p. 241). This approach is intended to address the problem of assessing convergent and discriminant validity of both idiographic measures and case formulations in a variety of frameworks, including the cognitive framework (Mumma, 2004). This method, however, requires a fair amount of time and labor on the part of both the assessor and the patient, who provides large amounts of data. As previously mentioned, case formulation is subject to continuous change over time, typically moving from a descriptive level toward a more complex explanatory level. Reliability of the formulation is negatively affected by the increase of complexity related to the inference process, in which a therapist theorizes the mechanisms involved (Kuyken et al., 2008). It is not surprising that providers would tend to agree more on observable self-reported problems and somewhat less on the underlying processes that led to the problems. In general, the existing research suggests that therapist training and experience may increase the reliability and validity of case formulation. It is unclear, however, whether the reliability and validity of cognitive case formulation approaches are acceptable at present. A formulation is valid if it represents the person’s particular presenting problems and underlying cognitions accurately and completely and if it provides guideposts for treatment. Testing this in a practical, empirical way is a challenge. However, we would suggest that formulation could be considered to have at least some predictive validity if it were shown to be associated with improvements in outcome, and we review this literature next. Effects of Case Formulation on Treatment Outcome Although it is theoretically possible to evaluate the impact of case formulation on treatment outcomes, research doing so is scant. One such study looked at formulation-guided CBT as compared with manual-based CBT in the treatment of 50 patients with bulimia (Ghaderi, 2006). Logical functional analysis (Hayes & Follette, 1992) was used to develop formulation and treatment. Logical functional analysis considers four dimensions: (a) inadequate antecedent stimulus

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control, (b) inadequate consequential control, (c) inadequate motivational conditions, and (d) restricted repertoire of behaviors. The manual-based condition used a manualized cognitive behavioral treatment for bulimia nervosa (Fairburn et al., 1993). Duration and frequency of sessions were matched across conditions. Both groups showed improvements at end of treatment that were sustained at 6-month follow-up, though participants in the formulationguided intervention showed greater improvements on some outcomes. Of those who were categorized as treatment nonresponders, most (80%) were in the manual-based treatment condition. These results suggest that individualizing treatment may have benefits for patients, although clearly more research is needed. Whether or not individualized case formulation has substantial benefits for treatment may be complicated. For one, treatment outcomes are multidetermined. In addition, any effects of formulation on treatment outcome may be moderated by patient characteristics such that more complex cases are associated with greater benefits. There is some evidence that patients with multiple comorbidities may benefit from empirically supported interventions guided by case formulation (Persons et al., 2006). Unfortunately, this study did not include a comparison group that did not receive treatment guided by case formulation, so the implications are limited. Nattrass et al. (2015) argued that most of the research investigating the effectiveness of case formulation focused on randomized control trials (RCTs) comparing the outcomes of CBT treatments delivered with and without patient-centered case formulation, finding that “CBT with patient-centered case formulation is no different or only marginally better” (Nattrass et al., 2015, p. 591). One study evaluated the effectiveness of individualized case formulation-based CBT in a sample of youths (9–17 years old) suffering from anxiety disorders (and their parents) who did not respond to group treatment based on manualized CBT (Lundkvist-Houndoumadi et al., 2016). In this study, 57% of the sample responded to the individualized case-formulation-based CBT, and the percentage increased to 79% after a 3-month follow-up. The response to treatment was assessed using the Clinical Global Impression-Improvement Scale (CGI-I; Guy, 1976), a 7-point Likert-type scale commonly used in clinical trials to study the response to treatment. The stability of the results was confirmed at 1-year follow-up, according to the authors, with significant improvements related to self-reported anxiety and life interference. However, this study, too, lacked a control group. Esbjørn et al. (2015) studied the impact of case-formulation-driven CBT on 54 children (7–12 years old) with anxiety disorders. Both treatments in the study were rooted in a formulation approach and included both parents and children; they were found to have a similar impact to manualized CBT treatments based on meta-analyses. Another study investigated the content, quality, and impact of case formulation treating a group of 29 patients with OCD (Nattrass et al., 2015). The authors concluded that formulation, routinely implemented in the early stages of the OCD treatment, had a significant impact on



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reducing patients’ OCD symptoms and psychological distress and on improving therapeutic alliance during the postformulation phase. The authors adopted three measures: the Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman et al., 1989), the Clinical Outcomes in Routine Evaluation–Short Form (CORE-SF; Evans et al., 2002), and the Agnew-Davies Relationship Measure (ARM-12; Cahill et al., 2012). Content and quality of case formulation were assessed using the Case Formulation Content Coding Manual Version 2 (CFCCM v2; Eells et al., 1998). No significant association between quality and outcome was found. However, an important limitation of this study is represented by the lack of a control group (Nattrass et al., 2015). Although this work suggests that case formulation has an impact in the early phases of treatment, the mechanisms underlying the improvements remain poorly defined and understood. Finally, a recent review on CBT case conceptualization concludes that its utility “has yet to be empirically demonstrated,” clarifying whether it directly or indirectly enhances treatment outcomes and the mechanisms involved (Easden & Kazantzis, 2018, p. 26). The effectiveness of case-formulation-driven CBT is comparable to that of single-diagnosis protocols and can be considered as a well-​grounded option to the latter (Waltman & Sokol, 2017). It remains possible that future research will find greater benefits of individualized cognitive case formulation for patients with complex problems as compared with simpler cases. There remain many unanswered questions about the reliability, validity, and utility of cognitive case formulation. Increased training and experience may yield better case formulations, providing “more descriptive, diagnostic, inferential, and treatment planning information” (Eells et al., 2011, p. 349). There are not, however, sufficient studies to suggest that a specific type of training or a particular approach to case formulation leads to higher reliability and validity. More research is needed to compare case-formulation approaches with respect to their feasibility, in terms of training and time required by the clinician; their reliability and validity; and their effects on treatment outcomes. In addition, more RCTs comparing individualized, formulation-based treatment to standard manual-based treatment could yield important information. Based on prior research, therapist expertise and skill in case formulation may be important variables to consider (Eells et al., 2011) when evaluating the utility of case formulation in treatment outcomes. Patient characteristics (in particular, case complexity) may be important to assess as well. The notion that the case formulation may be more valuable as case complexity increases is an interesting one. It may well be that for cases that are more routine, the nomothetic guide from a protocol that was likely developed for such cases provides sufficient grounding and actually fits the patient rather well. However, as complexity and comorbidity rise, it stands to reason that “off-the-shelf” protocols simply are not as valuable as a guide and that it is well worth producing a truly individualized formulation that fits this particular person, with these particular problems, and at this particular time. Assuming that future studies support the utility of case formulation in general, next steps should include dismantling studies, to determine which aspects

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of case formulation are the “active ingredients.” For example, is it a comprehensive problem list that is the most essential part of the formulation, or are the hypothesized mechanisms that maintain the problems a key component? Ideally, future research will establish (a) what sorts of training and/or experience are necessary to generate reliable and valid cognitive case formulations, (b) which approach to case formulation or which components of the approach lead to enhanced treatment outcomes, and (c) for whom these approaches are beneficial.

CASE FORMULATION AND NEWER COGNITIVE BEHAVIORAL INTERVENTIONS It stands to reason that, as CBT evolves, the role of case formulation may also change. Recent developments in CBT include low-intensity CBT, transdiagnostic approaches, and mindfulness-based treatments. We consider these in turn. Low-Intensity CBT Low-intensity CBT holds promise for increasing access to care. Although there is no agreed-upon standard definition of a low-intensity intervention, a unifying element is that low-intensity treatments ought to require substantially fewer clinical resources compared with conventional psychological therapies (National Collaborating Centre for Mental Health, 2011). Low-intensity CBT can take several forms, including guided use of patient manuals, online CBT, and large-group CBT. These interventions all require less therapist time for each patient and less emphasis on individualized case formulation; they, therefore, generally take a nomothetic approach. Given the therapist’s decreased role, patients must themselves figure out how the CBT model and associated interventions apply to them and their situations. Patients may essentially create their own informal case formulations of their problems, or they may just use the strategies suggested without seeking to understand the rationale for doing so. It seems likely that many patients would gain a deeper understanding of the factors that contribute to their difficulties. Consistent with the moderation model posited above, these low-intensity approaches may be largely sufficient for patients with less complex problems, whereas an approach that allows for individualized case conceptualization by a therapist may better serve patients with multiple or more severe difficulties. Transdiagnostic Interventions As the name suggests, transdiagnostic interventions, such as the unified protocol for the treatment of emotional disorders (Barlow et al., 2011), de-emphasize diagnosis in selecting treatment interventions, as compared with treatments that are geared toward one particular mental health disorder. Indeed, varia-



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tions in symptoms across disorders are considered to be “relatively trivial” (Barlow et al., 2011, p. 15). The transdiagnostic approach makes use of treatment modules that can be selected based on patients’ particular presentations. Therefore, clinical decision making is key, suggesting an important role for individualized case conceptualization. Formulation in a transdiagnostic framework should be used to identify specific presenting problems and symptoms, cognitive mechanisms, and distal causes; indeed, it could be argued that absent a clear primary diagnosis, even more emphasis should be placed on understanding each individual in their unique context. Mindfulness-Based Interventions Interventions that incorporate mindfulness have become increasingly popular in recent years, and research on them has proliferated as well. These approaches include mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT). Case formulations for mindfulness-based approaches share several components, but each also reflects different hypotheses about mechanisms, based on the theoretical underpinnings of the specific approach. For example, MBCT is based on a model that posits an increased cognitive vulnerability to depression relapse or recurrence as more episodes are experienced (Lau et al., 2004; Teasdale, 1988). According to this model, case formulation of a patient with recurrent depression would consider the patient’s awareness of patterns of negative thoughts as factors that might contribute to the development of current and future depressive episodes. In contrast, a traditional cognitive case formulation would focus on the content of thinking patterns, which suggest underlying negative core beliefs. Therefore, treatment from a traditional CBT perspective focuses on modifying the content of these negative thoughts whereas treatment from an MBCT perspective would seek to help the patient develop a new relationship with these thought patterns. One element of MBCT involves helping patients develop a plan for preventing relapse and maintaining wellness. This plan incorporates several aspects of formulation, including the kinds of thoughts and beliefs that might be triggered in the future. Another difference between traditional CBT approaches and mindfulness-based approaches to formulation is the emphasis that mindfulness-based interventions place on identifying patient strengths as well as vulnerabilities, whereas traditional cognitive formulation tends to focus more on difficulties and relatively less on strengths. Finally, when mindfulness-based treatment takes place in a group format, the therapist’s role in case formulation may be less important, and patients may be encouraged to seek a deeper understanding of the factors that contribute to their difficulties themselves. The emphases of case formulation within newer cognitive behavioral treatments may vary depending on the theoretical basis of the specific intervention, and the importance of formulation may likewise vary, depending on how much

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emphasis is placed on tailoring treatment to individual patients in the given approach. It seems likely, however, that most interventions derived from a CBT framework will always retain, in one sense or another, the notion of presenting problems and symptoms, underlying cognitive mechanisms, and distal causes that give rise to both.

FUTURE DIRECTIONS FOR CASE FORMULATION AND RESEARCH Interest in formulation in CBT continues to grow, and the topic of formulation has been taken up not only by individual authors but also by larger bodies representing professional groups. For example, in 2011, the Division of Clinical Psychology of the British Psychological Society published a document, Good Practice Guidelines on the Use of Psychological Formulation, that reviews definitions, contexts, skills, and implications of formulation. It also, interestingly, contains explicit and implicit messages about the role of formulation in the profession of psychology; in particular, it describes many unknowns in the evidence base and concludes that formulation is an advanced, critical skill. Such “position papers” encapsulate the fascinating dilemmas for formulation, which we enumerate as follows in a series of paradoxes: • Formulation is critical to psychotherapy but is variably defined and practiced. • There is enormous potential for formulation to benefit therapy and outcomes, but we have great difficulty “proving” this. • Formulation is done best by “advanced” practitioners, but the pathway toward becoming expert is not clear. We take no issue with any of these paradoxes, as they do reflect the state of the field at this time. What is needed to move on is described in the following simple (we hope) ideas: • We need to get a clearer picture of everyday use of case formulation by therapists in practice, including what methods and models are most frequently used, how much time is devoted to formulation, and so on. • More research is needed on the reliability and validity of case formulation and of its components, within and across approaches to formulation. In addition, research is needed to identify the types of clinician training and experience necessary to meet this standard. • Dismantling studies on the efficacy of case formulation are needed. Such studies should evaluate the relative contributions of the various components of case formulation. • Ideally, and especially if we could establish the three things above, RCTs comparing standard manualized treatment to individualized, formulation-based treatment are needed. These studies should consider therapist characteristics



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(such as experience or training in case formulation) as well as patient characteristics (such as level of case complexity) as possible moderator variables. • Finally, research conducting cost-benefit analyses of case formulation would be very useful. How much time is necessary for a therapist to create a helpful case formulation (including training, experience, and time spent constructing an individual formulation)? How does that amount of time compare to the magnitude of benefit to the patient, in terms of, for example, the degree of symptom improvement, the number of sessions needed to achieve desired outcomes, or longer term health outcomes? This research should be conducted in a wide variety of cultural groups and with attention to cultural considerations to determine whether implications are different for different groups and whether cultural adaptations to the formulation process are warranted. It may be that this “plan” is not particularly feasible; such points are easy to write and harder to execute. We posit that formulation (in CBT and elsewhere) remains one of the central topics for clinical psychology and that the questions raised by it (more than answered by it) are both fascinating and important.

REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Antony, M. M., & Barlow, D. H. (2011). Handbook of assessment and treatment planning for psychological disorders. Guilford Press. Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.). (2001). Practitioner’s guide to empirically based measures of anxiety. Springer Science & Business Media. https://doi. org/10.1007/b108176 Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press. Beck, A. T., & Dozois, D. J. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62(1), 397–409. https://doi.org/10.1146/annurevmed-052209-100032 Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory– II (2nd ed.). Psychological Corporation; Harcourt Brace. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Bieling, P. J., & Kuyken, W. (2003). Is cognitive case formulation science or science fiction? Clinical Psychology: Science and Practice, 10(1), 52–69. https://doi.org/10.1093/ clipsy.10.1.52 Bieling, P. J., McCabe, R. E., & Antony, M. M. (2009). Cognitive-behavioral therapy in groups. Guilford Press. Binder, J. L. (2004). Key competencies in brief dynamic psychotherapy: Clinical practice beyond the manual. Guilford Press. Cahill, J., Stiles, W. B., Barkham, M., Hardy, G. E., Stone, G., Agnew-Davies, R., & Unsworth, G. (2012). Two short forms of the Agnew Relationship Measure: The ARM-5 and ARM-12. Psychotherapy Research, 22(3), 241–255. https://doi.org/10. 1080/10503307.2011.643253

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Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. https://doi.org/10.1146/annurev.psych.52.1.685 Corcoran, K., & Fischer, J. (2013). Measures for clinical practice and research: Vol. 1. Couples, families, and children. Oxford University Press. Derogatis, L. R., & Unger, R. (2010). Symptom Checklist-90-Revised. In The Corsini encyclopedia of psychology. https://doi.org/10.1002/9780470479216.corpsy0970 Easden, M. H., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Journal of Clinical Psychology, 74(3), 356–384. https://doi.org/10.1002/jclp.22516 Eells, T. D. (2007). History and current status of psychotherapy case formulation. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., pp. 3–32). Guilford Press. Eells, T. D. (2016). Psychotherapy case formulation. American Psychological Association. Eells, T. D., Kendjelic, E., & Lucas, C. (1995). Case formulation content coding manual [Unpublished manuscript]. Eells, T. D., Kendjelic, E. M., & Lucas, C. P. (1998). What’s in a case formulation? Development and use of a content coding manual. Journal of Psychotherapy Practice and Research, 7(2), 144–153. Eells, T. D., Lombart, K. G., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The quality of psychotherapy case formulations: A comparison of expert, experienced, and novice cognitive-behavioral and psychodynamic therapists. Journal of Consulting and Clinical Psychology, 73(4), 579–589. https://doi.org/10.1037/0022-006X.73.4.579 Eells, T. D., Lombart, K. G., Salsman, N., Kendjelic, E. M., Schneiderman, C. T., & Lucas, C. P. (2011). Expert reasoning in psychotherapy case formulation. Psychotherapy Research, 21(4), 385–399. https://doi.org/10.1080/10503307.2010.539284 Esbjørn, B. H., Reinholdt-Dunne, M. L., Nielsen, S. K., Smith, A. C., Breinholst, S., & Leth, I. (2015). Exploring the effect of case formulation driven CBT for children with anxiety disorders: A feasibility study. Behavioural and Cognitive Psychotherapy, 43(1), 20–30. https://doi.org/10.1017/S1352465813000702 Evans, C., Connell, J., Barkham, M., Margison, F., McGrath, G., Mellor-Clark, J., & Audin, K. (2002). Towards a standardised brief outcome measure: Psychometric properties and utility of the CORE-OM. British Journal of Psychiatry, 180(1), 51–60. https://doi.org/10.1192/bjp.180.1.51 Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 361– 404). Guilford Press. First, M. B. (1997). Structured clinical interview for the DSM-IV Axis I disorders: SCID-I/P, Version 2.0. Biometrics Research Dept., New York State Psychiatric Institute. First, M. B. (2014). Structured Clinical Interview for the DSM (SCID). In The encyclopedia of clinical psychology. https://doi.org/10.1002/9781118625392.wbecp351 Fothergill, C., & Kuyken, W. (2002). The quality of cognitive case formulation rating scale [Unpublished manuscript]. Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy, 44(2), 273–288. https://doi.org/10.1016/j. brat.2005.02.004 Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011. https://doi.org/10.1001/archpsyc.1989.01810110048007



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Guy, W. (Ed.). (1976). ECDEU assessment manual for psychopharmacology (Rev. ed.). National Institute of Mental Health. Hayes, S. C., & Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behavioral Assessment, 14(3), 345–365. Haynes, S. N., Mumma, G. H., & Pinson, C. (2009). Idiographic assessment: Conceptual and psychometric foundations of individualized behavioral assessment. Clinical Psychology Review, 29(2), 179–191. https://doi.org/10.1016/j.cpr.2008.12.003 Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). American Psychological Association. Hersen, M., & Porzelius, L. K. (2002). Diagnosis, conceptualization, and treatment planning for adults: A step-by-step guide. Lawrence Erlbaum Associates Publishers. Huisman, P., & Kangas, M. (2018). Evidence-based practices in cognitive behaviour therapy (CBT) case formulation: What do practitioners believe is important, and what do they do? Behaviour Change, 35(1), 1–21. https://doi.org/10.1017/bec.2018.5 Hunsley, J., & Mash, E. J. (Eds.). (2018). A guide to assessments that work (2nd ed.). Oxford University Press. https://doi.org/10.1093/med-psych/9780190492243.001. 0001 Jones, J. M. (2009). Counseling with multicultural intentionality: The process of counseling and integrating client cultural variables. In J. M. Jones (Ed.), The psychology of multiculturalism in the schools: A primer for practice, training, and research (pp. 191–213). National Association of School Psychologists. Kendjelic, E. M., & Eells, T. D. (2007). Generic psychotherapy case formulation training improves formulation quality. Psychotherapy: Theory, Research, & Practice, 44(1), 66–77. https://doi.org/10.1037/0033-3204.44.1.66 Kuyken, W., & Dudley, R. (2013). Case formulation in cognitive behavioural therapy: A principle-driven approach. In L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of people’s problems (2nd ed., pp. 38–64). Routledge. Kuyken, W., Fothergill, C. D., Musa, M., & Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behaviour Research and Therapy, 43(9), 1187– 1201. https://doi.org/10.1016/j.brat.2004.08.007 Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https:// doi.org/10.1017/S1352465808004815 Lau, M. A., Segal, Z. V., & Williams, J. M. G. (2004). Teasdale’s differential activation hypothesis: Implications for mechanisms of depressive relapse and suicidal behaviour. Behaviour Research and Therapy, 42(9), 1001–1017. https://doi.org/10.1016/j. brat.2004.03.003 Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: Techniques, efficacy, and indications. American Journal of Psychotherapy, 60(3), 233–259. https://doi.org/10.1176/appi. psychotherapy.2006.60.3.233 Lundkvist-Houndoumadi, I., Thastum, M., & Hougaard, E. (2016). Effectiveness of an individualized case formulation-based CBT for non-responding youths with anxiety disorders. Journal of Child and Family Studies, 25(2), 503–517. https://doi.org/10. 1007/s10826-015-0225-4 Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28(6), 487–495. https://doi.org/10.1016/0005-7967(90)90135-6 Mumma, G. H. (2004). Validation of idiosyncratic cognitive schema in cognitive case formulations: An intraindividual idiographic approach. Psychological Assessment, 16(3), 211–230. https://doi.org/10.1037/1040-3590.16.3.211

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National Collaborating Centre for Mental Health. (2011). Common mental health disorders: Identification and pathways to care. British Psychological Society. Nattrass, A., Kellett, S., Hardy, G. E., & Ricketts, T. (2015). The content, quality and impact of cognitive behavioural case formulation during treatment of obsessive compulsive disorder. Behavioural and Cognitive Psychotherapy, 43(5), 590–601. https:// doi.org/10.1017/S135246581400006X Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2004). Cognitive-behavioral case formulation and treatment design: A problem-solving approach. Springer. Nezu, A. M., Ronan, G. F., Meadows, E. A., & McClure, K. S. (2000). Practitioner’s guide to empirically-based measures of depression. Springer Science & Business Media. Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press. Persons, J. B., Roberts, N. A., Zalecki, C. A., & Brechwald, W. A. (2006). Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients. Behaviour Research and Therapy, 44(7), 1041–1051. https://doi. org/10.1016/j.brat.2005.08.005 Rogers, G. M., Park, J.-H., Essex, M. J., Klein, M. H., Silva, S. G., Hoyle, R. H., Curry, J. F., Feeny, N. C., Kennard, B., Kratochvil, C. J., Pathak, S., Reinecke, M. A., Rosenberg, D. R., Weller, E. B., & March, J. S. (2009). The dysfunctional attitudes scale: Psychometric properties in depressed adolescents. Journal of Clinical Child and Adolescent Psychology, 38(6), 781–789. https://doi.org/10.1080/15374410903259007 Schulte, D., & Eifert, G. H. (2002). What to do when manuals fail? The dual model of psychotherapy. Clinical Psychology: Science and Practice, 9(3), 312–328. https://doi.org/ 10.1093/clipsy.9.3.312 Shadish, W. R. (1993). Critical multiplism: A research strategy and its attendant tactics. New Directions for Program Evaluation, 1993(60), 13–57. https://doi.org/10.1002/ev. 1660 Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22–33. Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., Milo, K. M., Stock, S. L., & Wilkinson, B. (2010). Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). Journal of Clinical Psychiatry, 71(3), 313–326. https://doi.org/10.4088/ JCP.09m05305whi Tanaka-Matsumi, J., Seiden, D. Y., & Lam, K. N. (1996). The Culturally Informed Functional Assessment (CIFA) Interview: A strategy for cross-cultural behavioral practice. Cognitive and Behavioral Practice, 3(2), 215–233. https://doi.org/10.1016/ S1077-7229(96)80015-0 Teasdale, J. D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2(3), 247–274. https://doi.org/10.1080/02699938808410927 Waltman, S. H., & Sokol, L. (2017). The generic model of cognitive behavioral therapy: A case conceptualization-driven approach. In S. G. Hofmann & G. J. G. Asmundson (Eds.), The science of cognitive behavioral therapy (pp. 3–17). Elsevier. https://doi.org/10. 1016/B978-0-12-803457-6.00001-5 Ware, J. E., Snow, K. K., & Kosinski, M. (2000). SF-36 Version 2 Health Survey: Manual and interpretation guide. Quality Metric Inc. Weissman, A. N. (1979a). Dysfunctional Attitude Scale (DAS). In J. Ciarrochi & L. Bilich (Compilers), Acceptance and commitment therapy. Measures package [Unpublished manuscript]. http://integrativehealthpartners.org/downloads/ACTmeasures. pdf



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Weissman, A. N. (1979b). The Dysfunctional Attitude Scale: A validation study [Doctoral dissertation, University of Pennsylvania]. ScholarlyCommons. http://repository. upenn.edu/edissertations/1182 Young, J. E. (2005). Young Schema Questionnaire – Short Form 3 (YSQ-S3). Cognitive Therapy Center. Young, J. E., & Brown, G. (1998). Young Schema Questionnaire: Short Form. Cognitive Therapy Center. Zivor, M., Salkovskis, P. M., Oldfield, V. B., & Kushnir, J. (2013). Formulation in cognitive behavior therapy for obsessive–compulsive disorder: Aligning therapists, perceptions and practice. Clinical Psychology: Science and Practice, 20(2), 143–151. https://doi.org/10.1111/cpsp.12030 Zlomke, K. R. (2009). Psychometric properties of internet administered versions of Penn State Worry Questionnaire (PSWQ) and Depression, Anxiety, and Stress Scale (DASS). Computers in Human Behavior, 25(4), 841–843. https://doi.org/10.1016/j. chb.2008.06.003

6 Dissemination and Implementation Bradley E. Karlin

F

or more than 40 years, cognitive behavioral therapy (CBT) has been established as the gold standard of psychological treatments. Initially developed for depression, CBT is now available and recognized as an evidence-based treatment for a number of other mental and behavioral health conditions. Indeed, for some conditions (e.g., posttraumatic stress disorder [PTSD] and other anxiety disorders, insomnia), CBT has been shown to be substantially more effective and have longer lasting effects than medications (e.g., Butler et al., 2006; Institute of Medicine, 2007). And for several conditions, CBT is recommended by experts at the highest level and as a first-line treatment (e.g., Department of Veterans Affairs & Department of Defense, 2017; National Institute for Clinical Excellence, 2005; National Institutes of Health, 2005). Unfortunately, however, the practice of CBT has remained far behind the science, resulting in its largely unrealized promise and potential.1 To this day, CBT remains largely unavailable on the front lines of communities (Finley et al., 2018; Lu et al., 2016; C. S. Rosen et al., 2004). In fact, it is estimated that as few as 5% of adults with depression or anxiety receive an evidence-based psychotherapy (EBP; Layard & Clark, 2014). Indeed, the gap between what we know works and the delivery of CBT (and other EBPs) is far greater than the research-to-practice gap in virtually any other area of health care. If one has diabetes, for example, and walks into the office of their primary An earlier version of this chapter was presented as part of Dr. Karlin’s Presidential Address for the Society of Clinical Psychology at the 124th Annual Convention of the American Psychological Association.

1

https://doi.org/10.1037/0000218-006 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  157 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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care provider or endocrinologist, they can be assured that they would reliably receive, or have the option to receive, the first-line, Grade A recommended treatment for that condition—insulin. But, if that same person has PTSD or another anxiety disorder, insomnia, or maybe even depression, there is a low likelihood that they will receive the corresponding recommended treatment. Most likely, they will receive medication—maybe an antidepressant or an anxiolytic—that for many mental health conditions has relatively limited efficacy, at least as a monotherapy (Zibman, 2014). In fact, psychopharmacotherapy has increased considerably over the past decade, though the same has so far not been true of psychotherapy, particularly CBT (Greenblatt et al., 2018). When it is delivered, CBT is often delivered with limited treatment fidelity such that treatment components that may be intended as CBT do not resemble the treatment as it was intended and shown to be efficacious (Creed, Wolk, et al., 2016; Madson & Campbell, 2006). The enduring gap in the delivery of CBT and other EBPs is largely a function of too little focus and guidance on strategic implementation—an area of substantial need and opportunity within clinical psychology and, more broadly, professional psychology. For decades, there has been perhaps an overreliance on developing effective interventions and little focus on how we make these available and utilized—accounting for both implementation process and context. The goal of the present chapter is to examine key principles, strategies, and findings related to the dissemination and implementation of CBT, based on findings from implementation science and practice. The chapter then reviews recent advances in the dissemination and implementation of CBT within large public and private systems incorporating structured implementation approaches.

MULTILEVEL ACCOUNTING FOR THE LIMITED DELIVERY OF CBT A growing literature seeking to account for the limited delivery of CBT and other EBPs has documented significant barriers to delivery at a number of levels, including provider, system, and patient levels (Aarons et al., 2011; Fixsen et al., 2005; Tabak et al., 2012). This literature reveals that requirements that are at different levels and that are highly context specific must be met for treatments, especially fairly complex treatments, to be delivered. Provider-level barriers generally relate to limited preparedness among clinicians to deliver CBT. Although mental health providers often receive training related to CBT as part of graduate training, this training generally consists of knowledge-based training designed to promote knowledge or awareness of CBT and its general components. This is very different from competency-based training that is required for skill mastery and requires ongoing practice and feedback on the clinical implementation of treatment components (Beidas et al., 2012; Newman, 2010; R. C. Rosen et al., 2017). Many therapists, in fact, significantly overestimate their CBT skills. In an empirical examination of therapist perceived versus actual CBT competency, Creed, Wolk, et al. (2016) compared



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therapist-labeled therapeutic orientation with expert ratings of the same therapists’ therapy sessions. Although the great majority of therapists reporting a therapeutic orientation at baseline identified CBT as composing all or part of their clinical work, only a small proportion of these therapists demonstrated minimum competency in CBT, based on expert ratings of session audio recordings. Further, the overall level of CBT competency among these therapists was similar to that of participants endorsing a therapeutic orientation other than CBT (e.g., psychodynamic, play therapy, family systems). In addition to limited behavioral preparedness that may limit CBT adoption is limited psychological preparedness, or unfavorable attitudes toward CBT. Some clinicians do not have favorable attitudes toward CBT and other evidencebased practices due to the perception that such interventions are overly structured, rigid, or not individualized (Aarons, 2004; Cook et al., 2017). Similarly, among some clinicians, there is the perception that EBPs, like CBT, emphasize techniques over the therapeutic relationship (Karlin & Cross, 2014a). This is unfortunate because competent delivery of CBT places significant emphasis on both “common factors” and therapeutic techniques. This inaccurate perception of CBT is a function of limited in-depth understanding of CBT practice and what I have referred to as a “contamination” of the CBT label resulting from its application to purely psychoeducational or skills-based approaches that, while possibly based on cognitive or behavioral principles, do not represent cognitive behavioral therapy (Karlin & Cross, 2014a, 2014b). A growing body of evidence has demonstrated that key to addressing providerlevel needs for promoting adoption and delivery of CBT is competency-based training that incorporates foundational training in the theoretical and applied aspects of CBT, followed by ongoing consultation on the application of newly learned skills. While initial foundational training, which usually takes the form of in-person workshop training, has been shown to increase knowledge, positive attitudes, and intention to deliver CBT, it is clear that ongoing consultation with regular feedback on audio- or video-recorded CBT sessions is necessary for promoting CBT competency (Beidas at al., 2012; Karlin et al., 2019; Stirman et al., 2017). One-time training does little to change clinical behavior. Foundational training that is more experientially oriented (as opposed to primarily didactic in nature) and includes participant and observer role-plays and interactive discussion and exercises tends to have greater impact on learner outcomes, including knowledge, positive attitudes, self-efficacy to deliver CBT, and initial skill development (Beidas at al., 2012; Karlin et al., 2019). In recent years, there has been growing interest in utilizing technologyfocused, distance-based approaches as alternatives to in-person training in CBT. The use of technology, such as video conferencing and web-based training approaches, for delivering foundational CBT training is intriguing for promoting efficiency and scale due to having greater reach and not requiring travel of training participants. Despite the interest and potential utility of distance-based approaches to training in CBT and other EBPs, empirical support for and training participant engagement in alternative training modalities for foundational

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training are more limited than for in-person training modalities (R. C. Rosen et al., 2017; Smith et al., 2017). However, telephone-based and video-based modalities for ongoing training consultation following initial foundational training have consistently been shown to be very effective, particularly when training consultation groups are conducted in small groups, led by a trained CBT training consultant, and developed and framed as a supportive learning opportunity as opposed to an evaluative process (Karlin & Cross, 2014a; Karlin et al., 2019; Stirman et al., 2017). Furthermore, recent findings suggest that training that is individualized to training participants through the identification of personal strengths and weaknesses and specific training goals, in addition to overall competency attainment, is especially useful for maximizing meaning, engagement, and outcomes (Karlin et al., 2019). In addition, CBT training and treatment protocols that provide for or even emphasize individualization of treatment, as opposed to highly structured approaches, appear to increase clinician interest and engagement in the treatment process (Cook et al., 2017; Karlin et al., 2019). At the systems level, most mental health care systems and facilities lack a clinical infrastructure to support the delivery of treatments such as CBT that require eight to 16 weekly sessions of 50 or more minutes each. Most facilities also lack an organized structure for identifying for whom more front-end intensive treatments like CBT are most appropriate (versus, for example, low-intensity treatments) and for organizing staff and stepped care processes accordingly so that resources can be appropriately aligned and available to support the delivery of treatments like CBT when clinically indicated. Moreover, many systems lack a treatment culture that is consistent with an evidence-based treatment model, as opposed to a supportive or palliative approach to mental health care. At the patient level, consumers often have very limited awareness of evidencebased psychological treatments or even of what “evidence-based” means, and the alphabet soup of acronyms for treatment labels (CBT, IPT, ACT, etc.) can be dizzying. This is largely a failure of the mental health care community in marketing these treatments, such as through direct-to-consumer education and outreach, in comparison with the considerable success in this arena of the pharmaceutical industry (Gallo et al., 2015; Karlin & Brenner, 2020; Karlin & Cross, 2014a). This limited public awareness of CBT contributes to limited treatment uptake and motivation.

MOVING TOWARD MORE SOPHISTICATED IMPLEMENTATION For decades, approaches to dissemination or spread of EBPs have generally relied on unidimensional approaches that have typically focused on individual clinicians and have neglected critical needs of the system, the local organization or clinic, and especially patients or consumers. Further, they have usually involved passive methods of information exchange, such as clinical practice



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guidelines, clinical reminder systems, and toolkits—for which we often have expectations that generally far exceed their possibilities. The need to better and faster implement evidence-based treatments across the health care delivery continuum has given rise to the field of implementation science, which is developmentally now well into gangly adolescence. Before turning to the components of effective implementation borne out by scientific and applied implementation, it is important to define a few key terms. Although dissemination and implementation are often used interchangeably, they have different meanings. Dissemination refers to the distribution of an innovation generally to a defined audience or group. Implementation refers to the strategic integration of an innovation within an identified setting or context. Relative to dissemination, implementation consists of a more strategic and specific process for initiating or promoting the delivery of the innovation in one or more specific settings. For example, dissemination may involve actively spreading treatment manuals, toolkits, or other resources to one or more target provider groups, whereas implementation involves actively and strategically working at multiple levels of an organization to promote the adoption and delivery of an intervention and typically involves addressing and leveraging barriers and facilitators to delivery that are specific to the organization or setting. Unlike passive approaches to promoting uptake of interventions, implementation involves a number of distinguishing characteristics (see Figure 6.1). First, implementation is planful and intentional—implementation is the intervention. Second, it is strategic. Third, it is informed by empiricism—accounts for facilitators and barriers identified in the literature. Fourth, it is context sensitive—the intervention approach accounts for the characteristics of the local context. Fifth, it is multilevel—it addresses implementation requirements not just at the practitioner level but usually at several other levels as well. And, finally, implementation begins before implementation—it does this through assessing and promoting preimplementation readiness to maximize the likelihood of implementation success. This critically important, but often overlooked, part of implementation is where I turn next. Preimplementation Readiness A major component of the preimplementation readiness phase is assessing the organization’s readiness for implementing the innovation at many levels, including, for example, the organization, staff, and often patients. This process has multiple functions and benefits. First, it provides due notice or “informed consent” so that the organization is aware, at the outset, of what is required for implementing the innovation. Second, it allows for enhancing preparedness before active implementation. This includes preparedness of various stakeholders or actors who will play a part in the implementation process, including but not limited to system or facility leadership, clinic leadership, clinical staff, administrative staff, information technology staff, labor representation, and potential community stakeholders. Third, the process allows for the important

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FIGURE 6.1. Characteristics of Effective Implementation

tailoring of implementation to best meet organizational needs, rather than applying it in nomothetic or “off-the-shelf“ fashion. Significantly, research shows that approaches to implementation that work to promote system fit generally yield greater success (Fixsen et al., 2005; Mittman, 2012). Key organizational readiness domains and examples are summarized in Table 6.1. To facilitate preimplementation assessment, organizational readiness assessment measures and checklists have been developed and are now available in different fields (e.g., public health, health care, mental health; see Chaudoir et al., 2011, for a review). While useful to support initial assessment and planning, most of these measures have little or no psychometric data available. One measure designed specifically for supporting the implementation of evidencebased interventions in behavioral health care organizations is the Checklist to Assess Organizational Readiness (CARI) for Evidence-Informed Practice (EIP) Implementation (Barwick, 2011). This measure includes 25 items with response choices rated on a 4-point Likert scale (1 = not even close, 4 = we’re there). Examples of items include “The service funder recognizes the importance of EIP”; “Technical assistance (e.g., EIP training, coaching, ongoing support) is available for the EIP(s) being implemented”; “Implementing the selected EIP is aligned with organizational, regional, or system goals”; “Senior leadership is willing and able to lead and shape the implementation”; and “There is an implementation framework selected to guide the implementation process (e.g., NIRN model).” Information yielded by the CARI is used to facilitate preimplementation planning and preparation along the different domains assessed by the measure (e.g., staff preparedness, leadership support, financial resources) to facilitate greater organizational readiness for implementation. The CARI is free to use and may be accessed at http://melaniebarwick.com/implementation-tools/.



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TABLE 6.1. Key Organizational Readiness Domains Organizational domain

Examples

Organizational and system capacity

Financial resources, staffing, incentives

Organizational culture/climate

Alignment to mission, attitudes, beliefs

Staff capacity

Readiness for learning/practice change, plan for staff selection

Evaluation and communication of impact

System for assessing and communicating impact and continuous performance improvement

Implementation plan

Implementation model identified, implementation team formed

Staff training

Foundational training, ongoing consultation and feedback on implementation, sufficient time allotted for training

Leadership support

Commitment, ongoing involvement, support

Patient characteristics

Perceived utility, preference

Note. Data from Chaudoir et al. (2011), Lusthaus et al. (2002), and Powell et al. (2012).

Implementation Process and Frameworks Moving from preimplementation to the overall implementation process, a growing number of specific dissemination and implementation frameworks and models have been developed to guide the implementation process. In recent years, as the field of implementation science has matured and the need for guiding models for promoting, classifying, and evaluating intentional and empirically informed implementation approaches has become increasingly needed, the number of implementation frameworks has grown to now include many dozens of frameworks. These frameworks identify specific factors that are likely to impact implementation (determinant frameworks) and include facilitators and barriers to implementation as well as the processes or strategies for addressing such (process models; Nilsen, 2015). Several review articles are now available that synthesize the elements of the many frameworks, which can appear quite similar or vary widely from one another (see, for example, Albers et al., 2017; Flottorp et al., 2013; Moullin et al., 2015; Tabak et al., 2012). Notably, some frameworks are more specific to prevention innovations (public health) and others are more specific to health care innovations. Furthermore, there is considerable variability in the degree to which available frameworks focus on dissemination, implementation, or both dissemination and implementation, as well as the specific level(s) or context of focus (e.g., organization, system, policy, individual) and the degree of breadth versus specificity. Tabak et al. (2012) provide a useful three-part typology for classifying specific frameworks based on where on the dissemination versus implementation spectrum they fall, the level of construct flexibility (i.e., broad vs. detailed, step-by-step actions), and the level(s) of focus (i.e., system, community, organization, individual). When considering among the many dissemination and implementation

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frameworks that now exist, it is essential that the chosen framework be specific to the innovation (prevention practice vs. complex treatment) and setting (community vs. health care system). Moreover, the implementation framework or model should be tailored to best fit the needs and circumstances of the system or organization rather than be nomothetically applied (Karlin & Cross, 2014a; Tabak et al., 2012). An interactive website for searching and adapting various dissemination and implementation frameworks may be accessed at http://www.dissemination-implementation.org/index.aspx. Following their review of implementation frameworks of innovations in healthcare, Moullin et al. (2015) developed the Generic Implementation Framework (GIF), which provides an elegant composite depiction of metaprocesses and core concepts of implementation. The GIF is a useful overarching heuristic to guide administrators, policymakers, practitioners, and researchers in developing and organizing specific implementation activities. As visually depicted in Figure  6.2, general stages of implementation are represented by preimplementation, implementation, and postimplementation (key for sustainability). The specific steps or stages within each of these general stages vary across individual frameworks. The innovation to be implemented is at the center, affected by the specific context that should be accounted for, specific factors that may facilitate or impede implementation, and strategies for addressing these. FIGURE 6.2. Generic Implementation Framework

Note. From “A Systematic Review of Implementation Frameworks of Innovations in Healthcare and Resulting Generic Implementation Framework,”" by J. C. Moullin, D. Sabater-Hernández, F. Fernandez-Llimos, and S. I. Benrimoj, 2015, Health Research Policy and Systems, 13(16), p. 8 (https://doi. org/10.1186/s12961-015-0005-z). CC BY 4.0. Reprinted with permission.



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Implementation strategies consist of “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” (Proctor et al., 2013, p. 2). Powell et al. (2012) have developed a compilation of implementation strategies, as well as a subsequent refinement based on expert consensus of 73 discrete strategies using a modified Delphi process (an iterative process of gathering expert feedback and consensus; Powell et al., 2015). Examples of implementation strategies are competency-based training (e.g., foundational training followed by consultation and feedback), financing (e.g., securing funding, incentive structures), restructuring (e.g., clinic restructuring, adaptations to professional roles), and policy change (e.g., policies prioritizing or emphasizing the innovation). In light of the foregoing, how might one interested in implementing an innovation generally proceed? French and colleagues (2012) developed a generic, step-by-step action framework, known as the Theoretical Domains Framework, that provides a systematic, yet streamlined, guide for developing a theoryinformed implementation intervention. As presented in Table 6.2, the framework includes four steps framed as questions, with specific associated tasks. TABLE 6.2. Theoretical Domains Framework Step

Tasks

Step 1: Who needs to do what differently?

• Identity evidence-practice gap • Specify behavior change/innovation • Specify target group

Step 2: Using a theoretical framework, which barriers and enablers need to be addressed?

• Select framework/theories to inform implementation and identification of barriers/facilitators

Step 3: Which intervention components could overcome barriers and enhance enablers?

• Use framework/theories and empirical evidence to inform implementation strategies • Develop implementation intervention that is feasible, locally relevant, and acceptable to current project

Step 4: How can behavior change be measured and understood?

• Select appropriate and feasible variables to be measured

Note. From “Developing Theory-Informed Behaviour Change Interventions to Implement Evidence Into Practice: A Systematic Approach Using the Theoretical Domains Framework,” by S. D. French, S. E. Green, D. A. O’Connor, J. E. McKenzie, J. J. Francis, S. Michie, R. Buchbinder, P. Schattner, N. Spike, and J. M. Grimshaw, 2012, Implementation Science, 7(38), p. 3 (https://doi. org/10.1186/1748-5908-7-38). CC BY 2.0. Adapted with permission.

STRATEGIC DISSEMINATION AND IMPLEMENTATION IN PRACTICE: BRINGING CBT TO LARGE HEALTH CARE SYSTEMS In recent years, large public systems and, even more recently, private systems have developed strategic implementation initiatives designed to make CBT and other EBPs more widely available in routine practice settings and to close the

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research-to-practice gap. As described in more detail below, organized efforts to leverage these treatments, utilizing strategic and individualized approaches to training and implementation, have witnessed robust improvements on multiple outcome domains. In 2005, the Department of Veterans Affairs (VA) health care system, the largest integrated health care system in the United States, launched a national initiative to disseminate and implement EBPs as part of the transformation of the service system to an evidence-based and recovery-oriented system of care (Karlin & Cross, 2014a). Beginning with specialized versions of CBT for PTSD (i.e., cognitive processing therapy and prolonged exposure therapy), the initiative ultimately extended to 16 EBPs addressing PTSD, depression, substance use disorders, serious mental illness, insomnia, chronic pain, relationship distress, and motivation and adherence. To maximize impact and sustainability, such that these treatments would be woven into and prioritized within the fabrics of the VA health care system, a multilevel approach to dissemination and implementation was developed and used to guide the implementation process. This dissemination and implementation model, based on the findings of implementation science, included important focus and specific activities at policy, provider, local systems, patient, and accountability levels (Karlin & Cross, 2014a). Significantly, specific strategies across these levels of implementation intervention included both push and pull activities tailored to the VA health care system. Push strategies, such as competency-based training and system policies designed to prioritize or incentivize a specific service, consist of “top-down approaches to push a product or service out to the field,” whereas pull strategies are designed to “promote interest in and demand for a product or service among potential users or other stakeholders or advocates (e.g., family members)” (Karlin & Cross, 2014a, p. 26). The dissemination and implementation of EBPs in the VA health care system, which has included the training of more than 14,000 VA mental health staff in one or more EBPs, represents the largest undertaking of its kind in the nation. Program evaluation findings from many of these training programs have demonstrated that EBP training and implementation is associated with large improvements in therapist preparedness to deliver CBT and other EBPs, including large increases in competencies and more favorable attitudes toward EBPs. Across a number of these training programs, the rate of competency achievement at the end of training was in the 80%–90% or greater range, which was generally at least twice the rate of competency achievement demonstrated at the beginning of training (e.g., Karlin et al., 2012, 2013; Stewart et al., 2014; Walser et al., 2013). Most significantly, EBP training and implementation in real-world clinical settings serving veterans has been consistently associated with robust improvements on multiple patient outcome domains, including reductions in symptoms in the medium to large effect size range and improvements in psychological and physical quality of life generally in the medium effect size range (e.g., Eftekhari et al., 2013; Karlin et al., 2012; Ruzek et al., 2016; Stewart et al., 2014, 2015; Trockel et al., 2015; Walser et al., 2013).



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Notwithstanding the positive outcomes associated with the broad dissemination and implementation of CBT and other EBPs throughout the VA health care system, recent data measuring the delivery of these treatments indicate that a relatively small proportion of veterans who can benefit from these treatments receive them (e.g., Kehle-Forbes et al., 2016; Lu et al., 2016). Among the most significant, but underrecognized, factors contributing to the low uptake and delivery of EBPs among veterans (and nonveterans) are individual patient factors, namely limited treatment awareness and patient engagement (Karlin & Cross, 2014a). To address these patient-level barriers, VA has developed and launched a unique, direct-to-consumer outreach and engagement strategy that centers around a national web-based platform (https://www.TreatmentWorksForVets. org) designed to promote EBP uptake and engagement using a two-factor engagement approach (Karlin & Brenner, 2020). The first part of this two-factor approach involves a national EBP public awareness website (veteran portal) designed to increase veteran (and nonveteran) awareness, interest, and initial help-seeking or conversation about CBT and other EBPs. It uses an innovative and creative design approach, along with animated, character-based content and interactive exercises, to promote veteran and family member knowledge of mental health conditions, EBPs, and the treatment process, as well as treatment locator tools for finding treatment. The second part of the engagement strategy involves developing a shared decision-making process prior to the initiation of treatment for increasing patient knowledge, informed choice, and treatment motivation once they are “in the door.” This is the focus of the provider portal of the Treatment Works For Vets platform (https://www.TreatmentWorksForVets.org/Provider) and the EBP Shared Decision-Making Toolkit for Mental Health Providers (Karlin & Wenzel, 2018), which may be accessed through the provider portal for increasing the engagement of veteran and nonveteran patients in EBPs and other mental health treatments. The toolkit may also be downloaded as a standalone resource, freely available. A primary focus of the toolkit is the Shared DecisionMaking (SDM) Session (Karlin & Wenzel, 2018), a structured yet flexible pretreatment intervention, typically delivered in a single session, that we have developed for promoting initial engagement in treatment. The toolkit also includes key processes and strategies for promoting ongoing treatment engagement for patients that choose to initiate treatment, including strategies and tools for assessing and enhancing the therapeutic alliance and for incorporating principles and processes of measurement-based care. Greater focus on pretreatment shared decision-making, patient engagement, and treatment readiness is essential for maximizing CBT uptake, engagement, and outcomes (Karlin & Brenner, 2020). With similar goals to make EBPs widely available on the clinical frontlines, the public health care system in the United Kingdom (U.K.) has embarked on a national initiative to disseminate and implement CBT and other EBPs, which has included the training of more than 7,000 therapists (Clark, 2018). This effort has demonstrated significant training outcomes among therapists and

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substantially increased consumer access to EBPs and yielded significant clinical improvements among patients, including a 51% recovery rate (Clark, 2018; Gyani et al., 2013). An additional implementation initiative designed to promote the availability of cognitive therapy within the public mental health care system in Pennsylvania is the Beck Community Initiative (BCI; Creed et al., 2014). Through a partnership between the University of Pennsylvania and the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, the initiative provides competency-based training and implementation support for promoting the availability of cognitive therapy among children, adolescents, and adults experiencing various mental health conditions. Training is provided through several intensive in-person workshops, followed by 6 months of weekly, group-based consultation on the application of newly learned skills. Based on data reported on 274 clinicians who have completed the BCI training (of 348 who initiated training), 60% reached competency by the end of training. When including work samples submitted by some clinicians after the training, the competency achievement rate was 80% (Creed, Frankel, et al., 2016). Clinicians reported overall high levels of acceptability and satisfaction with the training (Creed, Frankel, et al., 2016). Patient-level outcomes have not been reported. Following the successful initiatives to disseminate and implement EBPs within some of the largest public health care systems in the world, Kaiser Permanente (KP), one of the largest private nonprofit health care systems in the United States, recently developed and implemented a pilot initiative to disseminate and implement CBT for depression (CBT-D), designed for treating depression and co-occurring anxiety (Karlin et al., 2019). This initiative includes top-down (e.g., competency-based training) and bottom-up (CBT-D peer consultation groups) implementation strategies for increasing CBT delivery and sustainability, tailored to the KP system. As with the approach to EBP dissemination and implementation in the VA, U.K., and BCI initiatives, a central component of the KP CBT-D dissemination and implementation initiative is a competency-based and self-sustaining CBT-D training program. The CBT-D treatment protocol adapted for the KP health care system (Brown & Karlin, 2017) includes several distinguishing features for promoting the individualization of treatment, while ensuring high fidelity to the CBT model. This includes placing significant emphasis on the therapeutic alliance, a case conceptualization approach to treatment (including both cognitive and behavioral formulations to guide treatment), measurement-based care principles and processes, and a focus on co-occurring anxiety, which is common among KP members. In addition to the important emphasis placed on the individualization of treatment, the approach to CBT training in KP has placed significant and unique emphasis on individualizing the training experience for maximizing the engagement and outcomes of very busy clinicians in a large, private health care system. Similar to the experiences in the VA and U.K. systems, program evaluation results reveal that training in and implementation of CBT-D in the KP health



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care system is associated with robust therapist and patient outcomes (Karlin et al., 2019). Notably, while early in the process, 100% of therapists trained through the KP CBT-D Training Program to date have achieved CBT competency and successfully completed the training, which may be attributed in part to the unique individualized training approach as well as to the fact that the approach to treatment is one that is not overly structured but is individualized and honors clinical decision-making and broad therapy skills. Moreover, improvements in therapist skills, based on both observer and self-report, extended well beyond CBT-specific skills to include overall therapy skills (e.g., Understanding, Interpersonal Effectiveness, Collaboration, and Feedback; Karlin et al., 2019). Finally, as part of the focus on promoting internal CBT training capacity and sustainability within KP, the initiative has included the development of a comprehensive manual for training CBT training consultants (Brown & Karlin, 2018) as well as the CBT Training Consultant Rating Scale (Brown et al., 2018), modeled after the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980), for rating and providing feedback to training consultants leading training consultation sessions. Finally, particularly encouraging from a health economics standpoint is that, in addition to staff and patient-level improvements, researchers have documented significant service and cost offset—the “holy grail” in health care delivery—associated with the delivery of EBPs. Specifically, researchers within the VA health care system have demonstrated service and cost offset on the order of approximately 30% to 40% among veterans receiving EBPs (Meyers et al., 2013; Tuerk et al., 2013). In addition, recent research within the KP health care system has similarly demonstrated significant cost offset associated with the delivery of CBT (Dickerson et al., 2018). In fact, based on their findings, the investigators reported a greater than 90% probability that CBT is cost-effective over a 1- and 2-year period (Dickerson et al., 2018). The foregoing findings and additional research likely to emerge demonstrating CBT yielding back-end savings are essential for making the “business case” for CBT implementation, which is often necessary for eliciting leadership support for the front-end investment in CBT training and implementation. Demonstrating such a business case is often especially important in the mental health care arena, where concerns about access and clinical efficiency are particularly salient and where “front-heavy” 10- to 16-session treatments are typically not the norm.

CONCLUSION Despite its established efficacy and status as a highly recommended treatment in many clinical contexts, CBT remains largely unavailable and its potential unrealized in most community and health care settings. This wide and enduring research-to-practice gap is largely a consequence of unsophisticated, onedimensional, and passive attempts to promote CBT delivery. For too long, the field of clinical psychology, and the mental health care sector more broadly, has

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placed too much focus on the “what” (development of specific treatments) and too little focus on the “how” (how to get established treatments into routine clinical settings). Applying established principles and processes from the emerging field of implementation science provides significant opportunities for developing more informed, strategic, and multilevel approaches to promoting the delivery and sustainability of CBT on the clinical front lines. Just as empiricism guides the clinical application to CBT, so too should it increasingly guide organizational and system dissemination and implementation of CBT. Recent efforts within large public and private health care systems to actualize this promise provide significant optimism for the potential of strategic, intentional, and individualized approaches to CBT dissemination and implementation for increasing the availability of Grade A recommended mental health treatments in routine practice settings. Most significant is the impact yielded by these organized efforts at therapist, patient, and system levels, findings that have consistently and rather convincingly demonstrated the feasibility, effectiveness, and, most recently, cost-effectiveness of CBT delivered in real-world settings. As the experiences of these systems demonstrate, moving from the “what” to the “how” for leveraging evidence-based psychological treatments presents an opportunity for truly realizing the promise of science and for transforming the quality and delivery of mental health care. REFERENCES Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidencebased practice: The Evidence-Based Practice Attitude Scale (EBPAS). Mental Health Services Research, 6(2), 61–74. https://doi.org/10.1023/B:MHSR.0000024351. 12294.65 Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health, 38(1), 4–23. https://doi.org/10.1007/s10488-010-0327-7 Albers, B., Mildon, R., Lyon, A. R., & Shlonsky, A. (2017). Implementation frameworks in child, youth and family services: Results from a scoping review. Children and Youth Services Review, 81, 101–116. https://doi.org/10.1016/j.childyouth.2017.07.003 Barwick, M. (2011). Checklist to assess organizational readiness (CARI) for EIP implementation. Hospital for Sick Children Toronto. https://www.melaniebarwick.com/ implementation.php Beidas, R. S., Edmunds, J. M., Marcus, S. C., & Kendall, P. C. (2012). Training and consultation to promote implementation of an empirically supported treatment: A randomized trial. Psychiatric Services, 63(7), 660–665. https://doi.org/10.1176/appi. ps.201100401 Brown, G. K., & Karlin, B. E. (2017). Cognitive behavioral therapy for depression: A manual for Kaiser Permanente therapists. Education Development Center. Brown, G. K., & Karlin, B. E. (2018). Cognitive behavioral therapy for depression: A manual for Kaiser Permanente training consultants. University of Pennsylvania; Education Development Center. Brown, G. K., Karlin, B. E., & Creed, T. E. (2018). Cognitive behavioral therapy training consultant rating scale. University of Pennsylvania; Education Development Center. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. https://doi.org/10.1016/j.cpr.2005.07.003



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Chaudoir, S. R., Dugan, A. G., & Barr, C. H. I. (2011). Dissemination and implementation measurement compendium: A systematic review of structural, organizational, provider, patient, and innovation level measures. Connecticut Institute for Clinical and Translational Science. https://chipcontent.chip.uconn.edu//wp-content/uploads/2015/09/ DI-Measurement-Compendium.pdf Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology, 14, 159–183. https://doi.org/10.1146/annurev-clinpsy-050817-084833 Cook, S. C., Schwartz, A. C., & Kaslow, N. J. (2017). Evidence-based psychotherapy: Advantages and challenges. Neurotherapeutics, 14(3), 537–545. https://doi.org/10. 1007/s13311-017-0549-4 Creed, T. A., Frankel, S. A., German, R. E., Green, K. L., Jager-Hyman, S., Taylor, K. P., Adler, A. D., Wolk, C. B., Stirman, S. W., Waltman, S. H., Williston, M. A., Sherrill, R., Evans, A. C., & Beck, A. T. (2016). Implementation of transdiagnostic cognitive therapy in community settings: The Beck Community Initiative. Journal of Consulting and Clinical Psychology, 84(12), 1116–1126. https://doi.org/10.1037/ ccp0000105 Creed, T. A., Stirman, S. W., Evans, A. C., & Beck, A. T. (2014). A model for implementation of cognitive therapy in community mental health: The Beck Initiative. Behavior Therapist, 37(3), 56–64. https://www.abct.org/docs/PastIssue/37n3.pdf Creed, T. A., Wolk, C. B., Feinberg, B., Evans, A. C., & Beck, A. T. (2016). Beyond the label: Relationship between community therapists’ self-report of a cognitive behavioral therapy orientation and observed skills. Administration and Policy in Mental Health Services Research, 43(1), 36–43. https://doi.org/10.1007/s10488-014-0618-5 Department of Veterans Affairs & Department of Defense. (2017). VA/DoD clinical practice guideline for management of posttraumatic stress disorder and acute stress disorder (Version 3.0). https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal. pdf Dickerson, J. F., Lynch, F. L., Leo, M. C., DeBar, L. L., Pearson, J., & Clarke, G. N. (2018). Cost-effectiveness of cognitive behavioral therapy for depressed youth declining antidepressants. Pediatrics, 141(2), e20171969. https://doi.org/10.1542/ peds.2017-1969 Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949–955. https://doi.org/10.1001/ jamapsychiatry.2013.36 Finley, E. P., Noël, P. H., Lee, S., Haro, E., Garcia, H., Rosen, C., Bernardy, N., Pugh, M. J., & Pugh, J. A. (2018). Psychotherapy practices for veterans with PTSD among community-based providers in Texas. Psychological Services, 15(4), 442–452. https:// doi.org/10.1037/ser0000143 Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute. Flottorp, S. A., Oxman, A. D., Krause, J., Musila, N. R., Wensing, M., Godycki-Cwirko, M., Baker, R., & Eccles, M. P. (2013). A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science, 8, 35. https://doi.org/10.1186/1748-5908-8-35 French, S. D., Green, S. E., O’Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., Buchbinder, R., Schattner, P., Spike, N., & Grimshaw, J. M. (2012). Developing theoryinformed behaviour change interventions to implement evidence into practice: A systematic approach using the Theoretical Domains Framework. Implementation Science, 7, 38. https://doi.org/10.1186/1748-5908-7-38

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Gallo, K. P., Comer, J. S., Barlow, D. H., Clarke, R. N., & Antony, M. M. (2015). Direct-to-consumer marketing of psychological treatments: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(5), 994–998. https://doi. org/10.1037/a0039470 Greenblatt, D. J., Harmatz, J. S., & Shader, R. I. (2018). Update on psychotropic drug prescribing in the United States: 2014–2015. Journal of Clinical Psychopharmacology, 38(1), 1–4. https://pubmed.ncbi.nlm.nih.gov/29215384/ Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: Lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597–606. https://doi.org/10.1016/j.brat.2013.06.004 Institute of Medicine. (2007). Treatment of PTSD: An assessment of the evidence. National Academies Press. Karlin, B. E., & Brenner, L. A. (2020). Improving engagement in evidence-based psychological treatments among veterans: Direct-to-consumer outreach and pretreatment shared decision-making. Clinical Psychology: Science and Practice. Advance online publication. https://doi.org/10.1111/cpsp.12344 Karlin, B. E., Brown, G. K., Jager-Hyman, S., Green, K. L., Wong, M., Lee, D. S., Bertagnolli, A., & Ross, T. B. (2019). Dissemination and implementation of cognitive behavioral therapy for depression in the Kaiser Permanente health care system: Evaluation of initial training and clinical outcomes. Behavior Therapy, 50(2), 446– 458. https://doi.org/10.1016/j.beth.2018.08.002 Karlin, B. E., Brown, G. K., Trockel, M., Cunning, D., Zeiss, A. M., & Taylor, C. B. (2012). National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes. Journal of Consulting and Clinical Psychology, 80(5), 707–718. https://doi. org/10.1037/a0029328 Karlin, B. E., & Cross, G. (2014a). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System. American Psychologist, 69(1), 19–33. https://doi.org/10.1037/a0033888 Karlin, B. E., & Cross, G. (2014b). Enhancing access, fidelity, and outcomes in the national dissemination of evidence-based psychotherapies. American Psychologist, 69(7), 709–711. https://doi.org/10.1037/a0037384 Karlin, B. E., Trockel, M., Taylor, C. B., Gimeno, J., & Manber, R. (2013). National dissemination of cognitive behavioral therapy for insomnia in veterans: Therapistand patient-level outcomes. Journal of Consulting and Clinical Psychology, 81(5), 912– 917. https://doi.org/10.1037/a0032554 Karlin, B. E., & Wenzel, A. (2018). Evidence-based psychotherapy shared decision-making toolkit for mental health providers. Education Development Center. https://www. treatmentworksforvets.org/Provider/ Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8(1), 107–114. https://doi.org/10.1037/tra0000065 Layard, R., & Clark, D. M. (2014). Thrive: The power of evidence-based psychological therapies. Allen Lane. Lu, M. W., Plagge, J. M., Marsiglio, M. C., & Dobscha, S. K. (2016). Clinician documentation on receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. Journal of Behavioral Health Services & Research, 43(1), 71–87. https://doi.org/10. 1007/s11414-013-9372-9 Lusthaus, C., Adrien, M., Anderson, G., Carden, F., & Montalván, G. (2002). Organizational assessment: A framework for improving performance. IDRC Books.



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Madson, M. B., & Campbell, T. C. (2006). Measures of fidelity in motivational enhancement: A systematic review. Journal of Substance Abuse Treatment, 31(1), 67–73. https:// doi.org/10.1016/j.jsat.2006.03.010 Meyers, L. L., Strom, T. Q., Leskela, J., Thuras, P., Kehle-Forbes, S. M., & Curry, K. T. (2013). Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder. Military Medicine, 178(1), 95–99. https://doi.org/10.7205/MILMED-D-12-00302 Mittman, B. S. (2012). Implementation science in health care. In R. Browson, G. Colditz, & E. Proctor (Eds.), Dissemination and implementation research in health: Translating science to practice (pp. 400–418). Oxford University Press. https://doi.org/ 10.1093/acprof:oso/9780199751877.003.0019 Moullin, J. C., Sabater-Hernández, D., Fernandez-Llimos, F., & Benrimoj, S. I. (2015). A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework. Health Research Policy and Systems, 13. https://doi.org/10.1186/s12961-015-0005-z National Institute for Clinical Excellence. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care (Clinical Guideline 26). National Institutes of Health. (2005). National Institutes of Health State of the Science Conference statement on manifestations and management of chronic insomnia in adults, June 13–15, 2005. Sleep, 28(9), 1049–1057. https://doi.org/10.1093/sleep/ 28.9.1049 Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational, functional, and supervisory aspects. Psychotherapy: Theory, Research, & Practice, 47(1), 12–19. https://doi.org/10.1037/a0018849 Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10, 53. https://doi.org/10.1186/s13012-015-0242-0 Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., Glass, J. E., & York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review, 69(2), 123–157. https://doi.org/10.1177/1077558711430690 Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10, 21. https://doi.org/10.1186/s13012015-0209-1 Proctor, E. K., Powell, B. J., & McMillen, J. C. (2013). Implementation strategies: Recommendations for specifying and reporting. Implementation Science, 8, 139. https://doi.org/10.1186/1748-5908-8-139 Rosen, C. S., Chow, H. C., Finney, J. F., Greenbaum, M. A., Moos, R. H., Sheikh, J. I., & Yesavage, J. A. (2004). VA practice patterns and practice guidelines for treating posttraumatic stress disorder. Journal of Traumatic Stress, 17(3), 213–222. https://doi. org/10.1023/B:JOTS.0000029264.23878.53 Rosen, R. C., Ruzek, J. I., & Karlin, B. E. (2017). Evidence-based training in the era of evidence-based practice: Challenges and opportunities for training of PTSD providers. Behaviour Research and Therapy, 88, 37–48. https://doi.org/10.1016/j.brat. 2016.07.009 Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., Hembree, E. A., & Karlin, B. E. (2016). Effects of a comprehensive training program on clinician beliefs about and intention to use prolonged exposure therapy for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 348–355. https://doi.org/10. 1037/tra0000004 Smith, T. L., Landes, S. J., Lester-Williams, K., Day, K. T., Batdorf, W., Brown, G. K., Trockel, M., Smith, B. N., Chard, K. M., Healy, E. T., & Weingardt, K. R. (2017).

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Developing alternative training delivery methods to improve psychotherapy implementation in the U.S. Department of Veterans Affairs. Training and Education in Professional Psychology, 11(4), 266–275. https://doi.org/10.1037/tep0000156 Stewart, M. O., Karlin, B. E., Murphy, J. L., Raffa, S. D., Miller, S. A., McKellar, J., & Kerns, R. D. (2015). National dissemination of cognitive-behavioral therapy for chronic pain in veterans: Therapist and patient-level outcomes. Clinical Journal of Pain, 31(8), 722–729. https://doi.org/f7kcbh Stewart, M. O., Raffa, S. D., Steele, J. L., Miller, S. A., Clougherty, K. F., Hinrichsen, G. A., & Karlin, B. E. (2014). National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes. Journal of Consulting and Clinical Psychology, 82(6), 1201–1206. https://doi.org/10.1037/a0037410 Stirman, S. W., Pontoski, K., Creed, T., Xhezo, R., Evans, A. C., Beck, A. T., & CritsChristoph, P. (2017). A non-randomized comparison of strategies for consultation in a community-academic training program to implement an evidence-based psychotherapy. Administration and Policy in Mental Health and Mental Health Services Research, 44(1), 55–66. https://doi.org/10.1007/s10488-015-0700-7 Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research and practice: Models for dissemination and implementation research. American Journal of Preventive Medicine, 43(3), 337–350. https://doi.org/10.1016/j. amepre.2012.05.024 Trockel, M., Karlin, B. E., Taylor, C. B., Brown, G. K., & Manber, R. (2015). Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep, 38(2), 259–265. https://doi.org/10.5665/sleep.4410 Tuerk, P. W., Wangelin, B., Rauch, S. A. M., Dismuke, C. E., Yoder, M., Myrick, H., Eftekhari, A., & Acierno, R. (2013). Health service utilization before and after evidencebased treatment for PTSD. Psychological Services, 10(4), 401–409. https://doi.org/10. 1037/a0030549 Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., & Taylor, C. B. (2013). Training in and implementation of acceptance and commitment therapy for depression in the Veterans Health Administration: Therapist and patient outcomes. Behaviour Research and Therapy, 51(9), 555–563. https://doi.org/10.1016/j.brat.2013.05.009 Young, J., & Beck, A. (1980). Cognitive Therapy Scale: Rating manual [Unpublished manuscript]. Center for Cognitive Therapy. https://beckinstitute.org/wp-content/ uploads/2015/10/CTRS-current-10-2011-Cognitive-Therapy-Rating-Scale-2.pdf Zibman, C. (2014, October). Expenditures for mental health among adults, ages 18–64, 2009–2011: Estimates for the U.S. civilian noninstitutionalized population (Statistical Brief No. 454). U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. https://meps.ahrq.gov/data_files/publications/st454/stat454. pdf

7 The Therapeutic Relationship Amy Wenzel

T

he therapeutic relationship between a mental health provider who delivers psychotherapy and a client is arguably one of the most intimate yet complex relationships in which a person can engage. Many clients seek psychotherapy when they are in distress and are enduring a particularly difficult time in their lives; thus, they are searching for someone to help them. Even when clients seek psychotherapy for other reasons when their lives are going relatively well, such as for personal growth or for working through of problematic events from their pasts, they are still entering into a relationship in which they will be prepared to disclose personal, and sometimes embarrassing, information about themselves. In instances in which clients embark on a course of psychotherapy with a negative attitude toward treatment, such as when a spouse threatens to leave them if they do not get help or when they are court ordered to participate in psychotherapy, the therapeutic relationship can be the very factor that helps them come around and extract something positive out of the experience. The therapeutic relationship has been recognized as one of the most important factors to which clinicians should attend and cultivate in delivering successful psychotherapy (Castonguay et al., 2006; Doran, 2016; Wolfe & Goldfried, 1988). At the time of the writing of this chapter, a PsycInfo search using the keywords “therapeutic relationship” yielded 7,314 hits. Despite the pervasiveness of scholarship and clinical attention to the therapeutic relationship, cognitive behavioral therapy (CBT) is often (and incorrectly, from my perspective) viewed as a therapeutic approach that minimizes the importance of the https://doi.org/10.1037/0000218-007 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  175 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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therapeutic relationship (Gluhoski, 1994). Critics of CBT perceive it to be a technique-oriented treatment approach in which clinicians follow a step-bystep “recipe” regardless of what is happening in the therapeutic relationship and regardless of the needs and preferences of the individual client. At times, CBT is contrasted with other therapeutic approaches for which the therapeutic relationship is a central curative factor in a way that implies that the majority of what occurs in CBT is bland, overly structured, and overly didactic (e.g., Shedler, 2010). Although it is true that expert cognitive behavioral therapists view a strong therapeutic relationship as being necessary but insufficient to achieve a successful outcome from a course of psychotherapy (J. S. Beck, 2011), in no way do cognitive behavioral therapists ignore or neglect the importance of the therapeutic relationship. In fact, the therapeutic relationship is increasingly assuming a central focus of scholarly and clinical attention among cognitive behavioral therapists (e.g., Gilbert & Leahy, 2007; Kazantzis et al., 2017). Although, to give credit where credit is due, it most certainly has been addressed even in the earliest writings of the “father” of CBT, Aaron T. Beck (e.g., A. T. Beck et al., 1979). In this chapter, I describe the ways in which cognitive behavioral therapists foster and attend to the therapeutic relationship during the course of CBT. In fact, I argue that some of the very best CBT occurs in “real time” when the therapist and client address and work through something that is happening in the therapeutic relationship. To achieve these aims, I first describe basic definitions that are relevant to understanding the therapeutic relationship. Next, I consider the components of CBT that specifically enhance the therapeutic relationship. Then, I summarize empirical research on the impact of the therapeutic relationship on the process and outcome of psychotherapy, with an emphasis on results from studies that have examined aspects of the therapeutic relationship within the context of CBT. I also supply some clinical guidelines to guide cognitive behavioral therapists in the use of the therapeutic relationship as they deliver CBT, illustrating some of these guidelines with exemplars from my own clinical practice, and I include a clinical example that is modeled after a true case.1 I end the chapter with considerations for future scholarship and research, calling on cognitive behavioral therapists who are interested in this topic to reach beyond the CBT literature and consult the writings of scholar-clinicians who practice from other theoretical orientations to think deeply about the therapeutic relationship and apply their constructs within the cognitive behavioral framework.

DEFINITIONS According to Kazantzis et al. (2017), the therapeutic relationship is defined as the “exchange between therapist and client that develops for the purpose of sharing intimate thoughts, beliefs, and emotions in an endeavor to facilitate Clinical examples are disguised to protect patient confidentiality.

1



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change. This relationship is characterized by the safe, open, nonjudgmental atmosphere that imbues trust and confidence” (p. 17). I have had many clients express that there is nothing in the world that can replicate the experience of another person being fully attentive, devoted, and benign, without a competing agenda, in a calm, serene environment. Indeed, I have witnessed many clients almost sinking into their chairs as I begin to ask about their experiences in a warm, interested, undistracted manner. Clients become poised for self-examination and the implementation of meaningful changes in their lives when they are operating from a foundation in which there is an assumption that even if they are struggling or have flaws, they are decent human beings who are doing their best and who deserve respect, care, and concern. Therapeutic Alliance No construct associated with the therapeutic relationship has received as much attention as the therapeutic alliance (also called the working alliance; Doran, 2016). Although the construct was first developed within the psychoanalytic community (Greenson, 1965, 1967), the term as it is used in contemporary literature that cuts across theoretical orientations (cf. Doran, 2016) was advanced by Bordin (1979), who identified three key components: (a) the agreement of the therapist and client on therapeutic goals, (b) the agreement of the therapist and client on therapeutic tasks, and (c) the emotional bond between the therapist and client. More recently, Constantino et al. (2002) stated that “it is generally agreed that the alliance represents interactive, collaborative elements of the relationship (i.e., therapist and client abilities to engage in the tasks of therapy and to agree on the targets of therapy) in the context of an affective bond of positive attachment” (p. 86). Some scholar-clinicians have regarded the therapeutic alliance as the most essential ingredient in facilitating change in psychotherapy (Horvath & Bedi, 2002; Lambert & Simon, 2008), and many assessment tools have been constructed to operationalize the construct and measure its key components (Elvins & Green, 2008). It is not difficult to surmise ways in which a strong therapeutic alliance would facilitate a client’s positive experience in psychotherapy. When a therapist and client have agreed on the goals and tasks of therapy, it stands to reason that their work will be focused on important problems that both parties believe have great promise in achieving meaningful change. Such agreement has the potential to make therapeutic work efficient and productive, leaving the client with the sense that they are really “doing something” about their problems. Moreover, a strong emotional bond between the therapist and client can nurture an environment in which the client feels comfortable disclosing personal information and making a commitment to take risk in the spirit of enacting change. Very similar to what is posited by attachment theorists (e.g., Bowlby, 1969), the therapist can serve as a secure base from which the client can test out assumptions, practice new behaviors, and accumulate life experiences that are different and (presumably) healthier than those in which the client was immersed when they sought treatment. From a less profound standpoint, a strong emotional bond

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could also be associated with simple by-products such as the client looking forward to attending regular sessions and feeling eager to report new developments to the therapist, which certainly bode well for outcome. In psychotherapy research, when scholars include measures of the therapeutic relationship into their designs, they almost always focus specifically on the therapeutic alliance. Thus, the therapeutic alliance is the construct associated with the therapeutic relationship that has, by far, the most extensive base in the clinical science research literature. However, this construct is not without its critics. For example, some have argued that it focuses excessively on the agreement between the therapist and client without acknowledging other avenues to the development of a strong therapeutic relationship, making it more about compliance than the relationship itself (Cushman & Gilford, 2000). Others have raised the possibility that a strong therapeutic alliance conceptualized in this manner actually represents a pseudoalliance, such that the therapist and client ignore their own needs to attend to the needs of the other, or when the therapist and client agree with one another in order to avoid discord (Bender, 2005; Wachtel, 2008). These provocative insights raise the possibility that clients with certain personality characteristics, such as dependency or submissiveness, score higher on inventories of the therapeutic alliance than clients who do not have these characteristics (e.g., Muran et al., 1994). Not only would scores on the therapeutic alliance be artificially inflated in these cases (cf. Bender, 2005), but if therapists are guided by this way of understanding the therapeutic alliance, then they might deliver therapy in a manner that reinforces, rather than corrects, an interpersonal style that has contributed to a client’s life problems. Finally, it has been posited that the aspects of the therapeutic relationship that are reported by clients as being important to them are not typically represented in scales measuring the working alliance (Bachelor, 1995). Thus, the therapeutic alliance is undoubtedly a central aspect of the therapeutic relationship that has been subjected to rigorous empirical scrutiny. However, it is equally as important to recognize that the notion of the therapeutic relationship is broader than the therapeutic alliance and that the terms cannot be used interchangeably. Other Components of the Therapeutic Relationship What, then, are those other factors that could account for variance in our broad understanding of the “therapeutic relationship” in addition to the therapeutic alliance? Greenson (1971), for example, identified three unique components of the therapeutic relationship: (a) the working alliance, (b) transference and countertransference, and (c) the “real relationship” between the therapist and client. In the previous section, the therapeutic alliance was considered; now let us turn our attention to the other constructs identified by Greenson. Transference occurs when the client has a distinct reaction to the therapist, which is often reminiscent of something that happened in an important relationship in the client’s past. In many cases, that important relationship is with



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a parent, and the client is reacting to something that reminds them of a message that was either overtly or subtly communicated by the parent. Countertransference occurs when the therapist has a distinct reaction to the client, which also could be reminiscent of something that happened in a previous relationship. Transference and countertransference reactions are powerful to acknowledge and work through, as they provide a crucial learning opportunity for the client to resolve interpersonal issues and generalize that learning to their life. Practitioners of some schools of psychotherapy, such as psychodynamic psychotherapy, believe that good outcome in treatment is most likely to occur when transference and countertransference are identified and successfully addressed during the course of psychotherapy. Although the identification and resolution of transference and countertransference are not necessarily central tasks in CBT, these reactions can, without a doubt, serve as a vehicle for in-session CBT work to be done to resolve the issue, allow the client an opportunity to observe the firsthand application of cognitive behavioral skills in resolving relationship tension, and achieve important learning that can be applied to close relationships in the client’s life outside of sessions. The “real relationship” is a construct that, to my knowledge, has not been considered within the CBT literature. Charles Gelso and his collaborators have argued that the real relationship is the most important component of the therapeutic relationship and consists of a genuine relationship between two people that involves realistic perceptions of one another (Gelso, 2011; Gelso & Hayes, 1998). Research is mixed, however, on the degree to which the real relationship taps into a significantly different construct from the working alliance (e.g., Greenberg, 1994). What it does suggest is that there is something important that occurs when the therapist and client share genuine feelings and thoughts about their relationship and the work that they are doing together. As I have stated in my previous work (Wenzel, 2019), it is my belief that it is this sort of intangible connection that brings any type of psychotherapy to a higher level and sets up the therapist and client for a successful therapeutic experience (and an experience that can make a difference in both of their lives). Nonspecific Therapeutic Skills Many of the basic counseling skills that mental health trainees develop in their early coursework go a long way in establishing a sound therapeutic relationship. Karlin and Wenzel (2018), among many, many others throughout the past century, have described the skills that cultivate this relationship. For example, the skills of paraphrasing, reflecting, and summarizing communicate to clients that the therapist has heard and understood what they have communicated. Expressed empathy occurs when the therapist communicates genuine appreciation of the emotion associated with difficult experiences that the client is describing. All the while, the therapist’s tone of voice is characterized by warmth, or an inviting stance that signals to the client that the therapist is interested in hearing more about their experience and cares about their feelings. When the

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therapist exhibits confidence that they can be of service, this, in turn, instills hope in the client and can shape a positive expectation for treatment. Moreover, unconditional positive regard is demonstrated when the therapist shows full support and acceptance of the client regardless of what the client is describing or how they are behaving. In my professional experience, I have found it invaluable to periodically review lists of nonspecific therapeutic skills, such as those described in the previous paragraph, and check myself to be sure that I am cognizant of them during a session. Of course, the expression of these factors comes “from the heart” and cannot be manufactured or prescribed; in other words, they are wholly genuine. However, consider my experience as a supervisor of trainees who are hoping to achieve competence in the delivery of CBT and who are rated according to the Cognitive Therapy Rating Scale (Young & Beck, 1980), which includes items rating these nonspecific factors. Part of what goes into a higher score on the “Understanding” item (obviously something all therapists strive to achieve) is the overt expression of empathy. I have almost never rated a session in which I viewed a therapist delivering CBT as having been unempathetic; however, for a therapist to receive the highest rating on this scale, I must hear overt expressions of empathy. Without feedback, many therapists do not realize that they are making very few overt expressions of empathy. Therapists readily adjust their behavior when I provide this feedback, and when they make overt expressions of empathy in addition to communicating it in a nonverbal manner, overall scores on their sessions (not only scores on this single item) soar. I view this as occurring because therapists are more mindfully attending to these nonspecific therapeutic relationship elements and cultivating the relationship in an even more thoughtful manner, which, in turn, is associated with increased skillfulness in the delivery of CBT.

FEATURES OF CBT THAT FACILITATE THE THERAPEUTIC RELATIONSHIP There are many core aspects of CBT that were developed, in part, with the intention of fostering the therapeutic relationship. I elaborate upon many of these features in this section, including collaboration, the solicitation of feedback, respect for individual differences, and guided discovery. Collaboration Collaboration is a fundamental tenet of CBT, such that the therapist and client function as equal members of a team (Kazantzis et al., 2017; Okamoto et al., 2019). Both parties bring to each session issues that they believe are important to address, both parties make insightful observations about events that happen in the client’s life, and both parties contribute to the development of practice in which the client will engage between sessions. CBT has long been regarded as



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an active approach to treatment, the idea being that both the therapist and client are equally as active in working together to ensure that sessions are focused, efficient, and productive. Cognitive behavioral therapists do not simply tell their clients what to do or how to think—they respect the fact that clients are the ones living their own lives and that it would presumptuous to prescribe a course of action without having lived life in their shoes. It is hoped that the collaborative stance will contribute to clients’ sense that their input is valued and that they are working with someone who is truly invested in their wellbeing and progress toward life goals. Solicitation of Feedback Along with collaboration is the regular solicitation of feedback from the client. Cognitive behavioral therapists seek feedback in many different ways for many different reasons. Two opportunities for feedback come from two fundamental components of CBT session structure: (a) the bridge from the previous session that occurs near the beginning of the current session and (b) the final summary and feedback that occurs near the end of the session (Wenzel, 2019). In both of these instances, I have advocated for cognitive behavioral therapists to ask clients about what they have learned from their cognitive behavioral work, rather than simply supplying a brief summary of the cognitive behavioral work for them. This type of feedback allows for clients to put their own words onto cognitive behavioral strategies and principles of change, which will allow them to solidify their new knowledge so that there is an increased likelihood that they can retrieve and use it on their own outside of sessions. Questions to achieve these aims include “What did you take away from the previous session that ultimately made a difference in your life?” or “What have you learned today that you expect to observe or live out in between sessions?” When clients provide a thoughtful response that indeed reflects the cognitive behavioral strategies and principles that were considered in session, it provides important information to the therapist that they are on the same page with their clients and that their clients are learning something from sessions. In contrast, when clients falter when asked such a question, it raises the possibility that there is a disconnect in their therapeutic relationship, such that the therapist is not matching the client’s style or addressing needs that are important to the client. When the former occurs, the therapeutic relationship is often enhanced because clients realize how much they are taking from their cognitive behavioral work. When the latter occurs, it can be food for discussion in session so that the therapist and client can realign and ultimately strengthen their agreement on the goals and tasks of treatment. At an even more basic level, cognitive behavioral therapists routinely check in with their clients to ensure that they have an accurate understanding of what the client is expressing (cf. J. S. Beck, 2011). An example of a question to facilitate such understanding is “What I’m hearing you say is [insert sentiment that the client expressed]. Do I have that right?” When therapists ask a question

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like that, it communicates to clients that they have listened intently, that they are curious about clients’ lives, and that they care about making sure that they have accurate information. Such a question also reinforces an important aspect of the cognitive behavioral process—namely, that it is important to ask questions of clarification to ensure that one has the facts before proceeding and potentially acting upon inaccurate information. Finally, cognitive behavioral therapists check in with clients to ask whether they got anything wrong in their understanding of what the client was saying or whether the client experienced anything in the session as aversive or off-putting (J. S. Beck, 2011). Such explicit questioning increases the likelihood that any misunderstandings that could affect the therapeutic relationship are acknowledged by both parties. In addition, it communicates that the therapist is willing to hear honest feedback, discuss it, and work through it in order to repair any aspects of the therapeutic relationship that have been damaged. When clients affirm that something the therapist has said or done bothers them, time is taken in session to discuss it further, and it is followed up upon in subsequent sessions. Respect for Individual Differences Cognitive behavioral therapists assume a tremendous respect for individual differences, or the psychological characteristics that make each person unique and different from the next. Respect for individual differences means that cognitive behavioral therapists celebrate the fact that each person has unique strengths and proclivities that set a context for a very distinct way of experiencing the self, others, the world around us, and the future. In almost all instances in therapy, I work with my clients to see the “other side of the coin” to the tendencies that they view as problematic and that brought them into treatment in the first place. I remember distinctly a client I saw many, many years ago, who was perhaps the most painfully shy, introverted person I had ever met. Unfortunately, she viewed this trait as a weakness, to the point that she had formed the core belief “I’m defective.” As therapy progressed, she (quite brilliantly) developed her own homework exercise, in which she constructed a survey about her shyness and its advantages and disadvantages and administered it to several family members and friends. Although each survey responder indicated that they viewed her as shy, they all highlighted positive attributes of her demeanor, such as being “loyal” or “a good listener” (or “not being worried about you being obnoxious if we take you out in public!”). Cognitive behavioral therapists, then, help their clients dig deep to embrace the adaptive elements of characteristics that might have caused them problems in the past, helping their clients to make these characteristics work for them, rather than against them. When this occurs, the therapeutic relationship strengthens tremendously because clients see that their therapist believes in them and sees the best in them. In addition, respect for individual differences means that cognitive behavioral therapists understand that their clients might view their circumstances in a way that is different from how they might view those circumstances or differ-



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ent from the way in which many others would view those circumstances. Cognitive behavioral therapists understand that there is at least a grain of truth in their clients’ thinking, if not several grains of truth, and that their viewpoint is not wholly invalid. This point cannot be overstated, as in my experience, a mechanistic approach to cognitive restructuring can give the client the message that their thinking is “abnormal,” “distorted,” or “invalid” and that the problem is truly “in their head.” Skilled cognitive behavioral therapists instead help clients acknowledge and accept the facts of the situation and consider alternatives for the aspects of their thinking that might be assumptive or conjecture, arriving upon a conclusion that is accurate and balanced. When cognitive restructuring is approached in this manner, such that clients’ viewpoints of their life circumstances are validated, the therapeutic relationship can be strengthened. I have had many clients express gratitude for my support of their adopting an “unpopular” viewpoint among other people in their support system (e.g., reasons for remaining in a relationship with someone who has not treated them well), on the basis of careful examination of the facts and ways in which their mindset was adaptive for them. Finally, cognitive behavioral therapists also carry the utmost respect for individual cultural differences, broadly speaking (cf. Okamoto et al., 2019). The eminent psychologist Pamela Hays (e.g., Hays, 2016) developed a framework to guide clinicians in developing cultural competence in working with clients. This framework, referred to as ADDRESSING, is an acronym that calls clinicians’ attention to the following individual difference variables: (a) age and generational influences, (b) developmental or other disability, (c) religion and spiritual orientation, (d) ethnic and racial identity, (e) socioeconomic status, (f) sexual orientation, (g) Indigenous heritage, (h) national origin, and (i) gender. Although these variables are not necessarily psychological in nature, they often provide the context for distinctive beliefs and behavioral patterns to develop. Thus, cognitive behavioral therapists are cognizant to recognize the forces associated with these variables as they develop cognitive case formulations of their clients’ presenting problems. Moreover, they are encouraged to gain competence when they are working with a client characterized by one or more of these factors with which they are unfamiliar. Such competence could be developed by consulting writing or video resources, supervision or consultation, taking a course, or even (and in some cases, preferably) asking the client for their views about the influence of these factors on their cognitive and behavioral ways of responding to the world. Cognitive behavioral therapists who practice according to the ADDRESSING framework will almost undoubtedly enhance their therapeutic relationships because they are making the utmost effort to understand the internal (and often external) realities of their clients. Guided Discovery Guided discovery is a construct, as well as a strategy, that is often misinterpreted both within and outside the CBT community. Within the CBT community,

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sometimes it is used to define the process by which therapists question clients to identify their key thoughts and beliefs associated with the way they are making sense of a particular situation. In other instances, it is used to define a process of questioning (i.e., the application of Socratic questioning, named after the Greek philosopher Socrates) to help the client arrive upon a more adaptive way of viewing a situation than they were originally intending. I view the process of guided discovery as achieving both of these aims—helping clients identify the most fundamental meanings associated with situations and circumstances that cause emotional upset and using questioning to help clients arrive upon the most balanced and helpful way of viewing the situation or circumstances that feels right to them. I also view this as enhancing the therapeutic relationship because the therapist (a) demonstrates curiosity about the client’s subjective experience; (b) instills hope that there might be some relief by (possibly) shifting the client’s view of their subjective experience; (c) communicates that there, very well, is some truth in how they are experiencing the subjective experience; and (d) suggests that therapy has something tangible to offer as a “way out” of their emotional distress. In my clinical experience, many clients have remarked that they truly enjoyed and believed that they got much out of their previous therapeutic experiences, but they also realized that they were (regrettably) in a similar situation some years later when they were initiating treatment with me. Guided discovery often provides clients with the sense that something “more” can be added to the therapeutic experience. It facilitates the therapeutic relationship by helping the therapist develop a keen sense of the client’s internal reality and simultaneously cultivating client skill in critically evaluating the way in which they view the self, others, and the world; make sense of problems and current life experiences; and conceptualize a pathway to change. At times, clients joke that they are a bit exhausted after CBT sessions because they have been called upon to “think” to such a significant extent, but they also comment that they have developed a great deal of trust in the therapist and the therapeutic process and, therefore, perceive that their time, energy, and resources have been well spent. A Critic’s Perspective Despite these aspects that have been lauded by many experts as being essential in developing a strong therapeutic relationship, some critics continue to be skeptical about the importance that cognitive behavioral therapists place on the therapeutic relationship. One such critic is the renowned psychodynamic therapist Jonathan Shedler, who has often contributed critical thought about the comparison between psychodynamic psychotherapy and CBT. In one of his blog posts, Dr. Shedler highlighted an article about CBT that indicated that in order to build a strong therapeutic alliance, cognitive behavioral therapists must work collaboratively with clients, ask for feedback, and demonstrate warmth and interest in their clients’ lives. Shedler (2015) wrote in response,



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I expect that much from my hair stylist or real estate broker. From a psychotherapist, I expect something more. The CBT thought leader seemed to have no concept that the therapy relationship is a window into the patient’s inner world, and a relationship laboratory and sanctuary where lifelong patterns can be recognized and understood, and new ones created. (para. 14)

I do not know the original article to which Dr. Shedler is referring, and his criticism could certainly be interpreted as being a bit harsh. Nevertheless, in this narrative, he highlights just how crucial the therapeutic relationship is, as what happens between the therapist and client usually reflects the way in which the client interacts with others outside the therapy session. He also points out that the therapeutic relationship provides an invaluable corrective learning experience for the client to have a different kind of relationship with the therapist that can generalize to the client’s current and future relationships. In other words, it is important for all therapists, including cognitive behavioral therapists, to attend closely to the interactional pattern that unfolds in the therapeutic relationship, to notice the reactions that the client evokes in them, and to use these observations to create a different relationship from one the client might have had in their life, which will ultimately help improve their relationships. Dr. Shedler (2015) ends his blog post by stating, Some people may be satisfied with therapists who “work collaboratively” while conducting therapy according to an instruction manual. . . . Those who want to change their destiny will want a therapist with the self-awareness, knowledge, and courage to see and speak about what matters. (para. 15)

I could not agree more with this insightful statement. In the section below on clinical guidelines, I provide some guidance as to ways to apply CBT within the context of the therapeutic relationship to “see and speak about what matters.”

SELECT RESEARCH ON THE THERAPEUTIC RELATIONSHIP At least two major meta-analyses have aggregated data on the association between the most heavily researched aspect of the therapeutic relationship— the therapeutic alliance—and outcome. Reporting remarkably consistent findings, Horvath and Symonds (1991) obtained an effect size of r = .26, and Martin et al. (2000) obtained an effect size of r = .22. These values represent small effect sizes, indicating that a substantial proportion of the variance in outcome can be explained by other variables. Nevertheless, the fact that this magnitude of association has been obtained in many studies across a wide variety of samples suggests that this is a stable factor to which clinicians should attend in their work with their clients. At times, when my clients are having difficulty resonating with the cognitive behavioral concepts in strategies that I am attempting to share with them, I highlight aspects of our therapeutic relationship that are strong and educate them about the manner in which the relationship, itself, can influence outcome. I let them know that even if, at the moment, it seems that the cognitive behavioral strategies are not yielding their desired outcome,

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what we are doing with the relationship, itself, means something, and that will carry us through. A major question in the alliance-outcome literature is whether a strong therapeutic alliance has a causal influence on outcome or whether the therapeutic alliance strengthens as clients achieve gains in therapy (Barber, 2009). There is correlational evidence for both directions of causality. As stated previously, it is logical that clients would attend sessions, share information, and take risks when they believe they are respected, are cared for, and have mutually agreeable goals with their therapist, and conversely, it is logical that, when they begin to feel better, they would reflect with increasing fondness on the therapeutic relationship. The extant research on the role of the therapeutic relationship and outcome, specifically in CBT, focuses almost exclusively on the therapeutic alliance. Early research on the therapeutic alliance (as measured in the early sessions of treatment) and outcome in CBT found that the strength of the therapeutic alliance increased after prior symptom change, contrary to the prevailing assumption that a sound alliance is necessary before symptom change can occur (DeRubeis & Feeley, 1990; Feeley et al., 1999). When sudden gains occur in session (e.g., a substantial drop in scores on a standard depression inventory from one session to the next), the strength of the therapeutic alliance increases, which is presumed to set the stage for important cognitive changes in subsequent sessions (Tang & DeRubeis, 1999). Falkenström et al. (2016) found that the alliance predicted depressive symptoms not only in the subsequent session but also in the session thereafter in clients receiving either CBT or interpersonal psychotherapy (IPT). More generally, research on the association between alliance and outcome in the broader psychotherapy research literature has found that the strength of the alliance predicts outcome even when prior change has been controlled (Barber et al., 2000; Klein et al., 2003). Results from the studies clearly demonstrate the broad trend that outcome in CBT (and in psychotherapy in general) is associated with the therapeutic alliance. However, the specific mechanism by which the therapeutic alliance enhances outcome, either in a single session or at the end of the course of therapy, remains elusive. Specifically within the context of CBT, there is still a question as to whether the strength of the alliance is more or less important than adherence to concrete cognitive therapy techniques (Webb et al., 2012). Moreover, some research has yielded results that are not particularly compelling; for example, in one study, the association between the strength of the therapeutic alliance and outcome was rendered nonsignificant when usage of antidepressant medications was covaried in analyses (Strunk et al., 2012). As might be expected in light of CBT’s distinctive problem focus, cognitive behavioral therapists have a particular interest in discerning the specific components of the therapeutic alliance that are associated with outcome in CBT. The therapeutic alliance components that focus on the agreement between the therapist and clients about the goals and tasks of therapy appear very consistent with the most central tenets of CBT, whereas the emotional bond with the



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therapist is a factor that is central but equally as important in all psychotherapeutic approaches. Webb et al. (2011) examined just this issue. Their results indicated that early session ratings of goals and tasks predicted subsequent symptom change. Moreover, when therapeutic alliance was measured later in the course of therapy, both agreement on goals and tasks and the strength of the emotional bond were predicted by prior symptom change. Webb et al. concluded that this pattern of results reinforces the importance of early agreement on the goals and tasks of therapy and that the strength of the bond between the therapist and client may be more of a function of the gains clients make in treatment. All the research described to this point in this section used a measure of the therapeutic alliance based upon Bordin’s (1979) definition. One unique study investigated the therapeutic alliance and its association with outcome using a different definition of the therapeutic alliance in 193 depressed inpatients participating in intensive CBT (Schwartz et al., 2018). Two aspects of the therapeutic alliance considered in this study were the clients’ reports of their emotional bonds and contentment (or satisfaction) with their therapist. Not only did results indicate that higher ratings in these domains were associated with lower depression scores posttreatment, the authors determined that the contentmentoutcome link was mediated by clients’ reports of mastery and self-efficacy. These results suggest that satisfaction with the therapeutic relationship might instill confidence in clients in their ability to enact cognitive and behavioral change, which creates a positive self-fulfilling prophecy that facilitates a good outcome. In contrast, no mediator emerged to explain the association between clients’ reports of emotional bonds with their therapist and outcome. Consistent across the select studies reviewed in this section is that when separate components of the alliance are considered, components like collaboration and contentment, rather than the emotional bond, have stronger associations with outcome. An argument could also be made that there is a synergy between the strength of the therapeutic alliance and therapist adherence to the CBT approach and that, together, they predict outcome. Weck et al. (2015) examined the contributions of the therapeutic alliance and therapist adherence and competence in predicting treatment successes and failures in clients receiving CBT for depression, social anxiety, or hypochondriasis. The therapeutic alliance was measured by an inventory different from the one used by DeRubeis, Webb, and their colleagues, described previously, and it was focused primarily on collaboration between the therapist and client in working together toward mutually defined goals. Success was defined as either no longer meeting diagnostic criteria by the end of treatment or demonstrating a significant symptom drop on a clinical interview or self-report measure of the corresponding mental health problem. Failure was defined as dropout, diagnosis still present at the end of treatment, or an increase in symptoms on a clinical interview or self-report inventory. Results indicated that the therapeutic alliance was rated higher in treatment successes than in treatment failures. Moreover, when therapists had a better

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therapeutic alliance, therapist adherence was more strongly related to treatment outcome. In all, this body of research suggests that the therapeutic alliance is associated with outcome, although the direction of effect is still in question. Moreover, it seems that agreement and collaboration between the therapist and client on the goals and tasks of therapy, and the client’s satisfaction with that agreement, are more directly associated with outcome than the emotional bonds between the therapist and client. As indicated by the writings of A. T. and J. S. Beck, a strong therapeutic relationship is, indeed, essential in CBT, although there are clearly other elements of treatment that are associated with outcome, such as therapist adherence, therapist competence, and a host of other variables that have been considered by expert cognitive behavioral therapists and are not the subject of this chapter. It is intriguing that the emotional bond between the therapist and client is not consistently associated with outcome. Although it could easily be surmised that this dimension of the therapeutic alliance is less important than other dimensions in explaining outcome in CBT, I would exert caution in drawing this conclusion. It could be that the emotional bond between the therapist and client facilitates other important outcomes, such as retention in treatment, the completion of homework, or the return to therapy when a relapse is recognized. All of these alternative outcomes could be considered in future research in which outcome is defined more broadly than the reduction of symptoms or the absence of a psychiatric diagnosis.

CLINICAL GUIDELINES Previously, ways in which some of the fundamental tenets of CBT cultivate and enhance the therapeutic relationship were described. In this section, specific approaches for modeling the use of CBT strategies to strengthen the relationship are considered, along with ways to handle common occurrences that emerge in therapeutic relationships over time. In addition, this section highlights events that can occur in the therapeutic relationship (e.g., ruptures, transference, countertransference) and ways in which CBT interventions can be quite powerful in addressing them. It is hoped that the examples begin to illustrate ways to achieve what Jonathan Shedler (2015) described as the goal of meaningful psychotherapy—therapist self-awareness, knowledge, and courage to see and speak about what matters. Psychoeducation Cognitive behavioral therapists provide psychoeducation to their clients about the cognitive behavioral model, cognitive and behavioral principles of change, and CBT’s efficacy. The aim of psychoeducation is to empower clients with knowledge so that they need not remain in therapy indefinitely and so that they develop the know-how and confidence to generalize cognitive behavioral



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principles into their everyday lives without relying on a therapist. Cognitive behavioral therapists do not impose psychoeducation upon clients; instead, they respond to clients’ unique inquiries with psychoeducation, and when they sense a need to elaborate a bit upon it, they ask clients’ permission that it is okay to do so. Psychoeducation enhances the therapeutic relationship because it instills confidence about the promise for change. Many clients report that they appreciate the information that is provided through psychoeducation because it helps them better understand themselves and the problems that they bring to treatment. At times, clients present with a negative attitude toward treatment, perhaps because they perceive CBT as being overly simplistic or because they believe that they have tried CBT in the past and that it did not “work.” In these cases, cognitive behavioral therapists ask their client if it is okay to shed some light on their concerns, and they deliver psychoeducation in a warm, supportive manner, all the while monitoring the impact it is having on the client’s negative attitude and adjusting as necessary. Many clients indicate that the patience and care that cognitive behavioral therapists demonstrate in delivering psychoeducation to quell any concerns they might have about therapy go a long way in establishing a trusting therapeutic relationship. Cognitive Restructuring Cognitive restructuring is the process of identifying, evaluating, and modifying unhelpful thinking that exacerbates emotional distress. Cognitive behavioral therapists regularly help their clients acquire these skills and then apply them to upsetting situations that their clients encounter in their daily lives. However, savvy cognitive behavioral therapists are alert for ways in which cognitive restructuring can be applied to enhance the therapeutic relationship or to address issues that arise within it. Many clients, for example, have concerns about being judged negatively by others, and this concern extends to the therapist. The therapist might pursue gentle Socratic dialogue such as “Tell me what you know about me from our work together, and how that jibes with being judgmental of you” or “Has there been a specific time in your past when you felt judged by another person? How does what is happening between the two of us feel similar or dissimilar?” When cognitive behavior therapists ask these kinds of questions in a gentle, curious, and nonthreatening manner, most clients see that they are imposing their fears about being judged negatively onto the therapist, and they realize that the therapist is truly accepting of them regardless of what they are discussing. Taking the time to examine the accuracy of clients’ reactions toward the therapist can be an important learning experience because clients (a) learn to recognize when they are making assumptions about others’ views of them and (b) gain practice in checking out these assumptions in an interpersonally appropriate manner to base their views in evidence rather than conjecture. Moreover, the process of applying cognitive restructuring in this way provides an important

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experiential learning opportunity, as it supplies evidence that is inconsistent with a common prediction that clients often report, which is that talking openly about something that is happening in the relationship will necessarily lead to conflict, discomfort, and hard feelings. Social Skills Modeling Social skills are the verbal and nonverbal skills we use to communicate messages to others and engage in back-and-forth interaction. Cognitive behavioral therapists can make use of their interactions with clients in session to model appropriate social skills and provide a space for their clients to practice the use of appropriate social skills. Verbal content-based social skills training helps clients craft what to say in an array of situations ranging from small talk to potentially difficult conversations about hot or conflictual topics. Verbal social skills unrelated to content can also be considered, such as the speed or loudness of speech. Moreover, many cognitive behavioral therapists provide coaching in nonverbal social skills, such as eye contact, gestures, fidgetiness, and posture. Social skills can be targeted in treatment indirectly as the therapist continually models appropriate and effective skills in interactions with the client. However, the therapist can also use what is happening in the therapeutic relationship to teach about, model, and practice the modification of social skills that are causing life interference for clients. Cognitive behavioral therapists seize the very first opportunities to model appropriate social skills when they are scheduling the first appointment with a client and when they meet a client for the first visit. They speak confidently, but they model the tone, loudness, and rate of speech on the basis of the client’s reaction to them and other aspects of the client’s clinical presentation that are relevant to social interaction. They demonstrate warmth and openness to what their clients are saying by asking follow-up questions, looking directly at clients (instead of around the room or down at the chart), and assuming an open postural stance and even leaning forward to demonstrate interest in what the client is saying. If a client is describing problems with social skills and makes a comment like, “Well, it is easy for you, you really have a knack for connecting with others,” the therapist can ask a question like, “What is it about the way in which I interact with you that you find inviting? How might you infuse that into your interactions with others?” Such questioning prompts clients to consider social skills in the context of the therapeutic relationship and apply that learning to relationships in their everyday lives. When a potential rupture arises in the therapeutic relationship, the handling of it with the utmost social skill can provide a corrective learning experience for the client. In most cases, empathy and validation can go a long way. In but one example, upon entering my waiting room, a new client berated me for giving her substandard directions to my office and for having paperwork that she viewed as too cumbersome. Rather than responding in a defensive manner, I said (in a warm, inviting voice) something like, “Well, gosh, I will have to take another look at the directions that I send to my new clients. I’m so glad you



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made it here, nonetheless. Can I get you some coffee or water before we get started? I realize you have walked a good distance from the outer parking lot.” By the end of the session, she apologized for her abrupt stance with me, indicating that I was nothing like she had expected me to be (which, apparently, was the expectation that I would be stern and rigid) and that she was afraid that my response toward her would be anger because she did not complete all of the new client paperwork. I attributed her change of attitude toward me to the socially skilled, nondefensive stance that I took when she was initially confrontational toward me. At times, therapists will find themselves in the position in which clients do not “come around” with empathy and validation alone, such that clients continue to behave in a mildly belligerent or inappropriate manner. In these cases, I encourage cognitive behavioral therapists to take a dialectic stance, communicating empathy and validation while maintaining firm and consistent boundaries. After the situation has resolved, it can be helpful to ask the client what they learned from the experience, including the way in which the “lesson learned” can be applied to other relationships and reflection on which social skills were central in resolving the issue. Finally, cognitive behavioral therapists can help clients practice the use of social skills to facilitate interpersonal relationships. For example, for clients who worry about making small talk, therapists can have the client make small talk with them right in session. Not only does this exercise give the client a unique opportunity to practice social skills, but it also can enhance the therapeutic relationship because the therapist can learn things about the client that had not been evident until that time. My favorite instance of this was when I was working on social skills development with a young man who had been diagnosed with a psychotic disorder and struggled mightily with social anxiety. He enjoyed frequenting music venues, and he very much wanted to talk with others who attended shows at these venues with the goal of developing friendships with like-minded people. To address this goal, the two of us practiced a 5-minute small talk conversation about music, favorite bands, area venues, and the like, which had the potential to be relevant to conversations he would have with others who would frequent such a venue. I emerged from the conversation with a genuine feeling of closeness to my client, which I had not felt to that point, and the client indicated that he learned many ideas for keeping conversations going. Thus, the practicing of small talk allowed the client to acquire important skills that could apply in an arena that he very much valued. Moreover, our therapeutic relationship was enhanced significantly because of the genuine pleasure that we experienced in our interaction, the learning that occurred about one another’s preferences in music, and the client’s satisfaction that we were focusing on an area that had great relevance to his life. Ruptures A rupture occurs when there is a breakdown in the collaborative relationship between the client and therapist, ranging from mild tension to significant

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conflict or withdrawal (Safran et al., 2011). Drawing from Bordin’s (1979) conceptualization of the therapeutic alliance, Safran and Muran (2000) indicated that a rupture consists of “strains in the alliance . . . consisting either of disagreements about the tasks and goals of therapy or problems in the bond dimension” (p. 16). Ruptures allow for clients to have corrective emotional experiences (Alexander & French, 1946) that can help them generalize their new learning to improve relationships outside the psychotherapy session, much in the same way that I suggested earlier in regard to transference and countertransference. Thus, in the past two decades, attention has been devoted to how therapists handle rupture and tension in the therapeutic relationship to ultimately strengthen the relationship, often termed negotiation (Doran, 2016; Safran & Muran, 2006). Ruptures have only occasionally been the subject of study in research on CBT outcome. An intriguing study examining ruptures within the context of cognitive therapy for personality disorders found that both the strength of the early therapeutic alliance (i.e., before symptom change occurred) and the presence of an episode in which a rupture occurred but was repaired successfully predicted outcome in treatment (Strauss et al., 2006). In fact, most of the clients who experienced one of these “rupture-repair” episodes reported pre-post treatment symptom reductions of over 50% or greater on all outcome measures. This pattern of results suggests that a moderate level of tension in the therapeutic relationship has the potential to be optimal. Too little tension could signal that the therapist and client are overlooking areas that require focused work (which can be difficult at times) and the necessary expression of distressing affect, and too much tension could signal a breakdown in the therapeutic alliance that interferes with progress in treatment. However, it is important to note that one recent study found that ruptures and subsequent increases in the therapeutic alliance are more strongly associated with outcome in psychodynamic psychotherapy than in CBT (Zilcha-Mano et al., 2019). Thus, more empirical research and clinical thoughtfulness is needed to understand ways to maximize the repair of ruptures within a cognitive behavioral framework. The clinical implication of this is to acknowledge the rupture and deal with it in a nondefensive, above-board manner with the client. Cognitive behavioral therapists can be in tune with subtle expressions of negative affect from clients during the course of a session and use guided questioning to detect their presence and associated meaning. They can facilitate the use of cognitive restructuring to evaluate the manner in which clients have interpreted the therapist’s behavior or their interaction with the therapist, described in more detail in the subsequent section. They can model effective interpersonal skills in talking in an open, sensitive manner about the rupture and use social problem solving to arrive upon a mutually satisfactory solution. All the while, they communicate a warm, inviting, and validating stance to demonstrate that they can be present with the client’s negative affect and possible negative evaluation of them, normalize the client’s reaction, and help the client gain wisdom and growth from the experience.



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Transference and Countertransference One of the most common comments I receive from supervisees who are hoping to become certified cognitive behavioral therapists is that they believe acknowledgement and consideration of transference and countertransference are off-limits in CBT. Although it is true that many cognitive behavioral therapists might not necessarily use the words “transference” and “countertransference” or interpret them in the same way that a psychodynamic clinician might, the reactions clients have to their therapist and the therapeutic process and the reactions that therapists have to their clients provide very important information for the case formulation and very fertile grounds for important cognitive behavioral work to be done. When a cognitive behavioral therapist suspects that a client is demonstrating a transference reaction to them, the therapist might make a general observation such as “I’m noticing that you’re having a strong reaction toward me right now,” and they might ask a general question such as “Could you put words onto what you are experiencing, internally, right now?” When the client arrives upon an important realization (e.g., “That made me feel exactly like I was 12 years old again and was being scolded by my mother.”), the cognitive behavioral therapist provides an explicit statement of acknowledgement and validation (e.g., “Oh what a powerful reaction! No wonder you’ve found our conversation so upsetting.”). The cognitive behavioral therapist is simultaneously cognizant of demonstrating a stance of unconditional positive regard and empathy and providing space for the client to emote, while framing it in light of the case formulation that has been developed in collaboration with the client and gently posing Socratic questions to examine the accuracy and helpfulness of the reaction. As the client develops insight into the (possibly) maladaptive cognitive behavioral pattern into which they are falling, the cognitive behavioral therapist asks questions to facilitate a corrective learning experience, such as “What wisdom are you taking from this discussion here?” and “How might the insight you are gaining apply to other relationships in your life?” One of my favorite (albeit fairly basic) examples of dealing with my own reaction to a client’s style or behavior was with a young man who was diagnosed with obsessive-compulsive disorder and who demonstrated some traits of autism spectrum disorder. In session, he spoke very quickly and provided so much detail that I found it difficult to follow him; over time, I began to dread seeing him and often conjured the image of a babushka doll in which he told stories, within stories, within stories, and often did not respond readily to redirection. Despite my reaction to him, our therapeutic relationship developed nicely over time because he was quite compliant with homework, and he experienced significant reductions in his obsessive-compulsive symptoms. After approximately 12 sessions, he was describing some negative feedback he received about his interpersonal style, and I asked permission to share my observation about the way in which he communicated. I shared my feedback in a gentle way, free of judgment, and doing so allowed him to recognize that

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his communication style was actually another manifestation of his obsessivecompulsive disorder in that he believed that he needed to provide every single detail about scenarios he was describing or else the other person would not truly understand him. Moreover, he quickly recognized that this very interpersonal style had been associated with negative repercussions, as some time before the commencement of therapy, he had been promoted to a managerial position but then quickly demoted because he could not communicate effectively with his supervisees. He took the feedback as a challenge to practice effective social skills (and, thus, we used some of the guidelines described in the previous section to practice social skills in the context of our relationship). At the time of his final session, he was participating in speed dating sessions, something I could never have imagined for someone with his interpersonal style. Now, I reflect back upon the course of our therapeutic work with nothing but fondness. In all, clients’ reactions to their therapist and the therapeutic process and the therapists’ reactions to their clients’ behavior and interpersonal styles have the potential to facilitate highly effective cognitive behavioral work in session. Cognitive behavioral therapists are encouraged to be well versed in strategies to have keen awareness of their own and others’ cognitive and emotional reactions in order to facilitate a focus on these reactions during the course of treatment. When conceptualized as fertile ground for the advancement of the case formulation and the demonstration of cognitive and behavioral strategies in “real time,” these reactions can be viewed as opportunities for growth for both the client and therapist, rather than experiences that are to be dreaded or avoided. Personally, some of my fondest memories of clients are of instances in which a client and I experienced a rupture in the therapeutic relationship characterized by distinctively negative emotional reactions, we repaired it skillfully using the cognitive behavioral framework, and by the end of treatment, the client regarded the work done in treatment as transformative and pivotal.

CASE ILLUSTRATION: USING COGNITIVE BEHAVIORAL STRATEGIES TO REPAIR A RUPTURE “Jane” is a 52-year-old woman with a mixed depressive-anxious clinical presentation who sought treatment for stress associated with her job as assistant manager of a large restaurant. She formed a strong relationship with her therapist and readily acquired and applied many cognitive behavioral tools (e.g., cognitive restructuring, problem solving) to address her life problems. In fact, she sometimes sent her therapist messages in between sessions saying that she “CBT’d the hell” out of a stressor that she was facing, which was endearing to her therapist and served to strengthen their bond. During the course of treatment, it became evident that avoidance of close relationships was a significant factor that perpetuated loneliness, isolation, and behavioral inactivity (especially on her days off work). After her initial treatment goals were met, she



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continued in CBT with her therapist at a maintenance level (i.e., sessions every 2–4 weeks) to monitor and devise creative strategies to slowly modify this interpersonal pattern. During the course of maintenance treatment, Jane became romantically involved with a much younger man in his 20s with whom she worked. She kept the relationship secret because she was his supervisor. She and her therapist spent time in several sessions evaluating the strengths and drawbacks of this relationship, the therapist demonstrating unconditional acceptance of the unorthodox nature of the relationship. It was even concluded that, in some ways, the relationship was helping her achieve important growth because she was engaging in rather than avoiding a close relationship and learning how to let down her guard. The relationship lasted for a few months, and right before the therapist was going to go on maternity leave, Jane indicated that she was going to end the relationship because, even if it helped her grow, it was also inconsistent with the ethical standards on which she prided herself at work. The therapist expressed support for Jane’s decision and helped her consolidate the way in which this relationship contributed to the modification of negative beliefs about close relationships that Jane held so closely. The therapist went on maternity leave, and when she returned 10 weeks later, Jane came in for a session. The following conversation took place: JANE:

Oh yeah, I forgot to tell you that I’m back with John.

THERAPIST: Oh really? I’m surprised. [Therapist spontaneously expressed

this sentiment while remembering Jane’s conviction that she was going to end the relationship.] JANE:

[smiling] Yeah, I guess it didn’t stick.

THERAPIST: Well, as we had contemplated in previous sessions, there cer-

tainly are good reasons for remaining in the relationship. Nothing more was said about the relationship in this session, and Jane and her therapist continued to focus on the other issues that Jane had identified as being important to cover in that session. Jane had scheduled another session 2 weeks later. She was 10 minutes late for session, which was unlike her, and she seemed much more distant than usual. The following conversation took place during the bridge from the previous session: THERAPIST: Did you have any negative reactions to our session 2 weeks ago,

or was there anything that you thought I got wrong? JANE:

[narrowing her eyes] Yes! I just felt so judged by you!

THERAPIST: [using an empathic tone of voice] Oh my goodness, you felt

judged by me. [pause] First of all, I really have to commend you

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for bringing this to my attention. It takes a lot of courage to do that. And second, I’d very much like to talk more about this so that we might resolve any hard feelings. JANE:

Well, I don’t know what more there is to say, I just felt judged when I told you I was back with John.



[Therapist again expressed empathy, warmth, and praise for bringing this to the fore; confirmed with Jane that it was, indeed, okay to discuss it further; and asked Jane if there were any other issues she had hoped to address in session before diving into discussion of this one.]

THERAPIST: First and foremost, I would like to apologize to you for con-

ducting myself in a manner that seemed judgmental. That certainly is never my intent with you. And, I truly do believe that there are aspects of this relationship that are helping you to practice closeness with others, so in my heart, I truly do not view it in a negative light. [modeling the social skill of taking responsibility for making a mistake without being overly ingratiating] JANE:

Yeah, I know you do. I don’t know why I felt so judged.

THERAPIST: Would it be helpful to examine it more closely to see what we

can learn from it? [modeling the cognitive restructuring process of evidence gathering] JANE:

Sure, let’s do that.

THERAPIST: Can I share what I remember about that conversation? JANE:

Yes, go ahead.

THERAPIST: What I remember is that you told me that you were back with

John, and my response was something like, “Oh, I’m surprised.” Now, granted, that might not have been my best therapeutic moment! [Jane and her therapist both chuckle, as a shared experience of humor had been part and parcel of their therapeutic relationship to this point.] However, I had that reaction because I had been recalling the conviction with which you had decided that it wasn’t in the best interest to continue the relationship. So, my genuine response was truly that I was surprised. But that surprise had no valence associated with it—I was not viewing the fact that you were back with John as good or bad, because I truly don’t view it as a good or a bad thing. JANE:

It’s really interesting that you say that. [pause] You know what I think is going on?



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THERAPIST: [smiling warmly] What’s that? JANE:

I think I was judging myself. I know how much I’ve criticized other people in management for sleeping with their employees, and I don’t want to be like that. So I’m being a hypocrite. Rather than facing something about myself that is embarrassing, I turned it on you.

THERAPIST: [continue to smile warmly] Hmmm, you’re right, this is interest-

ing. So, the original way you were viewing this situation is that I was being judgmental, but now? [prompting Jane to articulate an adaptive viewpoint to replace her original perception] JANE:

Now I realize that it’s really myself not liking the choice that I made. You were fine. You’re never judgmental of me. That’s why I’ve worked with you for this long.

THERAPIST: It goes to show that there are many forces that contribute to the

way that we view a situation. I’d also encourage you to give yourself a break. There are several layers to this particularly complex situation. JANE:

Thank you for saying that. It just feels like if anyone else knew what I was doing, they would look at me as if I were the worst human being on the planet.

THERAPIST: [expressing unconditional positive regard] I think you’re far, far

from the worst human being on the planet. You’re a human being who has been isolated from others for many years, and a reminder of what it is like to connect with another person can feel amazing. JANE:

I guess we need to work on ways for me to get that connection in more appropriate ways?

THERAPIST: [smiling] Yes, we can absolutely do that. Perhaps we can revisit

the goals for our work together in light of this conversation? JANE:

That would be great.

THERAPIST: Before we do that, can you tell me what you have learned from

this misunderstanding between the two of us? JANE:

That you’re never being judgmental of me. That it’s on me if I feel like that.

THERAPIST: Well, it is true that I would not intentionally be judgmental of

you. But, again, I’d like to help you to be a bit kinder to yourself. There very well have been and will again be times in which I might not respond optimally to something that you have said. So it’s not all on you. A good lesson I’m taking away from this is

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that you and I are both human, with warts and all, and that we can use kindness, compassion, and the good will that we have developed in our relationship as a lens to interpret any exchange we might have that might not seem quite right. JANE:

Fair enough! I think that this is a great lesson to take away from all of this.

Jane continued to see her therapist for six more sessions, at which time she truly ended the relationship with John and focused on rebuilding relationships with some college friends whom she had recently run across at a reunion. She applied the cognitive restructuring, social skills, and self-compassion tools that she developed in therapy, including as a result of this possible rupture, to enhance these relationships. In the subsequent several years, she sent her therapist occasional selfies taken with her three college friends vacationing at the beach, expressing that therapy helped her see the value of close relationships and gave her an opportunity to practice negotiating them (and she included the relationship with the therapist among her close relationships). Approximately 6 years after the completion of CBT, Jane contacted the therapist to resume sessions after she had been diagnosed with terminal cancer, stating that the therapeutic relationship was extremely valuable to her and that she hoped to have some of the comfort of that relationship as she dealt with end-of-life issues.

CONCLUSIONS AND FUTURE DIRECTIONS It is my firm belief that some of the best examples of CBT are done in the context of understanding, addressing, and resolving an issue in the therapeutic relationship in a way that advances the client’s treatment goals and provides an important corrective learning experience. Many fundamental aspects of CBT (e.g., collaboration, solicitation of feedback, respect for individual differences, guided discovery) contribute a great deal to the development, enhancement, and repair of the therapeutic relationship. Mindfulness of nonspecific features of psychotherapy, such as warmth, genuineness, and unconditional positive regard, can provide an inviting tone or context in which these fundamental aspects are executed in general, as well as in instances in which the relationship is the focus of therapeutic work. It is also my belief that, when CBT is delivered with an eye toward seizing opportunities to enhance the therapeutic relationship, the connection that is formed is quite heartfelt, meaningful, and memorable to both the therapist and client. The future directions for research on the role of the therapeutic relationship in CBT are abundant. With a few exceptions (e.g., borderline personality disorder; Bedics et al., 2015; bulimia nervosa; Accurso et al., 2015), the majority of the research on the therapeutic relationship in CBT has focused on clients with depression. Clearly, it is important for empirical research to extend to other



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types of psychopathology. In but one example, I often lecture about the importance of a strong therapeutic relationship in the delivery of exposure therapy for clients with anxiety-related disorders, as facing their “worst fears” is exceptionally brave and, at times, requires a great deal of support in the early stages of treatment. A useful addition to the literature would be an empirical demonstration of the manner in which the strength of the therapeutic relationship early in the course of exposure-based CBT for anxiety-related disorders is associated not only with outcome but also with client retention and completion of homework in between sessions. A second line of future research would be to examine a very wide array of components of the therapeutic relationship and their association with outcome. I am struck by the definition of the therapeutic alliance described by Bedics et al. (2015), who focused on client commitment, therapist understanding, and agreement on goals as being paramount to the alliance. Although these factors are, undoubtedly, important ones to consider, they are also decidedly in the “CBT spirit” and do not focus on clients’ perception of connectedness, felt sense of being understood, and sense of being in a safe, nonjudgmental environment, all of which are also important for a strong therapeutic relationship. Indeed, many scholar-clinicians have identified important aspects of the therapeutic relationship other than the “tasks” associated with the alliance, including expressed empathy, positive regard, and genuineness (Castonguay & Beutler, 2006; Cronin et al., 2015; Norcross & Lambert, 2011). Thus, it is possible that research demonstrating that the therapeutic alliance (relationship) is a significant predictor of outcome in CBT has achieved its results as an artifact of the way in which the therapeutic alliance (relationship) is defined. Continued scholarly inquiry into the aspects of the therapeutic relationship beyond collaboration and agreement on the tasks and goals of therapy would be welcomed. A third line of scholarly inquiry would be to examine what makes a session “successful” or “unsuccessful” from the perspective of the therapeutic relationship. For example, when a cognitive behavioral intervention, such as cognitive restructuring or exposure, yields its desired outcome, is this itself the factor that is associated with a reduction in symptoms or an increase in functioning, or is it the shared experience with the therapist providing support, guidance, and cheerleading that affects this positive outcome? Or are there instances when a cognitive behavioral intervention proves to be unsuccessful but the therapeutic relationship is enhanced, nevertheless, which in turn affects outcome? These sorts of questions are ones that require sophisticated research designs and statistical models. However, from a clinical perspective, they raise the possibility that a skilled and interpersonally effective handling of an unsuccessful intervention by the clinician could provide an even more pivotal clinical experience than if the intervention had been successful in a more straightforward manner. More broadly, much scholarship has been published over the past century on the importance of the therapeutic relationship in psychotherapeutic traditions outside the cognitive behavioral realm. I call upon those in the CBT community to become familiar with this important, often older, literature and contemplate the lessons that can be learned from these traditions to elevate our

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work, especially in the realm of using the therapeutic relationship as a catalyst for change.

REFERENCES Accurso, E. C., Fitzsimmons-Craft, E. E., Ciao, A., Cao, L., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., Crow, S. J., Wonderlich, S. A., & Peterson, C. B. (2015). Therapeutic alliance in a randomized clinical trial for bulimia nervosa. Journal of Consulting and Clinical Psychology, 83(3), 637–642. https://doi.org/10.1037/ccp0000021 Alexander, L. B., & French, T. (1946). Psychoanalytic therapy. Ronald Press. Bachelor, A. (1995). Clients’ perceptions of the therapeutic alliance: A qualitative analysis. Journal of Counseling Psychology, 42(3), 323–337. https://doi.org/10.1037/ 0022-0167.42.3.323 Barber, J. P. (2009). Toward a working through of some core conflicts in psychotherapy research. Psychotherapy Research, 19(1), 1–12. https://doi.org/10.1080/ 10503300802609680 Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2000). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Journal of Consulting and Clinical Psychology, 68(6), 1027–1032. https://doi.org/10. 1037/0022-006X.68.6.1027 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Bedics, J. D., Atkins, D. C., Harned, M. S., & Linehan, M. M. (2015). The therapeutic alliance as a predictor of outcome in dialectical behavior therapy versus nonbehavioral psychotherapy by experts for borderline personality disorder. Psychotherapy: Theory, Research, & Practice, 52(1), 67–77. https://doi.org/10.1037/a0038457 Bender, D. S. (2005). The therapeutic alliance in the treatment of personality disorders. Journal of Psychiatric Practice, 11(2), 73–87. https://doi.org/10.1097/00131746200503000-00002 Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16(3), 252–260. https://doi.org/10. 1037/h0085885 Bowlby, J. (1969). Attachment and loss: Vol. 1. Loss. Basic Books. Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change: A task force on participants, relationships, and techniques factors. Journal of Clinical Psychology, 62(6), 631–638. https://doi.org/10.1002/jclp.20256 Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, & Practice, 43(3), 271–279. https://doi.org/10.1037/0033-3204.43.3.271 Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the “scientist-practitioner” model in psychotherapy. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 81–131). Allyn & Bacon. Cronin, T. J., Lawrence, K. A., Taylor, K., Norton, P. J., & Kazantzis, N. (2015). Integrating between-session interventions (homework) in therapy: The importance of the therapeutic relationship and cognitive case conceptualization. Journal of Clinical Psychology, 71(5), 439–450. https://doi.org/10.1002/jclp.22180 Cushman, P., & Gilford, P. (2000). Will managed care change our way of being? American Psychologist, 55(9), 985–996. https://doi.org/10.1037/0003-066X.55.9.985



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DeRubeis, R. J., & Feeley, M. (1990). Determinants of change in cognitive therapy for depression. Cognitive Therapy and Research, 14(5), 469–482. https://doi.org/10.1007/ BF01172968 Doran, J. M. (2016). The working alliance: Where have we been, where are we going? Psychotherapy Research, 26(2), 146–163. https://doi.org/10.1080/10503307.2014. 954153 Elvins, R., & Green, J. (2008). The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review, 28(7), 1167–1187. https:// doi.org/10.1016/j.cpr.2008.04.002 Falkenström, F., Ekeblad, A., & Holmqvist, R. (2016). Improvement of the working alliance in one treatment session predicts improvement of depressive symptoms by the next session. Journal of Consulting and Clinical Psychology, 84(8), 738–751. https:// doi.org/10.1037/ccp0000119 Feeley, M., DeRubeis, R. J., & Gelfand, L. A. (1999). The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 67(4), 578–582. https://doi.org/10.1037/0022006X.67.4.578 Gelso, C. J. (2011). The real relationship in psychotherapy: The hidden foundation of change. American Psychological Association. https://doi.org/10.1037/12349-000 Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory, research, and practice. Wiley. Gilbert, P., & Leahy, R. L. (Eds.). (2007). The therapeutic relationship in cognitive behavioral psychotherapies. Routledge. https://doi.org/10.4324/9780203099995 Gluhoski, V. L. (1994). Misconceptions of cognitive therapy. Psychotherapy: Theory, Research, & Practice, 31(4), 594–600. https://doi.org/10.1037/0033-3204.31.4.594 Greenberg, L. S. (1994). What is “real” in the relationship? Comment on Gelso and Carter (1994). Journal of Consulting Psychology, 41(3), 307–309. https://doi.org/b5zqbp Greenson, R. R. (1965). The working alliance and the transference neurosis. Psychoanalytic Quarterly, 34(2), 155–181. https://doi.org/10.1080/21674086.1965.11926343 Greenson, R. R. (1967). Techniques and practice of psychoanalysis. International Universities Press. Greenson, R. R. (1971). The “real” relationship between the patient and the psychoanalyst. In M. Kanzer (Ed.), The unconscious today: Essays in honor of Max Schur (pp. 213– 232). International Universities Press. Hays, P. A. (2016). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (3rd ed.). APA Books. https://doi.org/10.1037/14801-000 Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). Oxford University Press. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. https://doi.org/fjvvfk Karlin, B. E., & Wenzel, A. (2018). Evidence-based psychotherapy shared decision-making toolkit for mental health providers. Education Development Center. Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavioral therapy: A clinician’s guide. Guilford Press. Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., Arnow, B., Blalock, J. A., Manber, R., Markowitz, J. C., Riso, L. P., Rothbaum, B., McCullough, J. P., Thase, M. E., Borian, F. E., Miller, I. W., & Keller, M. B. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Consulting and Clinical Psychology, 71(6), 997–1006. https://doi.org/cmsqch

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Lambert, M. J., & Simon, W. (2008). The therapeutic relationship: Central and essential in psychotherapy outcome. In S. F. Hick & T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp. 19–33). Guilford Press. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. https://doi.org/10.1037/0022-006X.68.3.438 Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62(1), 185–190. https://doi.org/ 10.1037/0022-006X.62.1.185 Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy: Theory, Research, & Practice, 48(1), 4–8. https://doi.org/10.1037/a0022180 Okamoto, A., Dattilio, F. M., Dobson, K. S., & Kazantzis, N. (2019). The therapeutic relationship in cognitive behavioral therapy: Essential features and common challenges. Practice Innovations, 4(2), 112–123. https://doi.org/10.1037/pri0000088 Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press. Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, & Practice, 43(3), 286–291. https://doi.org/10.1037/0033-3204.43.3.286 Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy: Theory, Research, & Practice, 48(1), 80–87. https://doi.org/10.1037/ a0022140 Schwartz, C., Hilbert, S., Schlegl, S., Diedrich, A., & Voderholzer, U. (2018). Common change factors and mediation of the alliance-outcome link during treatment of depression. Journal of Consulting and Clinical Psychology, 86(7), 584–592. https://doi. org/10.1037/ccp0000302 Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378 Shedler, J. (2015, March 18). The therapy relationship in psychodynamic therapy versus CBT: A good therapy relationship is more than warm feelings. Psychology Today. https://www.psychologytoday.com/us/blog/psychologically-minded/201503/ the-therapy-relationship-in-psychodynamic-therapy-versus-cbt Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., Laurenceau, J. P., & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337–345. https://doi.org/10.1037/0022-006X.74.2.337 Strunk, D. R., Cooper, A. A., Ryan, E. T., DeRubeis, R. J., & Hollon, S. D. (2012). The process of change in cognitive therapy for depression combined with antidepressant medication: Predictors of early intersession symptom gains. Journal of Consulting and Clinical Psychology, 80(5), 730–738. https://doi.org/10.1037/a0029281 Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67(6), 894–904. https://doi.org/10.1037/0022-006X.67.6.894 Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. Guilford Press. Webb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S. (2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom change. Journal of Consulting and Clinical Psychology, 79(3), 279–283. https://doi.org/10.1037/a0023252 Webb, C. A., Derubeis, R. J., Dimidjian, S., Hollon, S. D., Amsterdam, J. D., & Shelton, R. C. (2012). Predictors of patient cognitive therapy skills and symptom change in two randomized clinical trials: The role of therapist adherence and the therapeutic



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alliance. Journal of Consulting and Clinical Psychology, 80(3), 373–381. https://doi.org/ 10.1037/a0027663 Weck, F., Grikscheit, F., Jakob, M., Höfling, V., & Stangier, U. (2015). Treatment failure in cognitive-behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. British Journal of Clinical Psychology, 54(1), 91–108. https://doi.org/10.1111/bjc.12063 Wenzel, A. (2019). Cognitive behavioral therapy for beginners: An experiential learning approach. Routledge. https://doi.org/10.4324/9781315651958 Wolfe, B. E., & Goldfried, M. R. (1988). Research on psychotherapy integration: Recommendations and conclusions from an NIMH workshop. Journal of Consulting and Clinical Psychology, 56(3), 448–451. https://doi.org/10.1037/0022-006X.56.3.448 Young, J. E., & Beck, A. T. (1980). Cognitive Therapy Scale rating manual [Unpublished manuscript]. University of Pennsylvania. Zilcha-Mano, S., Eubanks, C. F., & Muran, J. C. (2019). Sudden gains in the alliance in cognitive behavioral therapy versus brief relational therapy. Journal of Consulting and Clinical Psychology, 87(6), 501–509. https://doi.org/10.1037/ccp0000397

II STRATEGIES AND TECHNIQUES

8 Cognitive Restructuring Christine Purdon

I

n the 1960s, Dr. Aaron T. Beck observed that people with depression exhibited internal thoughts and images that accounted logically for the problematic emotional and behavioral responses characteristic of their depression and that were fully accessible to awareness. He reasoned that accessing and altering these cognitions could produce constructive behavioral and emotional change. At around the same time, other theorists were also beginning to posit that cognition mediates the relation between a stimulus and behavior (e.g., Mahoney, 1974), an idea that is now considered fact (Dobson & Dozois, 2019). Furthermore, there was emerging evidence that altering internal selftalk produces improvement in mood and performance (e.g., Meichenbaum, 1974). Cognitive therapies began emerging in the 1970s and were distinctive in that, unlike behavioral models, they emphasized the importance of cognition, and, unlike psychodynamic models, they viewed the cognition-explaining emotional and behavioral symptoms as accessible and as a key to understanding and treating mental health difficulties in and of itself, as opposed to being a product of conflicts inaccessible to consciousness. Although A. T. Beck’s cognitive theory represents a departure from behaviorism and psychoanalysis, his theory incorporates key ideas of those traditions. For example, the model includes principles of classical and operant conditioning, and it recognizes that early childhood experiences help form core ideas about self, world, and future, which, in turn, inform the assumptions and situational appraisal that influence moment-to-moment emotion and behavior (A. T. Beck, 1976). For a more https://doi.org/10.1037/0000218-008 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  207 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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detailed history, see Dobson and Dobson (2017) and Volume 1, Chapter 1 of this book. A. T. Beck’s cognitive theory is based on assumptions that are empirically testable, and there is a vast literature now dedicated to examining the validity of its tenets. In turn, the model has evolved in response to empirical data, which may be why it arguably has been the dominant cognitive model since its introduction. Cognitive therapy and the family of cognitive behavioral therapies (CBTs) have also been subject to decades of empirical examinations of efficacy and effectiveness and are now identified in practice guidelines as a first-line treatment (with or without medication) for a wide range of mental health problems. This chapter focuses on cognitive restructuring as introduced by A. T. Beck and developed by scholar-practitioners such as Greenberger and Padesky (2016), Dobson and Dobson (2017), and J. S. Beck (2011). Cognitive restructuring is a fundamental feature of CBT. It is the process by which selected cognitions are treated as hypotheses rather than facts and examined within the context of all relevant information as opposed to just the information that is implicitly available via automatic attentional, memory, and other cognitive processes, as well as learning history. If situational appraisals (e.g., “My boss was really abrupt with me—I must have made an important error and now it’s going to be noted in my performance review!”) can be reconsidered in light of all available evidence (e.g., “He is under substantial pressure today from the head office and is being abrupt with everyone, and my work has been of the same quality as always.”), then there is opportunity for constructive emotional and behavioral change (e.g., “There actually is no reason to assume I have made an important error.”). As the person begins to identify the thoughts mediating the behavioral and emotional responses of complaint, recognize that thoughts are not facts, and bring the range and breadth of relevant information to bear on the appraisal, the beliefs and assumptions evoking that appraisal start to become untenable. Cognitive restructuring is the hallmark of cognitive therapy and of many therapies within the family of CBTs and has been a central therapeutic tool from the genesis of the model and the treatment deriving from it.

UNDERLYING THEORY The central theoretical premises underlying cognitive restructuring are that (a)  the special meaning of an event is “encased” in cognition, (b) cognition mediates the emotional and behavioral response to an event, (c) cognition is accessible and amenable to change, and (d) the accuracy and usefulness of cognition is subject to evaluation (A. T. Beck, 1976; Dobson & Dozois, 2019). The latter assumption derives from philosophers of the Stoic tradition who, according to A. T. Beck (1976), “considered man’s [sic] conceptions (or misconceptions) of events rather than the events themselves as the key to his emotional upsets” (p. 3). The cognitive model generally assumes that mental health diffi-



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culties are more likely to be characterized by poorly informed ideas about emotionally relevant events than by well-informed ideas, and even when an idea is well informed, a catastrophic misconception regarding its meaning or importance is likely to occur. Another idea that is central to A. T. Beck’s model is that people not only have an innate ability to successfully override misinterpretations, they also do so frequently, even when experiencing a mood disturbance. In general, people respond adaptively to their environment by recognizing the logical fallacy of initial misinterpretations, acquiring adequate information, and modifying their ideas accordingly. A. T. Beck (1976) wrote, “Man [sic] has the key to understanding and solving his psychological disturbance within the scope of his awareness” (p. 3). For example, if one of our family members has an accident at an intersection on a snowy day, our immediate response could be to perceive the intersection to be dangerous. However, after considering the actual base rate of accidents at the intersection and the number of times that we and others we know have used that intersection without incident, we are able to modify our conclusion to “this intersection is actually no more dangerous than most intersections; snow can make any intersection more dangerous.” Another construct of central importance to A. T. Beck’s model is that of the schema. In the field of psychology, this term refers to an operating framework for a category of people, places, and things in which previously encoded information about that category is stored. Schemata allow us to quickly anticipate what is going to happen next and prepare ourselves to respond. Once a schema is activated, relevant memories, images, thoughts, and emotions accompany it, along with evaluative or summative conclusions (i.e., beliefs) about that category. For example, when we enter an establishment called a “restaurant,” we require no effortful processing to expect that there will be a menu from which we will choose something to eat, that what we choose will subsequently be served to us, and that we will need to pay for that food. We will also know that we cannot go into the kitchen to help ourselves, that we cannot take the things on the table home with us, and that we are expected to be courteous to those who serve us. The mental image the schema produces will be based on salient past experiences. One person’s image may be a luxurious carpeted dining room in which one eats a four-course meal served by black-clad waitstaff, or it may be a bustling place on a busy street where one lines up to order food and then carries it to a melamine table. All of this knowledge requires no effortful processing of the situation; it is implicit, produced by our schema for “restaurant.” Some schemata are active more of the time than others. Whereas our schema for restaurants may only be active when we are actively searching for a place to eat or when passing by a restaurant, schemata for self, world, and future are likely to be active much of the time. These “core” schemata are represented in summative and evaluative core beliefs (e.g., “I am bad,” “the world is dangerous,” “the future is bleak”). Once a schema has developed, information consistent with it tends to be noticed and encoded (e.g., stories of planes crashing), whereas information inconsistent with it tends to be ignored, trivialized,

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or discounted (e.g., impressive statistics on flight safety). Thus, schemata can readily give rise to information-processing biases. Within the context of mood and anxiety difficulties, negative schemata about self, world, and future are activated and direct the prioritization of information that is attended to and encoded, producing enumerative generalizations that are based on this subset of information. Neutral and positive information is ignored, discounted, or trivialized; mood state declines; and the capacity to identify, reflect on, and modify misconceptions deriving from the schema is compromised. For example, Sarmila has generalized anxiety disorder and believes that she is uniquely vulnerable to harm. This core belief is the evaluative summation of one of her primary self-schemata.1 Based on childhood experiences, she has grown to believe that she can and should be able to anticipate and plan against potential harm and that if harm occurs, it is her fault for failing to have done so; thus, her self-schema is built upon the idea that she lacks capacity to prevent harm and is therefore vulnerable. Hearing about a family member’s accident at an intersection on a snowy day activates Sarmila’s core idea of unique vulnerability. She readily recalls accidents that have been reported in the news and by people she knows, as well as memories for times that she has had “near misses” while driving. Meanwhile, Sarmila also recalls instances in which she was scolded for not having better anticipated and thwarted problems and instances of authoritative people criticizing others for not being proactive enough in avoiding difficulties rather than responding compassionately. When she thinks about driving through the intersection, she experiences a vivid flash forward in which she gets into an accident and her family members are reluctant to come to her aid because they view her as having brought it on herself by using that intersection in the first place. She thus appraises the intersection as a threat to be avoided. However, as a result of avoidance, Sarmila is unable to learn anything new about the safety of the intersection, so she will continue to appraise it as dangerous. At the same time, Sarmila is likely to attribute the nonoccurrence of driving accidents to the wise course of avoidance, and memories of past times in which avoidance was followed by the nonoccurrence of a feared event are likely to be quite accessible. Were she to cross the intersection without incident, she would likely attribute the nonoccurrence of an accident to luck. Ironically, then, the lack of incident at the intersection actually reinforces her core idea of unique vulnerability. If she were to have an accident, the experience would heavily reinforce her schema, and she would likely conclude that the accident happened because she simply was not good enough at anticipating and planning against threat, which in turn would make her feel more anxious and uniquely vulnerable. Finally, the appraisal of the intersection as dangerous is now highly primed, and her fear may begin to generalize to a wider range of driving situations (“If it could happen there, it could happen anywhere!”). Clinical examples are disguised to protect patient confidentiality.

1



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The identification of Sarmila’s thoughts elucidates the internal logic of her emotional and behavioral responses. It is clear that the central culprits in Sarmila’s anxiety are the schema of unique vulnerability and the assumption that one can and should anticipate and plan against threat. In turn, these generate situation-specific appraisal of danger/harm/threat, as well as behavioral responses, which, although reasonable responses to the perception of threat, prevent new learning and perpetuate the system. Notice that Sarmila’s cognitions are predicated on information from external (e.g., news, anecdotes from family and friends) and internal (e.g., memories, predictions) sources that are indicative of threat. Our ability to function adaptively in the environment relies on an attentional system that prioritizes internal and external information, such that information relevant to key goals readily receives attentional capture. There is a wealth of evidence that mood states influence attentional scope, making mood-congruent information from both external and internal sources (e.g., threat-relevant information in anxious states, failure/loss information in depressed states) more accessible and experienced as more important. Thus, once Sarmila’s sense of threat was aroused, information relevant to that threat became highly salient and received priority processing, whereas other information (e.g., the number of times her family member had traversed the intersection without getting into an accident, information regarding her own excellent driving record, information that the vast majority of accidents do not result in injury) was not. Similarly, information relevant to the importance of accurately anticipating and planning against harm was given full priority, such as memories of being scolded for not having planned better to avoid a problem or of trusted adults stating confidently that “forewarned is forearmed” or of times that threat was averted because of advance planning. At the same time, information relevant to the cost versus benefits of attempting to anticipate and plan against harm and the extent to which other people experienced problems relative to how frequently she experienced problems did not come readily to mind. We all possess many and diverse schemata. Here is an experiential exercise that may illustrate your own schema in action. In this exercise, you will be presented with a hypothetical scenario followed by a yes-or-no question. When you read the question, answer it instantly, with no deliberation. You are walking in a wealthy area of the downtown of a large city. A stretch limo drives by and pulls up ahead of you. A woman in a fur coat with a large diamond ring emerges and begins striding purposefully toward the entrance to a hair salon and spa. There is a homeless person near the entrance asking for money. Does the woman give him money?

Now reflect on what ideas and assumptions guided your immediate answer. The scenario may have activated a number of relevant schemata, including schemata about people with ostentatious wealth, homeless people, women, people who wear furs, people who reside in cities, or people in a hurry. As your answer may illustrate, schemata influence the way in which we process information. This is not in and of itself problematic because, first, schemata help us

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navigate a very complex world by providing information-processing shortcuts and, second, they are amenable to change. If your initial answer was an immediate and confident “yes” or “no,” this may reflect that it was being evoked by an absolute schema (e.g., “Wealthy people never give money to the poor”). However, since answering, you may have already identified the schema as overgeneralized and have modified it accordingly (“Actually, how do I know for sure what she will do? It is quite possible that many wealthy people give money; when I think about it, I have often heard of wealthy people who give money to the poor.”). According to the cognitive model, the problem in mental health difficulties is that schemata about self, world, and/or future are negative and absolute, permitting only a narrow range of information to be assimilated; yielding priority processing of negative information at the expense of other, equally valid (or even more valid) information; and trivializing, discounting, or ignoring disconfirming information. This prevents accommodation and produces enumerative generalizations (e.g., “I am more vulnerable to harm than others.”) that are informed by only a subset of information. Because the schemata at play are those that define the self, world, and future, they are of maximal importance. Furthermore, they are activated within the context of high emotional arousal when motivation to assuage the emotional arousal and protect the self is especially high. Thus, in the moment, it can be difficult for people to identify the key appraisal driving emotion and responses, broaden their awareness, and adjust their ideas in response to this broadened perspective, even if they realize afterward that their response was out of proportion. What, then, is the goal of cognitive restructuring? One long-standing myth about CBT is that its goal is to replace negative thinking with positive thinking. However, A. T. Beck et al. (1979) pointedly emphasized that the goal of cognitive restructuring is not to induce a state of spurious optimism that things are better than they are. Instead, the role of cognitive restructuring in overcoming emotional disturbance is to facilitate the reconsideration of ideas that yield the emotional and behavioral responses of complaint, which in turn fosters the development of new, more flexible schemata.

DESCRIPTION OF MAIN PROCEDURES The primary methods of cognitive restructuring include (a) downward arrow (i.e., asking successive questions through which the core personal meaning or importance of an event is revealed), (b) Socratic dialogue (i.e., engaging in dialogue in which hypotheses about a situation, person, or thing are examined and rejected or accepted), (c) evidence weighing (i.e., identifying a key hypothesis and examining the evidence that supports it and that which does not support it), and (d) core belief continua (i.e., identifying a core belief about the self and placing it on a continuum between worst and best exemplars of that category). Each of these methods is described later in the chapter. It is important to note that exposure (i.e., putting the client in the situation and having them stay until



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distress decreases substantially) and behavioral experiments (i.e., testing a hypothesis in the real world, collecting data, and accepting or rejecting the hypothesis) yield new learning that has a powerful effect on appraisal, assumptions, schemata, and behavioral responses, but this chapter focuses exclusively on the cognitive methods used in CBT. Another important point is that cognitive (and behavioral) strategies were never developed or intended to be used outside a strong cognitive behavioral formulation for the persistence of the presenting problem(s). A. T. Beck et al. (1979) wrote, “The specific therapeutic techniques employed are utilized within the framework of the cognitive model of psychotherapy and we do not believe that the therapy can be applied effectively without knowledge of the theory” (p. 4). There are several reasons why this is the case. First, people experience thousands of thoughts in a given day. In order to identify an appropriate target for restructuring, the therapist and client must understand which thoughts are mediating the emotional and behavioral responses of complaint. This, in turn, requires that the therapist and client share an understanding of the idiographic formulation of the client’s distress. The idiographic formulation is collaboratively derived and is based on specific types of information regarding cognition that the client provides, which is unlikely to be well solicited outside the context of an assessment of the problem from a cognitive perspective. A corollary to this would be for a cognitive behavioral therapist to embark on dream analysis without having conducted a psychodynamic-oriented assessment or developed a formulation regarding the unconscious conflicts driving the presenting problem. Second, the client in CBT is systematically empowered to identify, reflect on, and, if warranted, modify cognition produced by the information processing biases that occur during emotional arousal. Therapy proceeds in phases, each phase building on the last. Before a client is likely to benefit from cognitive restructuring, they need first to understand the problem within the cognitive framework, then become able to identify key “hot” thoughts mediating the emotional and behavioral responses of complaint, and finally develop a new awareness of thoughts not as facts but as hypotheses that are derived from and maintained by a myriad of internal and contextual cues. Unlike facts, hypotheses are open to examination and reconsideration. Only then is cognitive restructuring introduced in order to facilitate that exploration and reconsideration. My personal observation is that when CBT fails, the cause is most often that cognitive restructuring has been introduced before the previous skills and insights have been consolidated, and it degenerates into the therapist attempting to persuade the client of their own perspective on the thought. This is also a sign that the therapist has not established a therapeutic relationship characterized by collaborative empiricism, as described in the subsequent section. Collaborative Empiricism and Guided Discovery A. T. Beck et al. (1979) used the term collaborative empiricism to describe the process of working with the client to broaden their understanding of mediating

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thoughts and facilitate empirical tests of their hypotheses, via behavioral experiments, exposure, and reasoning. Tee and Kazantzis (2011) observed that although collaborative empiricism is considered a hallmark of CBT, it has not been well defined in the literature and is identified variously as a therapy philosophy, characteristic, or technique. Following a comprehensive review, they proposed that collaborative empiricism is best understood as an approach to therapy that is based on self-determination and empiricism. Meanwhile, as Overholser (2011) noted, the term guided discovery has also not been well defined. He suggested that it is best understood as the use of thoughtful questions to develop a case formulation and identify and examine hypotheses that mediate the emotional and behavioral response of complaint. Taken together, we can perhaps most profitably view collaborative empiricism as an approach to therapy that is based on self-determination and empiricism and that uses guided discovery to facilitate understanding and amelioration of the presenting problem(s). In the spirit of collaborative empiricism, then, the therapist engages the client as an active participant in understanding and overcoming the problem(s) of complaint. The therapist is naive as to the cognitions that mediate the behavioral and emotional responses of complaint and is genuinely ignorant of and curious about the internal and external evidence that informs the client’s hypotheses. The client and therapist consider hypotheses together and examine how well they account for the broad range of relevant information, as opposed to the narrow subset of information/evidence accessible to the client in the moment. The client then evaluates the hypotheses and generates hypotheses that best account for the relevant information. A common misconception about CBT is that it involves challenging negative thoughts. As J. S. Beck (2011) wrote, “challenging a cognition violates a fundamental principle of CBT, that of collaborative empiricism” (p. 170). Overholser (2011) similarly asserted that the goal of collaborative empiricism is not to replace a client’s irrational beliefs but to “develop skill in objective thinking and hypothesis testing” (p. 63). In the spirit of true collaborative empiricism, the therapist uses guided discovery to identify the internal (e.g., memories, images, predictions, bodily sensations) and external (e.g., facial expressions, environmental cues) evidence that, in the moment, supports the mediating hypothesis and introduces consideration of other types of information/evidence in the appraisal of the situation. The hypotheses are mutually explored, but it is the client who revisits the original hypothesis and modifies it; the therapist trusts the client to make decisions about their hypotheses (Overholser, 2011). Indeed, to challenge a thought is to prejudge it as unworthy, which is just as biased as prejudging the thought as worthy. Furthermore, therapeutic change pivots on the client’s, not the therapist’s, understanding of the hypothesis (e.g., Overholser, 2011). In challenging a thought, the therapist imposes their own understanding of its meaning, and “therapy” becomes little more than an attempt to persuade the client of that understanding. The myth that CBT is focused only on changing the content of thoughts may have its origins in this corruption of its practice.



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Best Practices for Cognitive Restructuring Cognitive restructuring is conducted within the context of a strong case formulation that does not simply describe the problem but elucidates the causes of the persistence of the problem and provides a simple (but not simplistic) explanation for the central emotional and behavioral responses of complaint. The therapist and client agree on the central culprits, or causes, of the problem, and both understand the role the culprits play in the persistence of the difficulty. Otherwise, the client may experience cognitive restructuring as an attempt on the therapist’s part to induce spurious optimism and, out of fear of being lulled into a false sense of complacency, may begin working at odds with the therapist to defend their perspective. By the time clients seek therapy, they have typically been barraged with well-intended but ineffective reassurances by family and friends (e.g., that they are good people, that there is nothing to worry about, that everything will be okay) and may feel especially let down and alienated if the therapist seems to be offering only similar reassurances. Cognitive behavioral therapists are expected to have a solid training in basic therapeutic skills of active listening, paraphrasing, reflection, and empathic responding. A long-standing myth about CBT is that it is simply a “bag of techniques” that are applied outside the context of a therapeutic relationship. Given (a) that from his earliest writings, A. T. Beck has emphasized the importance of the therapeutic alliance and (b) that a hallmark of CBT is the solid collaboration between therapist and client, this is one of the more surprising myths. However, it is the case that cognitive restructuring can be quite misunderstood and poorly executed. As mentioned previously, one mistake therapists can make is failing to engage in true collaborative empiricism and instead simply attempting to persuade the client of their interpretation of the thought. When embarking on cognitive restructuring, the therapist proceeds gently, warmly, and respectfully. In my experience, the best result occurs when the therapist is agnostic about the outcome of the cognitive restructuring, with both parties discovering new insights into the cognition. There is no doubt that the therapist is typically able to spot logical fallacies, inconsistencies, and biased information processing before the client, but therapeutic change rests on the client’s examination of the evidence that supports the hypothesis and that which does not. Furthermore, the therapist will often have little advance knowledge of the nature, range, and breadth of the internal information (e.g., memories, images, learning history) that supports the client’s unique thoughts and must provide enough space in the execution of cognitive restructuring to allow this to emerge.

Language It is not uncommon to see the words “distortions,” “dysfunctional,” and “maladaptive” used to describe targets for CBT, and in fact a commonly used means of identifying negative automatic thoughts is a monitoring form titled the Daily

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Record of Dysfunctional Thoughts. Clients can experience these words as accusatory and as suggestive of general deficits in their cognitive functioning, poor motivation, and/or lack of willpower. Referring to “negative thinking” can also be problematic because thoughts that are negative do not lack merit simply because they are negative. Furthermore, North American clients will have undoubtedly been exposed to the popular culture idea that thinking negatively is a willful act of self-sabotage and that we can avoid problems if we simply choose to think positively. In my view, there is considerable utility in assuming a more neutral attitude toward mediating thoughts, understanding them as logical products of the information-processing system as it currently is, and treating the target schema and assumptions behind them as having developed in ways similar to how any schema develops and persists over time. Certainly, there seems little to be lost in discussing “immediate conclusions” and “hypothesis at the time” as opposed to “distortions,” referring to “appraisals that were hijacked by anxiety/depression” rather than “maladaptive thinking,” or identifying the “hot thought” as opposed to the “dysfunctional thought.” Laying the Necessary Groundwork The success of cognitive restructuring methods relies on identification of the most useful targets for restructuring, which, as already discussed, can be derived only from a solid case formulation. An effective way to lay the groundwork for identifying specific mediating thoughts, as experienced by the client in the moment, is to have the client complete thought records right from the first session (described in more detail later in the chapter). The records at this stage need include only the following columns: date, situation, cognitions (best labeled more accessibly as “What was going through my mind”), feelings, and responses (best labeled as “How I coped/what I did”). After receiving a clear rationale and appropriate psychoeducation, clients complete a record when they notice their mood changing for the worse. The benefits are numerous: For example, (a) the client learns from the start to be an active participant in treatment, (b) the client begins developing skill at introspecting early on, (c) the client can begin to observe for themself the relation between situational appraisal and emotional/behavioral responses, and (d) the information is valuable in the development of the case formulation. As A. T. Beck (1976) observed, “A person who is trained to track his thoughts can observe repeatedly that his interpretation of a situation precedes his emotional response” (p. 23). Of course, research has clearly established that the relation between mood and thought is reciprocal, and A. T. Beck fully acknowledged this, but the point is that introspection helps the client develop awareness of the associations between mood, thoughts, and behavioral responses as they unfold in real time. Another strategy that therapists can use to assist clients in recognizing that thoughts are not facts is to provide clients with a taxonomy of informationprocessing biases, or cognitive distortions such as all-or-nothing thinking, cata-



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strophizing, overgeneralization, discounting the positive, and mind reading (see J. S. Beck, 1995, 2011). Once clients begin to identify the mediating thoughts, they can gain objective distance by identifying the bias represented in the thought. However, it is important to emphasize that the goal is to recognize thoughts as products of information processing, rather than the act of proper taxonomizing itself. Selecting Targets of Restructuring Identifying the target of restructuring requires a solid case formulation and good collaboration on the part of the therapist and client. The goal is to identify the thought that is the main culprit when the emotional and/or behavioral response of complaint occurs. At the start of therapy, most clients are aware of thoughts such as “This is awful,” “I want to get out of here,” or “I hate this.” These thoughts are accurate statements of the client’s experience of the situation. The therapist’s job is to help the client see beyond their opinion of the situation to the meaning of the situation or its outcome, which causes them to feel that so much is at stake in what are most often very ordinary situations (e.g., attending a party, meeting a friend, starting a report). The thought that captures this meaning is the best target for restructuring. Greenberger and Padesky (2016) referred to this as the “hot thought,” observing that examination and reconsideration of the hot thought will have the most therapeutic benefit. J. S. Beck (2011) advised that an excellent way to facilitate introspection is to have the client mentally relive a recent situation in which they experienced the emotional or behavioral response of complaint. In her instructional video, Padesky (1996b) deftly demonstrated the process of identifying the hot thought using a three-column thought record of situation, moods, and automatic thoughts. The client, whose presenting problem was depression, had completed a record, noting the situation, her feelings, and her thoughts. Padesky first asked a number of questions about the situation. This is an important step because it helps the therapist apply the case formulation to understanding the aspects of the client’s response to the situation that have been “hijacked” by the anxiety or mood disturbance. For example, if the client had reported a situation in which she had just received a summons to her boss’s office and was overwhelmed with dread and hopelessness, it would be helpful to find out more about her work environment, her relationship with her boss, her work performance evaluations, and the nature of the boss. If the boss is reasonable and the work history positive, it is likely that the emotional response is being driven by biased information processing. If the boss truly is arbitrary, harsh, and intolerant, it is reasonable for the client to be quite concerned and potentially pessimistic about the summons, and the therapist can make a mental note to consider catastrophic predictions about what it would mean to have a negative meeting with the boss (e.g., that she will end up homeless). If none are present, then the emotional response is not symptomatic of the mood disturbance of complaint; just because thoughts are

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negative does not mean they are pathological. Furthermore, it is often useful to determine what the client feels is at stake in the situation. For someone with social anxiety, the situation of attending a party may be viewed as the sole opportunity to make a good impression, and thus it is not simply a social occasion for them. Once the situation had been better understood, Padesky (1996b) then reviewed the emotions that the client listed. The client had also rated her intensity. Padesky reviewed each emotion, clarified the relative intensity of each, and asked if there was any other emotion the client may have been feeling but did not recognize or record. In the above work-related example, a catastrophic prediction of homelessness may be associated with a feeling of despair that the client had not fully recognized. Padesky then reviewed the thoughts that the client had listed. The therapist is looking for thoughts that, in and of themselves, explain the breadth and range of the emotions experienced and their intensity, as well as the behavioral response; that is, at this point the therapist is looking for the internal logic of the system, or the thoughts that mediate the responses. One effective strategy for identifying the key thoughts is the downward arrow technique. Downward Arrow Technique The downward arrow technique is simply a series of questions used to help identify the thought that mediates the behavioral and emotional responses of complaint. Consider the example of Ben, a client with social anxiety who brought in a thought record regarding a recent social situation. Ben is attracted to a woman who recently joined an organization of which he is a member. In the situation he reports, he was attending a picnic held by the organization, and he saw her sitting alone. He joined her and struck up a conversation about the organization, but after a few moments, she announced that she needed something to drink and left for the drinks table. A couple of minutes later, Ben saw her standing with a drink and chatting with a group of people. In the Feelings column Ben had written “embarrassed” and “miserable,” the latter being the most intense. In the Response column, he noted that he left the picnic quite soon thereafter. In the Thoughts column, Ben identified his hot thought as “She doesn’t like me.” Ben’s thought “She doesn’t like me” may well be the product of biased information processing, and there is no doubt it was the gateway to the emotional and behavioral responses for which he was seeking treatment. However, it actually does not, in and of itself, account for his misery and his abrupt departure from the party. Someone in the same situation could think “She doesn’t like me, and that’s too bad, but there are other women who will like me.” To identify the mediating thought, we need to understand what it means to him if she does not like him. The therapist can use the downward arrow technique to identify the hot thought that truly mediates the emotional and behavioral response of concern:



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BEN:

She got up and left, which means she doesn’t like me.

THERAPIST: What does it mean, for you, if she doesn’t like you? BEN:

Well, she’s a really nice woman who seems to like everyone; it shows that I am incapable of being likeable to women.

THERAPIST: Okay, let’s examine this a little more. What is the worst part

about being incapable of being likeable to women, for you? BEN:

Well, it means I will never find a wife.

THERAPIST:

Which we know is an awful prospect because you want to marry and have a family. Let’s just go one more step together with this—what does it mean if you will never find a wife?

BEN:

It means I am unlovable.

The therapist has now identified the thought that accounts for both Ben’s despair and his early departure from the picnic (“I am incapable of being likeable to women”) as well as a core belief (“I’m unlovable” or “Maybe I’m unlovable”). Like all CBT strategies, the downward arrow technique should be introduced and explained, for example: “Let’s figure out what made this so intense for you.” It needs to be executed gently and collaboratively; the tone is supportive, warm, and curious. The therapist is not interrogating the client or belittling their appraisal, but rather the client and therapist are working together to identify the mediating thought, or the culprit. Additional questions can include “What bothers you the most about that?” “What’s the worst part about that for you?” and “If that happened, what would it mean about self/world/future?” (see Greenberger & Padesky, 2016, for more examples). It is also important to emphasize that the therapist and client seek the meaning the thought had in the moment when the client was distressed; sometimes, in retrospect, clients recognize that the situation realistically should not mean much, but in the moment, it felt like it did. One final point is that the therapist may want to avoid treating ideas that have not been examined yet as facts. In the above example, the client had concluded that the woman’s departure meant she did not like him. The therapist and client had yet to mutually establish whether this hypothesis best fit the available information. Thus, rather than repeat a hypothesis that may ultimately prove to poorly account for the range of relevant information, the therapist instead says, “What would that mean, if she doesn’t like you?” as opposed to “What does that mean that she doesn’t like you?” Obviously, if there is clear evidence that the woman did not like him, the latter is appropriate. Cognitive restructuring begins once the client understands the way in which hot thoughts mediate emotional and behavioral responses to complaint (as well as how the consequences of their responses feed back into schemata and assumptions) and is able to use the downward arrow technique themself to

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identify hot thoughts that mediate mood and their response. The goal of cognitive restructuring is to help the client learn to override the automatic processes producing the hot thought and reevaluate the hypothesis within the context of all relevant information. Through repeated reevaluation and overriding information-processing biases, the assumptions and schemata become untenable (e.g., Padesky, 1996a). Socratic Dialogue Definition Although Socratic dialogue is considered to be a hallmark feature of CBT, there are few formal definitions of the term and very few clear explications of its components, process, and goals. A. T. Beck and Dozois (2011) defined Socratic dialogue as “a method of guided discovery in which the therapist asks a series of carefully sequenced questions to help define problems, assist in the identification of thoughts and beliefs, examine the meaning of events, or assess the ramifications of particular thoughts or behaviors” (p. 401). This definition offers a sound description of the circumstances under which the strategy is used, although it does not explain what is being discovered or the purpose of doing so. Clark and Egan (2015) defined Socratic dialogue as “verbal exploration (incorporating questions, summaries and reflections on part of both patient and therapist) that helps patients become aware of, reflect upon and achieve insight regarding, a particular subject of discussion and which prompts patients to generate their own conclusions” (p. 865). Finally, Overholser (1993) described the Socratic dialogue as “a series of questions designed to facilitate independent thinking” (p. 67). Drawing from modern philosophy and pedagogy, one might more clearly define Socratic dialogue as a form of cooperative discussion during which a facilitator (i.e., the therapist) promotes independent, reflective, and critical thinking, through which the validity of hypotheses is evaluated, those hypotheses that lead to contradictions are abandoned, and new hypotheses are formed. Within the context of CBT, hot thoughts, assumptions, and schemata can all be understood as hypotheses (e.g., Ben’s hypothesis is that the woman left his company because she did not like him). In the course of a Socratic dialogue, the client and therapist first identify the hypothesis to be discussed. The therapist then facilitates a dialogue in which the merits of the hypothesis are discussed and new hypotheses are generated. The dialogue is facilitated by systematic questions meant to transcend information gathering and instead develop a rich integration and synthesis of different sources of information, using inductive reasoning to explore hypotheses and their consistency with the range of available information (Overholser, 1993). Power of Persuasion Versus Facilitation of Self-Discovery Therapists will rely on the case formulation and their own observations during the discovery process to keep the dialogue focused and the questions systematic, but whether or not the therapist should be leading the client to the thera-



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pist’s own predetermined conclusions has been a matter of debate in the literature (Carey & Mullan, 2004; Clark & Egan, 2015). Some therapists assume the role of prosecuting attorney, putting the client on the stand and, bent on challenging the legitimacy of the client’s thoughts, assault them with leading questions until the client finally gives up and admits that their thoughts are “wrong” and that the therapist’s interpretation is the “correct” one. Overholser (1993) observed that although the Socratic form of inquiry originally followed a cross-examination format designed to force students or adversaries to admit their ignorance, the resultant public humiliation renders this style inappropriate for therapy. In my experience, this approach is at best ineffectual and at worst results in leaving clients with a sense of being small, stupid, and powerless. Padesky (1993) encouraged therapists to use the Socratic dialogue as a means of guided discovery rather than as a means of changing minds. Overholser (2011) emphasized the merits of “Socratic ignorance,” in which “collaborative empiricism is combined with sincere intellectual modesty about clients and their struggles” (p. 64). The cognitive restructuring techniques described in the next sections of this chapter adopt this latter viewpoint. Not only is it more respectful of the client; it also facilitates better communication and understanding, and it better fosters the client’s innate ability to identify, address, and modify overgeneralized hypotheses. This, in turn, enhances self-efficacy for independent management of the behavioral and emotional responses of complaint. Finally, from a process perspective, it requires the client to assume an active role in understanding and overcoming their presenting problems and to share ownership of the therapy process. Conducting the Socratic Dialogue Within the context of the Socratic dialogue, the therapist and client examine key hypotheses (e.g., “I am not capable of being attractive to women,” “I am more vulnerable to harm than others”), considering all of the experiences relevant to the hypothesis and making an inductive generalization based on the expanded base of information. In addition to questions, the therapist can use analogies, which are powerful ways of comparing objects, people, or events, based on relevant but not obvious similarities. For example, in Ben’s case, the therapist could make the observation that he seems to have likened himself to Charlie Brown (of Peanuts fame) and examine similarities and differences between Ben and this exemplar of the traits he believes they have in common. Padesky (1993) offered a detailed description of the Socratic dialogue. She identified the following four components of the dialogue: (a) informational questions, (b) empathic listening, (c) frequent summaries, and (d) synthesizing questions. Informational questions have two purposes. First, they are used to better understand the extent to which the hypothesis is consistent with the available objective information. Returning to Ben, the hypothesis in question is that he is incapable of being attractive to women. The therapist would want to ask informational questions about Ben’s dating history, frequency of contact with women, clear versus ambiguous indicators of rejection, and Ben’s social skills

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when interacting with women. That is, the questions are directed at considering relevant external information. Second, informational questions are used to identify the information, images, ideas, memories, experiences, bodily sensations, feelings, and predictions that lead the client to conclude that the mediating thought is valid, or perhaps even fact; that is, internal information. One of the keys to understanding the internal logic of the client’s presenting problem is empathic listening. Empathic listening and warmth were, of course, identified by Carl Rogers as essential to the therapeutic relationship and considered the building blocks of therapeutic change. Empathic listening is integral to assessment and the execution of all components of CBT (e.g., Thwaites & Bennett-Levy, 2007). Within the context of the Socratic dialogue, the term refers to active listening to glean an understanding of the reasoning that leads to the hypothesis under consideration, attending to what the client says (e.g., “My boss wants me to speak up more in meetings”) and what the client does not say (e.g., that the client had just received a promotion), as well as nonverbal language. Empathic listening is a hallmark of collaborative empiricism in that the therapist is genuinely curious about how the client’s hypotheses are framed and the information on which they are based. The therapist mentally notes contradictions in the hypothesis, all the while checking in and ensuring that their understanding of the client’s discourse is correct. The therapist also provides frequent summaries of the discussion to help them both keep track of the key insights in the discussion and maintain focus. Once the client and therapist have richly considered the hypothesis and the external and internal information that supports it, the therapist begins to ask synthesizing questions to illustrate contradictions. For example, examination of Sarmila’s hypothesis “I can and should be able to predict and prevent harm” revealed that her attempts to do so interfered significantly with her happiness and ability to focus on her studies. Not only did these strategies fail to stave off harm, they actually created problems for her. The therapist might therefore say, “You have noticed that despite your best attempts to prevent harm, bad things still happen. I’m wondering what that means about the feasibility of preventing all harm, all the time?” and “If we look at how there is a 100% chance that trying to prevent harm actually interferes with your ability to do the things you want to do, and the harm you are trying to prevent is vague and uncertain, is there merit in reconsidering the idea that you can and should prevent harm?” Synthesizing questions can also be interspersed with psychoeducation about learning, memory, and attentional processes that influence information processing and generate hypotheses at an implicit level. For example, in Ben’s case, the client and therapist learned that the hypothesis “I am incapable of being attractive to women” was supported by memories of being taunted by his first crush; his perception of himself as awkward, weak, and physically unattractive; and his experience at the picnic when the woman in whom he was interested left his company. As part of the case formulation, the therapist will already have implicated anxiety-driven biases in information processing and the impact of autonomic arousal on behavior. The therapist can remind Ben of these pro-



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cesses and ask him how they may have influenced his conclusions and his decision to leave the picnic. The therapist can validate the strength of Ben’s conviction in his conclusion by observing that the only information immediately available to him in the moment is that supporting his conclusion; information that does not support it either failed to breach his attentional threshold or was ignored, trivialized, or discounted. Sometimes clients can have difficulty recognizing that their hypotheses are inconsistent with available information. Myriad strategies have been developed to help therapists illustrate inconsistencies. For example, Sarmila might have difficulty recognizing the factors besides her own behavior that can influence outcomes and, therefore, finds it hard to treat her hypothesis that she is responsible to prevent harmful outcomes as anything but fact. One way to help her broaden her perspective would be to use a pie chart, as well explicated by Dobson and Dobson (2017). The therapist simply asks the client to record all the factors contributing to an outcome, in addition to their actions (or inactions), and then assign the proportion of responsibility each factor bears, with their portion left until last. The proportions are then charted on a pie graph. The visual effect can powerfully illustrate the contradiction. Purdon and Chiang (2016) illustrated the probability calculation method for addressing the overestimation of a feared outcome. The client and therapist identify all the steps that would have to occur for the outcome to be realized and then estimate the rough probability of each step occurring. In their example, a client with obsessive-compulsive disorder (OCD) feared that she would fail to turn the stove off before leaving for work and that her cat would burn himself. The therapist helped the client identify all the steps necessary for this to happen, which included (a) failing to turn the stove off after using it, (b) failing to see that the stove was on when checking before leaving the house, and (c) the cat jumping onto that specific burner despite the heat. The probabilities were then multiplied and the result subtracted from 100. In this example, the probability of the feared event not happening was 99.9997%. However, the probability that her elaborate stove-checking routines resulted in her being late for work was 85%. This provided a solid grounding for discussing the morality and feasibility of reducing checking behavior in the service of improving her work performance. Note that the goal is not to disabuse the client of the validity of obsessive thought but instead to learn to accept uncertainty and take reasonable risks in order to meet key proximal goals rather than compromise the latter by pursuing vague, distal, and impossible goals. These are just two examples, but many more are available in books on CBT. The therapist is free to develop their own strategies to identify contradictions. For example, to help clients recognize that they may not be able to accurately understand what someone else is thinking (i.e., that they are mind reading), I have used an empty chair technique. The client is seated beside an empty chair and conducts a dialogue between themself and the other person as if that person were in the other chair. The client is asked to distinguish between what is known versus what they have surmised about the other’s thoughts or potential

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responses, as well as to consider the issue from the other’s perspective by switching chairs. Finally, the therapist role plays the other person as if they are thinking what the client fears, and together they examine how important and survivable that is. The strategy used is not as important as ensuring that (a) the idea in question has been articulated and agreed upon as a culprit, (b) the strategy is effective in illustrating contradictions, and (c) the strategy will be compelling for the client. It is worthwhile to note that, in the early stages of intervention, the idea that thoughts may not be facts but rather are products of information processing is typically still novel for clients. Recall that, in Ben’s case, although the downward arrow technique revealed that the hot thought concerned his ability to be attractive to women, the thought that initiated the cascade (i.e., “She doesn’t like me”) appeared to be the product of information-processing biases, as there was no clear evidence that the woman disliked him. Such gateway thoughts can be targeted early on as a means of illustrating how mood state, assumptions, and schema can hijack situational appraisal. Thought Records Thought records are relied upon in CBT as means of helping clients develop the skills of identifying hot thoughts, overriding the automatic processes that produce them, and modifying the ideas/hypotheses as appropriate. The thought record is meant to help the client learn these skills well enough that they are able to override information-processing biases mentally in the moment, as opposed to after the fact. As discussed previously, CBT proceeds in stages, each stage building on the last. The goal of the first stage is to help clients learn to identify the thoughts that mediate the mood and behavioral responses of complaint and begin to recognize that thoughts are not facts. In this stage, clients record the situation, feelings, thoughts, and responses. The client and therapist work to help the client develop their ability to (a) understand noteworthy aspects of the situation and the stakes (e.g., the situation was perceived as the sole opportunity to make friends); (b) identify the range of feelings experienced and label them precisely (e.g., rather than just record “upset,” unpack the components of that feeling, such as “frustrated,” “anxious,” “pessimistic”); (c) identify thoughts that go beyond the client’s opinion of the situation (e.g., not just “this is awful,” but the reason it was awful) as well as begin to notice images, memories, and predictions; and (d) identify all the strategies used to cope with the situation (e.g., safety behaviors, avoidance, escape, cautious behavior) and recognize the role of those behaviors in the persistence of schemata, assumptions, mood, and capacity to achieve new learning. The therapist and client also begin to identify key culprits that perpetuate the problem. Once the client is able to introspect in this manner, they are ready to identify the thought(s) that mediate the emotional and behavioral responses of complaint. The therapist helps the client look for the ideas that account for the most intense emotions and logically lead to the behavioral response. In this stage,



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clients learn to use the downward arrow technique to identify their hot thoughts and move into identifying contradictions in the hypotheses implicit in them. The thought record is now expanded to include columns for “evidence that supports the hot thought” and “evidence that does not support the hot thought.” The therapist can then use Socratic dialogue to add to the two columns. Using informational questions, empathic listening, and frequent summaries, the therapist helps the client identify the internal and external evidence that supports the hypothesis while mentally noting potential biased information processing and contradictions. The client records the evidence as it emerges. The therapist then helps the client identify information that does not support the hypothesis, and again the client records as they go. Finally, synthesizing questions are used to help the client reconcile the two columns and identify a hypothesis that does not have contradictions. The client then forms a new hypothesis. Padesky (1996b) provided an excellent demonstration of this process. Throughout the three stages of thought record use, the client is encouraged to do mental thought records whenever the problematic emotional or behavioral response is experienced, with the goal of being able to identify and modify hot thoughts before those responses become acute. Once the client becomes skilled in this, the new hypotheses begin to prevail, and the assumptions and core beliefs start to become less tenable. Meanwhile, in session, the therapist and client rely increasingly less on the written thought records and move to exclusively verbal Socratic dialogues. Addressing Core Beliefs The core beliefs of concern in CBT are broad, general, deeply held ideas about the self, world, and future. They have often framed an individual’s perspective for many years and are experienced as facts. Because they operate at an implicit level, they are seldom explicitly identified or explored independently. Clients may feel especially worried about being lulled into a false sense of complacency regarding the self, world, and/or future, the exposure of which will be devastating. Dobson and Dobson (2017) also observed that the process of addressing core beliefs may involve facing painful experiences and seeing loved ones in a different light. Finally, a shift in core belief may not be well tolerated by the client’s loved ones. For example, someone who moves from believing they are flawed and worthless and into viewing themself as worthy as anyone else may no longer be as tractable as their loved ones are accustomed, which may generate hostility. There may even be active resistance from the client’s loved ones to changes in schemata. I worked with a young woman with OCD whose core idea was that she was less worthy than others, and her assumption was that she had to compensate for that. Many of her rituals involved protecting the family from harm, to the point of almost total sacrifice of her own goals. There was a high degree of enmeshment between one parent and the client and the client’s

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sister, along with a high level of family discord. Within the family, the accepted explanation for the latter was that the discord resulted from the stress created by the client’s rituals. Once the client began shifting to a less negative self-view and did not experience the same need to compensate for perceived shortcomings, her rituals at home decreased substantially, and she began to establish and enforce greater interpersonal boundaries. However, the absence of her rituals and the challenge to enmeshment exposed the other profound family problems, and the enmeshed parent began thwarting the client’s treatment in passive but highly effective ways. Dobson and Dobson (2017) recommended that the therapist discuss the core beliefs examined through schema work with the client so they can make a fully informed decision as to whether or not to proceed. Dobson and Dobson also pointed out that, in two studies, adding core belief change work to behavioral activation in treatment of depression did not result in an improvement in outcome over behavioral activation alone, nor did it reduce relapse. However, there is very little research in this area, and, on the basis of anecdotal experience, core belief work is advocated by many clinicians. Also, it is important to point out that once the client has had considerable experience in overriding situational appraisal and intermediate beliefs/assumptions, and as symptoms are becoming less intense, the core belief may already start to weaken or a previously dormant, less absolute schema may start to become active. One of the most commonly used strategies for addressing core beliefs is the cognitive continuum method. As in all cognitive restructuring, the goal is to help clients identify contradictions in the hypotheses that mediate the behavioral and emotional response of complaint. In the case of core beliefs, hypotheses will be about the self, world, or future and will be quite general and often absolute. To begin, the therapist and client identify a specific core belief of concern and review its role in the persistence of the presenting problem. To help understand the possible origin of the belief, the therapist may choose to observe links between it and relevant autobiographical details. For example, in Sarmila’s family, it was accepted that people can and should anticipate and prevent harm and that failure to do so was considered irresponsible and was associated with harsh criticism and withdrawal of support. When the discussion includes parental behavior or that of other loved ones, it is important to be clear that the goal is not to blame or judge but rather to understand how the core idea might have been formed, as well as the subsequent learning history that helped sustain it. It is also important to acknowledge good intention rather than simply its impact. For example, Sarmila’s parents were trying to help her learn to avoid harm. Once the therapist and client have agreed to examine the core belief, the therapist writes the core belief at the top of the page and draws a horizontal line with 0 and 100 as the anchors. The therapist then asks the client to add descriptors to the scale anchors vis-à-vis the core belief. For example, if the core belief is “I am a bad person,” the client may choose to use the descriptors “Worst



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person in the world” at 0 and “Best person in the world” at 100. The therapist then asks the client to identify someone from any period of history who they would put near 0 (many clients identify Hitler) and write that name at the anchor, and then identify someone who they would put near 100 (a common choice is Mother Theresa) and write in the name. The therapist can then foster a discussion of what qualities the client considered most in placing those individuals on the continuum. This helps the client develop awareness of their implicit assumptions about the quality in question. Clients are then asked to identify someone they know whom they would put near 0 on the continuum and write in the name, as well as someone they know who falls near 100 on the continuum. Often clients begin to realize that even the people they loathe/ admire fall at least at some distance from the exemplars of each anchor. Clients then plot their spouse/significant other or very closest friend and then two of their friends. Finally, the client plots themself. Clients typically cannot place themselves on par with the exemplar of the 0 end of the continuum (if only because they have at least not been responsible for murder), and this automatically means that the schema, as worded, is not consistent with fact. The therapist and client then discuss what qualities the client attends to when plotting themself, identify hypotheses about the self and the quality, and engage in a Socratic dialogue to identify contradictions. Is the client holding themself to a higher standard than others? Is the client only attending to specific criteria or past events/behaviors at the expense of other criteria? Is the client weighting some criteria much more heavily than others? Have the client’s friends and loved ones ever made errors or hurt someone? If clients have placed themselves at a distance from their spouse and friends, the therapist can observe and query what qualities they lack that their loved ones have and discuss whether the idea that they lack that important quality is consistent with all relevant information. Once these ideas have been considered, clients are invited to reconsider where they are on the continuum. The client is then enjoined to reexpress the belief in words that are more consistent with all the information reviewed. Finally, the therapist and client can process the implications of the new core belief. If the client shifts from “I am bad” to “I am not as good as I would like but not as bad as I thought,” what compensatory strategies may no longer be necessary? What information-processing biases can be targeted? For example, it may be that the client has attended to perceived indications that one is “bad” (e.g., thinking something negative about a coworker) and has ignored instances of behavior they view as worthy (e.g., helping a coworker, doing volunteer work) because the latter is viewed as “a given” or a minimum standard of behavior. Clients can make it a point to catch themselves engaging in what they consider to be worthy behavior, even if it is just their minimum standard. Clients can also be enjoined to catch the old belief in action, ask themselves what appraisal would derive from the new belief, and then try behaving in a way consistent with it.

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OUTCOME DATA In their review of meta-analyses of the efficacy of CBT, Hofmann et al. (2012) concluded that the evidence base of CBT is “very strong and especially so for anxiety disorders” (p. 436). However, they also identified a continued need for rigorous randomized control trials examining its efficacy. Clark and Egan (2015) noted that in studies of client experiences of what was effective for them, clients identified use of thought records and learning to interpret experiences differently. Newman and Fisher (2010) found that in people undergoing CBT for generalized anxiety disorder, treatment expectancy and the credibility of treatment increased between the fourth and seventh sessions of treatment and that this change accounted for 40% of symptom reduction. One extrapolation from these findings is that the collaborative empiricism, in which the client and therapist build the formulation together, is effective in enhancing the treatment credibility and instills optimism. However, more research is required on the impact of the structure and process of CBT on expectancy and credibility as compared with other treatment modalities. Very few studies have been conducted on the efficacy of specific cognitive restructuring methods. As Clark and Egan (2015) noted, Socratic dialogue is considered integral to, or indeed the essence of, CBT, as are guided discovery, the downward arrow method, and thought records. Thus, it would not make sense to conduct dismantling studies to attempt to isolate their impact on outcome; executing CBT without cognitive restructuring would be like executing client-centered therapy without practicing unconditional positive regard. Froján-Parga et al. (2011) reported on the development of a system for coding the functionality of Socratic questions. On the basis of previous work, they hypothesized that a Socratic question has one of seven functions: (a) discriminative (i.e., elicits a verbal or nonverbal response), (b) elicitation (i.e., elicits an emotional response), (c) reinforcement (i.e., provides agreement, reward), (d) punishment (i.e., expresses disagreement), (e) instructional (i.e., promotes a behavior outside the therapy session), (f) motivational (i.e., highlights benefits from a course of action), and (g) informative (i.e., includes any function not capture by the previously mentioned features). Froján-Parga et al. (2009) analyzed Socratic debates in a case study, finding that reward and punishment shaped the client’s verbalizations in ways consistent with the therapeutic outcome. In a larger follow-up study, CaleroElvira et al. (2013) examined 65 fragments of sessions from seven clients, and they again found that together their use shapes the client’s response in the desired therapeutic direction. The strategy of analyzing the impact of the therapist’s response on that of the client follows the tradition of Carl Rogers (1977). Operationalization of the therapeutic goal is critical for future research. However, this series of studies seems to suggest that the therapist has a specific outcome in mind with respect to the content of the thought they desire or that there is a correct answer to the therapist’s questions. Furthermore, the questions posed by the therapist in the examples given are often closed, so the client



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produces either yes or no answers and thus has a 50/50 chance of responding “correctly.” It may be more important to study whether, for example, a synthesizing question produces a shift in the client’s hypothesis. Braun et al. (2015) used a more basic approach to examine the impact of Socratic questioning on symptoms of depression in people undergoing a 16-session treatment for depression. The audiotapes of the first four sessions of treatment were coded for frequency of use of Socratic questions. They found that more frequent use of Socratic questioning in one session was associated with a reduction in depression symptoms the following session, controlling for depression in the current session as well as general factors such as therapeutic alliance. Subsequently, Stone and Strunk (2020) examined cognitive change from session to session of treatment and found that therapeutic alliance and therapist use of cognitive methods predicted high (versus low) cognitive change. Meanwhile, there is a wealth of evidence suggesting that CBT results in cognitive change that is concomitant with changes in symptoms (see A. T. Beck & Dozois, 2011). Examples include Kleim et al. (2013), who conducted a largescale study of CBT for posttraumatic stress disorder (N = 268) and found that change in appraisal of the trauma led to a subsequent reduction in symptoms. Change in appraisal has been found to precede change in symptoms in treatment of chronic pain (Burns et al., 2003), panic disorder with agoraphobia (Bouchard et al., 2007), panic disorder (Hofmann et al., 2007), OCD (Wilhelm et al., 2015), posttraumatic stress disorder (Kleim et al., 2013), and depression (e.g., Kwon and Oei, 2003). Goldin et al. (2012) found that perceived capacity to reappraise thoughts mediated the effect of CBT for social anxiety. In their large study of cognitive therapy for depression, Jarrett et al. (2007) found that changes in cognition could be detected early and differentiated treatment responders from nonresponders, although they found that change in depressive symptoms preceded change in cognition, rather than vice versa. Finally, Schmidt et al. (2019) examined cognitive change between and within sessions in people receiving cognitive therapy for depression. They assessed cognitive change at the end of each session (i.e., immediate cognitive change) and at the beginning of the next session (i.e., sustained cognitive change). When examining within-session change, they found that sustained cognitive change mediated the relations between immediate cognitive change and symptom change. Thus, Hofmann et al.’s (2013) conclusion that there is strong evidence that changes in cognition mediate change in symptoms continues to be supported.

COGNITIVE REAPPRAISAL VERSUS COGNITIVE RESTRUCTURING There is a large body of literature on emotion regulation, the process of changing emotions. James Gross and his colleagues (2014) have identified a number of strategies that people use to change or control their emotions, of which cognitive reappraisal is one. Whereas some emotion regulation strategies are

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considered maladaptive (e.g., suppression, punishment), cognitive reappraisal is considered adaptive. McRae et al. (2012) defined cognitive reappraisal as “altering emotions by changing the way one thinks” (p. 250). As in the cognitive behavioral model, appraisal is assumed to mediate the relation between situational events and emotional response. However, there are important distinctions between the two constructs. The goal of cognitive restructuring is to identify the idea, or hypothesis, that is associated with the behavioral and/or emotional response of complaint, revisit that idea in light of all relevant information, and where appropriate, form new hypotheses. That is, the goal is not emotion regulation, although the reduction of certain emotions and the increase of others may result from the process. However, there is no doubt that cognitive restructuring changes the way one thinks and can technically be viewed as cognitive reappraisal. Furthermore, in some studies investigating cognitive reappraisal as an emotion regulation strategy, cognitive reappraisal is generally conceptualized as thinking positively about negative events; that is, by finding the silver lining (e.g., Troy et al., 2010). That is emphatically not the goal of cognitive restructuring.

APPLICATION TO DIVERSE POPULATIONS Cultural competence is considered a core competence now for psychologists, regardless of theoretical orientation. Therapists need to be sensitive to and aware of salient cultural differences, such as gender roles, responsibilities and obligations to family, understanding of and attitudes toward mental health, and understanding of and attitudes toward professionals. It is also important to be familiar with verbal and nonverbal behavior that can give offense, as well as cultural attitudes toward topics relevant to the client’s problem (e.g., sexuality, suicidality). Therapists also need to be aware of cultural variations in communication styles to avoid misinterpreting nonverbal behavior. For example, in some cultures, it is not appropriate to make full eye contact with someone in authority or with someone of another gender. It is also helpful to understand the events and celebrations that have important meaning for clients. However, it is also important not to assume that a client conforms to the norms of their culture. The bottom line is that therapists will do well to identify and avoid acting solely on their own cultural assumptions. Cognitive restructuring relies on verbal strategies, and thus the therapist must have superb verbal fluency in the client’s language or have an interpreter with this degree of fluency in both languages who can readily translate the vocabulary of therapy/mental health in general and CBT specifically. Another consideration is that metaphor and analogy are a common means of illustrating inconsistencies, but, of course, to be effective they need to be culturally relevant. Earlier in the chapter, the cartoon character Charlie Brown was referenced, but this analogy only works with a certain demographic within North America. However, clients themselves can provide a rich supply of analogies and metaphors if you simply ask them. For example, the therapist can ask



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about literary or historical figures the client has in mind when they think of a “loser,” or what scriptural texts are relevant to the situation under discussion. Finally, in cognitive restructuring, the therapist is on the lookout for inconsistencies between the client’s hypotheses and relevant information. Therapists need to be aware of the influence of cultural norms on how they guide discovery. For example, suppose the therapist is working with a woman from a nonWestern culture who reports feeling deep shame, anxiety, and despair about having caused her husband embarrassment at a public gathering. According to Western cultural norms, the wife’s actual behavior at the gathering was quite reasonable and the embarrassed response of the husband was an overreaction. If the therapist applies Western cultural norms to the situation, the therapist might then view the client’s acceptance that she had behaved poorly as an inconsistency. However, within the client’s culture, failure to preserve one’s husband’s dignity in public is a breach of one’s principal duty as a wife (a role that she fully accepts). The inconsistency is that she sees this (actual) breach as evidence of being generally incompetent in multiple domains and wholly incompetent in her role as a wife.

CONCLUSION AND FUTURE DIRECTIONS In sum, the goal of cognitive restructuring is to mutually examine hypotheses with the client, observe contradictions, and reconsider the original hypothesis in light of those contradictions. Through this process, the client begins to recognize that thoughts are not facts and that the evidence supporting them may include ideas, memories, and autobiographical information that are outdated and/or are the products of information-processing biases. While engaging in cognitive restructuring, the therapist is genuinely interested in and curious about the external and internal information that informs the client’s hypotheses. The therapist’s goal is not to change the client’s mind or prove their hypotheses wrong but rather to guide the client’s discovery of contradictions in their hypothesis and facilitate their reconsideration. Thus, cognitive restructuring is not intended to challenge thoughts, nor is its goal to change the content of thoughts. Instead, it seeks to help the client override the automatic processes that yield the behavioral and emotional responses of complaint. There is strong evidence that CBT is effective (although there is a need for more randomized controlled trials) and that changes in cognition precede symptom reduction. Cognitive restructuring is a key instrument of therapeutic change in CBT. There is evidence that changes in hot thoughts, assumptions, and beliefs mediate symptom reduction. There has been little research on clients’ subjective experience of cognitive restructuring methods and what they personally found transformative. There could be considerable merit in developing a better understanding of client engagement with cognitive restructuring methods. There is also very little research on the extent to which the intent of cognitive restructuring methods equals its impact. The goal of cognitive restructuring is to

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override automatic processes driving the emotional and behavioral responses of complaint by explicit processing of information, considering a broader range of information to assess the “goodness of fit” of hypotheses, and improving critical thinking as applied to the self. Traditionally, we examine the success of an intervention in terms of symptom reduction, which is the distal goal. Research that examines the functionality of a specific Socratic question and examination of its impact on a moment-to-moment basis will help clarify mechanisms of action. Another outcome measure may be the speed with which a new conclusion is developed and the range of information that is considered when drawing a conclusion. However, it may also be interesting to examine the larger proximal milestones required for symptom reduction to occur. There is a large literature in the area of education that examines the impact of use of Socratic techniques on learning and critical thinking. For example, in one small study, use of Socratic dialogue to explore students’ solution to a medical problem was associated with better performance on the California Critical Thinking Test (Yang et al., 2005). Such a framework has obvious relevance to the evaluation of cognitive restructuring within larger CBT packages.

REFERENCES Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press. Beck, A. T., & Dozois, D. J. A. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62, 397–409. https://doi.org/10.1146/annurevmed-052209-100032 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. Guilford Press. Beck, J. S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). Guilford Press. Bouchard, S., Gauthier, J., Nouwen, A., Ivers, H., Vallières, A., Simard, S., & Fournier, T. (2007). Temporal relationship between dysfunctional beliefs, self-efficacy and panic apprehension in the treatment of panic disorder with agoraphobia. Journal of Behavior Therapy and Experimental Psychiatry, 38(3), 275–292. https://doi.org/10. 1016/j.jbtep.2006.08.002 Braun, J. D., Strunk, D. R., Sasso, K. E., & Cooper, A. A. (2015). Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression. Behaviour Research and Therapy, 70, 32–37. https://doi.org/ 10.1016/j.brat.2015.05.004 Burns, J. W., Kubilus, A., Bruehl, S., Harden, R. N., & Lofland, K. (2003). Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis. Journal of Consulting and Clinical Psychology, 71(1), 81–91. https://doi.org/10.1037/0022-006X.71.1.81 Calero-Elvira, A., Froján-Parga, M. X., Ruiz-Sancho, E. M., & Alpañés-Freitag, M. (2013). Descriptive study of the Socratic method: Evidence for verbal shaping. Behavior Therapy, 44(4), 625–638. https://doi.org/10.1016/j.beth.2013.08.001 Carey, T. A., & Mullan, R. J. (2004). What is Socratic questioning? Psychotherapy: Theory, Research, Practice, Training, 41(3), 217–226. https://doi.org/dz9z5c



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Clark, G. I., & Egan, S. (2015). The Socratic Method in cognitive behavioural therapy: A narrative review. Cognitive Therapy and Research, 39(6), 863–879. https://doi.org/ 10.1007/s10608-015-9707-3 Dobson, D., & Dobson, K. S. (2017). Evidence-based practice of cognitive-behavioral therapy (2nd ed.). Guilford Press. Dobson, K. S., & Dozois, D. J. A. (2019). Historical and philosophical bases of the cognitive behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 16–52). Guilford Press. Froján-Parga, M. X., Calero-Elvira, A., & Montaño-Fidalgo, M. (2009). Analysis of the therapist’s verbal behavior during cognitive restructuring debates: A case study. Psychotherapy Research, 19(1), 30–41. https://doi.org/10.1080/10503300802326046 Froján-Parga, M. X., Calero-Elvira, A., & Montaño-Fidalgo, M. (2011). Study of the Socratic method during cognitive restructuring. Clinical Psychology & Psychotherapy, 18(2), 110–123. https://doi.org/10.1002/cpp.676 Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., & Gross, J. J. (2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology, 80(6), 1034–1040. https://doi.org/10.1037/a0028555 Greenberger, D., & Padesky, C. A. (2016). Mind over mood (2nd ed.). Guilford Press. Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (p. 3–20). Guilford Press. Hofmann, S. G., Asmundson, G. J. G., & Beck, A. T. (2013). The science of cognitive therapy. Behavior Therapy, 44(2), 199–212. https://doi.org/10.1016/j.beth.2009. 01.007 Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1 Hofmann, S. G., Suvak, M. K., Barlow, D. H., Shear, M. K., Meuret, A. E., Rosenfield, D., Gorman, J. M., & Woods, S. W. (2007). Preliminary evidence for cognitive mediation during cognitive-behavior therapy of panic disorder. Journal of Consulting and Clinical Psychology, 75(3), 374–379. https://doi.org/10.1037/0022-006X.75.3.374 Jarrett, R. B., Vittengl, J. R., Doyle, K., & Clark, L. A. (2007). Changes in cognitive content during and following cognitive therapy for recurrent depression: Substantial and enduring, but not predictive of change in depressive symptoms. Journal of Consulting and Clinical Psychology, 75(3), 432–446. https://doi.org/10.1037/0022006X.75.3.432 Kleim, B., Grey, N., Wild, J., Nussbeck, F. W., Stott, R., Hackmann, A., Clark, D. M., & Ehlers, A. (2013). Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 383–393. https://doi.org/10.1037/a0031290 Kwon, S.-M., & Oei, T. P. S. (2003). Cognitive change processes in a group cognitive behavior therapy of depression. Journal of Behavior Therapy and Experimental Psychiatry, 34(1), 73–85. https://doi.org/10.1016/S0005-7916(03)00021-1 Mahoney, M. J. (1974). Cognition and behavior modification. Ballinger. McRae, K., Ciesielski, B., & Gross, J. J. (2012). Unpacking cognitive reappraisal: Goals, tactics, and outcomes. Emotion, 12(2), 250–255. https://doi.org/10.1037/a0026351 Meichenbaum, D. H. (1974). Cognitive behavior modification. General Learning Press. Newman, M. G., & Fisher, A. J. (2010). Expectancy/credibility change as a mediator of cognitive behavioral therapy for generalized anxiety disorder: Mechanism of action or proxy for symptom change? International Journal of Cognitive Therapy, 3(3), 245–261. https://doi.org/10.1521/ijct.2010.3.3.245

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Overholser, J. C. (1993a). Elements of the Socratic method: I. Systematic questioning. Psychotherapy: Theory, Research, & Practice, 30(1), 67–74. https://doi.org/10.1037/00333204.30.1.67 Overholser, J. C. (2011). Collaborative empiricism, guided discovery, and the Socratic method: Core processes for effective cognitive therapy. Clinical Psychology: Science and Practice, 18(1), 62–66. https://doi.org/10.1111/j.1468-2850.2011.01235.x Padesky, C. (1993, September 24). Socratic questioning: Changing minds or guiding discovery? [Keynote address]. European Congress of Behavioural and Cognitive Therapies, London, England. Padesky, C. (1996a). Identifying the hot thought. New Harbinger Publications; The Center for Cognitive Therapy. Padesky, C. (1996b). Socratic dialogue. New Harbinger Publications; The Center for Cognitive Therapy. Purdon, C., & Chiang, B. (2016). Treatment of obsessive-compulsive disorder. In A. Carr & M. McNulty (Eds.), The handbook of adult clinical psychology: An evidence-based practice approach (2nd ed., pp. 492–514). Routledge. Rogers, C. R. (1977). Carl Rogers on personal power. Delacorte Press. Schmidt, I. D., Pfeifer, B. J., & Strunk, D. R. (2019). Putting the “cognitive” back in cognitive therapy: Sustained cognitive change as a mediator of in-session insights and depressive symptom improvement. Journal of Consulting and Clinical Psychology, 87(5), 446–456. https://doi.org/10.1037/ccp0000392 Stone, S. J., & Strunk, D. R. (2020). Fostering cognitive change in cognitive therapy of depression: An investigation of therapeutic strategies. Cognitive Therapy and Research, 44(1), 21–27. https://doi.org/10.1007/s10608-019-10055-6 Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science and Practice, 18(1), 47–61. https://doi.org/10.1111/j.1468-2850.2010.01234.x Thwaites, R., & Bennett-Levy, J. (2007). Conceptualizing empathy in cognitive behavior therapy: Making the implicit explicit. Behavioural and Cognitive Psychotherapy, 35(5), 591–612. https://doi.org/10.1017/S1352465807003785 Troy, A. S., Wilhelm, F. H., Shallcross, A. J., & Mauss, I. B. (2010). Seeing the silver lining: Cognitive reappraisal ability moderates the relationship between stress and depressive symptoms. Emotion, 10(6), 783–795. https://doi.org/10.1037/a0020262 Wilhelm, S., Berman, N. C., Keshaviah, A., Schwartz, R. A., & Steketee, G. (2015). Mechanisms of change in cognitive therapy for obsessive compulsive disorder: Role of maladaptive beliefs and schemas. Behaviour Research and Therapy, 65, 5–10. https:// doi.org/10.1016/j.brat.2014.12.006 Yang, Y.-T. C., Newby, T. J., & Bill, R. L. (2005). Using Socratic questioning to promote critical thinking skills through asynchronous discussion forum in distance learning environment. American Journal of Distance Education, 19(3), 163–181. https://doi.org/ 10.1207/s15389286ajde1903_4

9 Behavioral Activation Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter

A

long-standing characteristic of behavioral activation (BA) is its potential for widespread dissemination to reduce the burden of depression, particularly among populations that have been and continue to be underserved (Dimidjian et al., 2011; Kanter & Puspitasari, 2016). Across several decades, empirical findings have accumulated showing that the use of BA successfully reduces depression and produces other desirable outcomes across a variety of populations and contexts (Dimidjian et al., 2011). Client improvements have been observed among affluent, European-origin individuals treated in university settings and low-income, non-European-origin individuals treated in community settings. Given these findings and others described below suggesting its cost-effectiveness (e.g., Richards et al., 2016), BA is a recommended treatment package for depression in low-resource settings worldwide (World Health Organization, 2016). Specific features of BA, which may contribute to its promise for broad dissemination, include its culturally adaptable rationale and specific techniques that can be easily learned and tailored to what is meaningful for and needed by individuals in diverse settings. The BA rationale suggests that depression is reduced when a person reengages in their life through value-based and meaningful activities in response to adversity and despair. The task of determining what is “value based” and “meaningful” is largely one of eliciting from the client and assessing what is valuable and meaningful in their life. Thus, the BA rationale is considered to be cross-culturally adaptable, and BA has been found to be acceptable to individuals of diverse backgrounds (e.g., Kanter et al., 2015). https://doi.org/10.1037/0000218-009 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  235 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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BA’s core components are flexible and broadly applicable and usable alone or in combination with non-BA techniques (e.g. Beck et al., 1979). Selected BA techniques may also be implemented in a variety of provider settings, including primary care and other medical settings where underserved individuals traditionally seek care for mental health concerns. Techniques may be delivered within a relatively short time span, an important consideration given time constraints that exist within systems of care and the issue of early service termination among underserved individuals. Collectively, these features speak to BA’s promise for broad, effective dissemination. This chapter reviews BA’s history, theory, mechanism, core techniques, and empirical support before engaging in a thorough discussion of issues surrounding BA dissemination and implementation. Henceforth, we refer to the BA strategy to mean the entire treatment package, composed of specific BA techniques. A theme throughout is that the core BA technique of activity scheduling may exist as a primary component of stand-alone BA packages (which we discuss below) but may also be implemented in the context of other treatment approaches, whenever a clinician seeks to activate a client toward a behaviorally defined treatment-related goal.

HISTORY BA has its origin in the philosophy of science of radical behaviorism, put forth by the influential American psychologist B. F. Skinner. Skinner’s approach led scientists and clinicians, particularly Peter Lewinsohn (1974), to examine environmental factors and people’s sensitivity and responsiveness to their environments to understand depression and its treatment. According to Lewinsohn, depression occurs when stable sources of positive reinforcement are lost and an individual lacks the social skills to reestablish lost sources of reinforcement. Treatment, therefore, should encourage activity scheduling to reestablish contact with positive reinforcement and skills training to target behavioral deficits that interfere with contacting reinforcement (Lewinsohn et al., 1976). The 1970s witnessed the development of interventions based on this basic behavioral model of depression and studies in support of their efficacy and effectiveness (Kanter, Manos, et al., 2010), stimulating the development of multiple interventions that varied in their degree of consistency with Lewinsohn et al.’s (1976) approach. Interventions based on alternative behavioral models were also developed, some of which did not incorporate exclusively behavioral techniques (e.g., McLean, 1976; Rehm, 1977). These treatments have been identified as variants of BA by researchers who have conducted meta-analyses of the efficacy of BA treatments as a group (e.g., Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009). These analyses have documented that BA and its variants, collectively, perform very well in randomized controlled trials. BA consistently outperforms wait-list and no-treatment controls and, in general, is comparable to cognitive therapy at the end of treatment and follow-up (Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009).



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Toward the end of the 1970s, largely in line with the zeitgeist of the time rather than scientific findings, use of strictly behavioral intervention techniques were abandoned in favor of cognitive techniques or a combination of cognitive and behavioral techniques. Cognitive approaches to depression treatment ascended in popularity. Two studies by Lewinsohn and colleagues were influential in propelling this shift toward cognitive approaches. First, in a small yet impactful comparison of cognitive and behavioral techniques, cognitive techniques outperformed the behavioral in terms of significantly fewer depressive symptoms (Shaw, 1977). Second, in an analysis of the components of Lewinsohn et al.’s (1976) approach, no differential effectiveness was observed between activity scheduling (i.e., a key component of BA), skills training (not unique to BA and recommended to address skills deficits), and cognitive techniques (Zeiss et al., 1979). These findings culminated in Lewinsohn and his colleagues adopting a cognitive behavioral therapy (CBT) rather than a strictly behavioral approach to the treatment of depression, evidenced by the publication of the self-help book Control Your Depression (Lewinsohn et al., 1978) and the therapy manual Coping With Depression (Lewinsohn et al., 1984). After this point, although behavioral techniques continued to be used, they were generally implemented within a cognitive change framework. Thus, the primary BA technique of activity scheduling continued to be implemented within CBT, and development of stand-alone BA packages stagnated. Within CBT, rather than help a person through behavior change, behavioral methods were meant to help shift a person’s underlying assumptions or irrational beliefs. Such was the case with Beck et al.’s (1979) Cognitive Therapy of Depression, the most widely investigated and utilized set of techniques for treating depression (DeRubeis & Crits-Christoph, 1998). The CBT model reigned as the gold standard framework for the psychotherapeutic treatment of depression until the 1990s, when Jacobson et al. (1996) conducted a dismantling study in which they compared the full CBT package to the treatment’s components, including the element focused on BA. They found no differential effectiveness (i.e., recovery and relapse rates, number of well weeks, and survival time to relapse) of behavioral and cognitive techniques at the end of treatment and 2 years later (Gortner et al., 1998). They concluded that adding cognitive techniques to BA did not improve outcomes. In addition, they raised the notion that BA techniques were superior to cognitive techniques given their comparable efficacy and, at the same time, that BA techniques had greater efficiency with regard to training and in-session implementation. Jacobson et al.’s (1996) findings inspired renewed interest in implementing exclusively behavioral strategies and the development of contemporary standalone BA techniques grounded in behavioral conceptualizations of depression and treatment. Since the early 2000s, two variants in particular have surfaced as the dominant approaches, namely BA (Jacobson et al., 2001; Martell et al., 2001, 2013) and behavioral activation treatment for depression (BATD; Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011). Combined, BA and BATD have been the basis of abundant research with individuals from an array of populations and pathology profiles, which we discuss later in this chapter.

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Although the two primary variants of BA share core components, noteworthy differences exist between them. In the early 2000s, Martell et al. (2001) developed a treatment manual for BA that was grounded in contextualism. Given this theoretical underpinning, key to understanding the nature of an individual’s depression and the ideal strategies to treat it was understanding the client’s full historical and environmental context. Martell et al. (2001) also considered that treatment intervention for the client should be determined by the functional analysis of client behaviors. A functional analysis helps a therapist and client develop hypotheses about the events that lead to, maintain, and strengthen client behaviors that create problems and interfere with improvement. More specifically, it helps them develop hypotheses about the events that produce the behavior for the client at that particular time and under those conditions (Kanter et al., 2004). In BA, therapists and clients use the straightforward Antecedent-Behavior-Consequences (A-B-C) model to identify the events/antecedents (A) that lead to the client’s clinically relevant behavior (B) and the consequences (C) that maintain it. A major focus of BA is to help a client develop and engage in healthy or adaptive behaviors when presented with events that have historically led to engagement in depressed behaviors (such as those that function to escape or avoid aversive situations). Martell et al.’s (2001) approach to BA can be delivered over 10 to 16 sessions. It is both comprehensive and flexible concerning the pacing of BA techniques used throughout treatment. To that end, Martell and colleagues described BA as an approach rather than a treatment composed of a series of techniques. Contemporaneously, Hopko, Lejuez, and colleagues developed BATD (Lejuez, Hopko, & Hopko, 2001). The BATD protocol can be implemented over eight to 10 sessions and is focused on distilling core BA techniques into a condensed session-by-session treatment package. Their aim was to create a treatment package that was easy to teach and could be implemented in a range of settings. Additionally, BATD incorporated a formal values assessment in various life domains (i.e., inventory of the client’s personally held values) to facilitate values-consistent activation through treatment.

UNDERLYING THEORY A Behavioral Account of Depression In line with BA’s behavioral origins, reinforcement has been a central concept in its models of depression. A reinforcer is any consequence that makes it more likely that a specific behavior will occur in the future when that consequence occurs soon after the behavior occurs. For example, in an attempt to obtain a hug, Mike asks his partner, “Can I have a hug?” Presuming hugs are indeed reinforcing for Mike, if Mike’s verbal request (i.e., behavior) results in a hug (i.e., consequence), Mike is more likely to make the same or similar request of his partner when he wants a hug in the future. In this case, the consequence of



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receiving the hug is the positive reinforcer that makes it more likely that Mike will ask for a hug. The conceptual work of Ferster (1958, 1973, 1974) informed the thinking of other BA experts. Ferster hypothesized that nondepressed, healthy behaviors maintained by positive reinforcement likely were absent from the repertoires of individuals with clinically significant problems. Furthermore, Ferster proposed that a person with clinically significant problems might be more likely to engage in behaviors reinforced by escaping from or avoiding aversive events and that this might effectively limit their access to positive reinforcement for healthy behavior. In more technical terms, such a person’s behaviors would be primarily maintained by negative reinforcement. For instance, whenever Martha, who is diagnosed with depression, spends time with friends, she feels sadness and anxiety. Martha might decline invitations to spend time with her friends to avoid these aversive consequences. Although the behavior of declining invitations has the consequence of avoiding difficult feelings (i.e., negative reinforcement), it simultaneously serves as an obstacle for attaining positive reinforcement for healthy behavior and feeling better. Ferster (1958) also hypothesized that individuals with environments characterized by impoverished reinforcement might engage in the indicated healthy behaviors but at inappropriate times or when the behavior is not likely to be reinforced. For example, Martha might call on a friend unannounced at work with the desire to have an intimate interaction with her friend. Rather than respond as Martha had hoped, the friend hurriedly explains that she is running late to a meeting. Although Martha engaged in a desirable healthy behavior, she did so at a time when the consequence that might maintain her behavior in the future was not likely to occur. Although these early theoretical writings on depression emphasized positive reinforcement, negative reinforcement, and issues of timing and reinforcer availability, Lewinsohn’s (1974) behavioral theory of depression largely emphasized reductions in contact with positive reinforcement, as exemplified by the case of George. George worked hard at his job to provide financial stability for his family. In his free time, George began growing tomatoes and chilies (i.e., behavior) after he discovered that he enjoyed and felt accomplished upon harvesting his yield (i.e., positive reinforcement). He also received a favorable response from his family and believed that he had contributed meaningfully to the family (i.e., more positive reinforcement). In addition to providing fresh food from his garden, George also bonded with his children by partaking in their activities, taking them on outings, and reading to them at night. According to Lewinsohn’s model, depression is the product of losses of, reductions in, or chronically low levels of response-contingent positive reinforcement (RCPR), or positive reinforcement that is dependent on specific behaviors. When George developed an illness that severely limited his physical abilities, much of the mentioned positive reinforcement was lost. After the onset of his illness, George was no longer able to engage in a variety of physical activities that helped him contribute to meeting his family’s needs, including tending to his garden and

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working for an income. He continued to read to his children regularly, but the illness significantly interfered with his ability to join in their activities and take them on outings. As a result of these behavioral changes, George experienced multiple losses of and reductions in sources of positive reinforcement. In time, George experienced an extinction of other healthy behavior as he stopped talking to his wife and close others. Lewinsohn (1974) proposed that RCPR depends on three factors: (a) differences between individuals in what is reinforcing, (b) the availability of that which is reinforcing in a particular individual’s environment, and (c) an individual’s skill at obtaining and maintaining contact with the necessary reinforcement. For example, in George’s case, gardening and family involvement are very reinforcing, but consider Louise, who, in contrast, is less family oriented but is reinforced by spending time with friends and engaging in sports activities. To avoid depression, it is best for George to live near his family and have a plot of land available so he can garden, whereas it is best for Louise to live near friends and within access to a park where she and her friends can play sports. Furthermore, it is beneficial that George knows how to successfully keep his garden alive, whereas Louise can experience success at sports due to her athletic ability. According to the behavioral model, these conditions are important for BA therapists to consider as they develop treatment plans (discussed below). To bring together the lines of conceptual work of these BA pioneers (Ferster, 1973, 1974; Lewinsohn, 1974) and modern BA developers (e.g., Lejuez, Hopko, & Hopko, 2001; Martell et al., 2001), Manos et al. (2010) clarified a comprehensive and current BA model of psychopathology, which is visually depicted in Figure 9.1. According to this model, depression involves four interrelated elements, namely reinforcement, mood, behavior, and depression. Psychopathology starts with an environment typified by losses of, reductions in, and/or chronically low levels of positive reinforcement, due to individual differences in what is reinforcing (which can include genetic factors), the availability of reinforcement in the environment, and the person’s skill in obtaining it. The onset of depression is also characterized by the greater availability of negative reinforcers in the environment. Lejuez, Hopko, LePage, et al. (2001) emphasized a third reinforcement process in their behavioral activation variant, BATD, which is the positive reinforcement of depressed behavior. Combined, these changes in reinforcement occur such that positive reinforcement for healthy behavior is subsequently reduced, lost, or chronically deficient in a person’s environment. In response, a person will experience affective changes associated with depression, such as depressed mood, irritability, and anhedonia. Because of environmental changes, the person—simply put—feels depressed (Kanter et al., 2008, 2009). Behavioral changes occur as a consequence of changes in reinforcement as well. When positive reinforcers are lost, reduced, or chronically low, the model predicts reductions in or the extinction of healthy behaviors. A person with this positive reinforcement environmental profile may be expected to engage in fewer specific behaviors that had previously led to contact with positive

Reinforcement   R+ for healthy behavior (  R– and R+ for depressed behavior)

Behavior

  activation (  avoidance and depressed behavior)

Treatment

Provision of BA techniques

  depressed mood

Mood

 depressive symptoms

  activation (  avoidance and depressed behavior)

  depressed mood

  R+ for healthy behavior (  R– and R+ for depressed behavior)

Treatment

Depression

Behavior

Mood

Reinforcement

Psychopathology

FIGURE 9.1. Psychopathology and Treatment Mechanism Underlying Behavioral Activation (BA)

  depressive symptoms

Depression

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reinforcers (e.g., going to work, engaging in hobbies, taking care of personal responsibilities). If changes in reinforcement for a person include increases in negative reinforcers, the model predicts increases in avoidance behaviors, wherein the depressed person engages in behaviors to escape or avoid aversive experiences. A person’s environment may also be characterized by increases in positive reinforcement for depressed behaviors, which would lead to greater engagement in these behaviors, such as complaining to friends and subsequently receiving warmth and attention. According to the model, clinically significant depression occurs when initial changes in reinforcement, mood, and behavior lead to a self-sustaining cycle of further changes in the relations among these elements that lead to and maintain a depressive environment or lead to worsening of depressive symptoms. Take the case of Alexis, who took on a job from which she believed she gained very little (e.g., did not allow her to develop new skills, did not offer many opportunities for upward mobility) and that resulted in relatively low positive reinforcement and feelings of dissatisfaction and unhappiness. She disengaged from her job (i.e., quit) before finding alternative employment and, as a result, lost a major source of positive reinforcement and began to feel “down” most days. Alexis’s job had allowed her to meet financial responsibilities and engage in a variety of social activities (e.g., enjoying dinner with friends regularly, attending artistic events), which she was no longer able to do once unemployed. In time, Alexis disengaged from other healthy behaviors (e.g., paying bills, going out with friends) and felt even worse, experiencing another worsening in difficult feelings. In this case, Alexis experienced a reduction in positive reinforcement and a sense of dissatisfaction and unhappiness when she began her job. The level of available positive reinforcement was insufficient to maintain her engagement in the job. Upon leaving her job, she lost the job-related sources of positive reinforcement altogether, automatically felt other difficult feelings (i.e., depressed mood and anxiety), disengaged from other healthy behaviors, lost other sources of positive reinforcement, and felt considerably worse over time. A Behavioral Approach for Reversing the Cycle of Depression Manos et al. (2010) also clarified the corresponding BA treatment model and the hypothesized mechanism through which BA treatment techniques affect depression change. Specifically, it is proposed that the cycle of depression is reversed in the context of BA when treatment techniques are implemented and subsequently lead to activating new or reactivating previous healthy behavior that has decreased. In particular, activity scheduling is the primary technique for increasing a person’s engagement in healthy, nondepressed behavior. Treatment implementation also involves the use of secondary treatment techniques to address issues that interfere with the ultimate goal of increasing a person’s activation, namely avoidance, depressed behaviors, skills deficits, and contingency management. Through increases in activation, a



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person experiences increases in contact with positive reinforcement that is available in the environment, which strengthens desirable changes in behavior over time. With sustained successful contact with positive reinforcement, a person is expected to experience improvements in mood and, ultimately, decreased depressive symptoms. In some cases, a person’s efforts to engage in activation and disengage from avoidance and other depressed behaviors may be hindered by an environment in which consequences (i.e., reinforcers) are not supporting improved behavior and/or are sustaining problematic behavior. The provision of BA treatment in these cases would include the use of contingency-management techniques to alter the environment to support desired behavioral changes. In combination, changes in the client’s behavior and direct contingency-management techniques result in changes in the environment (more specifically, changes in reinforcers) that ultimately reverse the cycle of depression. Thus, BA’s fundamental goal is to help a client become activated to increase contact with diverse and stable sources of positive reinforcement, which should lead to a reduction in or elimination of depression. Over time, a client not only changes their behavior but also begins to understand the BA model itself. The client learns how behavior, environment, and mood are related and learns to predict situations that might lead to loss of positive reinforcement. The client, then, is able to maintain healthy behavior in those situations and prevent future episodes of depression.

DESCRIPTION OF MAIN PROCEDURES Multiple treatment manuals are available for readers wishing for detailed descriptions of treatment techniques and specific protocols that have been employed in BA research studies (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011; Martell et al., 2001, 2013). These manuals present a host of BA treatment techniques, ideas, and options for clinicians depending on the clinician’s specific needs. The Lejuez manuals are relatively brief and structured, with concrete session-by-session guidelines, specific homework, and other forms that can be used. The Martell manuals are longer, with more clinical examples and discussion of behavioral processes as part of the text. Our analysis of these and other BA protocols is that a set of core BA techniques can be distilled and identified from the multiple BA treatment approaches that have been published and empirically supported (Kanter, Manos, et al., 2010). In our view, these core techniques represent the functional essence of BA—activating a client to engage in antidepressant behavior per a unique case conceptualization of that client— and allow clinicians to flexibly implement BA across diverse settings and clients, without requiring lengthy training protocols that provide details that may be unrealistic for a given setting. Therefore, the core BA techniques also may be employed within the context of other treatment approaches, whenever a clinician wishes to engage in specific behaviors (i.e., activate) as part of a larger treatment plan.

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In previous work, microskills for each of the techniques we describe have been operationalized, and brief training protocols have been developed and evaluated for effectively increasing competence in implementing them (Puspitasari et al., 2013, 2017). Here, we present an overview of each core BA technique, including (a) provision of a BA rationale, (b) assessment techniques (i.e., values assessment and activity monitoring), (c) activity scheduling, and (d) techniques to cope with avoidance and other barriers to activation. Presenting a Rationale Though it is common to all psychotherapies (e.g., Ilardi & Craighead, 1994), the provision of a rationale for treatment is considered a core BA treatment technique (Puspitasari et al., 2013). Simply put, the BA rationale is that when people face difficult life circumstances, they are likely to get depressed, shut down, and stop engaging in life. Thus, BA will help the client get active again. How the client gets active will be determined through a collaborative process between the therapist and the client and will be sensitive to the unique needs and circumstances of the client’s life. The therapist and client will identify weekly activation goals, schedule these assignments specifically, discuss and problem solve obstacles to successful activation, monitor how increasing activation is addressing the client’s depression and life problems, and modify the action plans accordingly to maximize the chance that increased activation will affect the key variables maintaining depression in the client’s life. A strength of BA is that this rationale, while based on a strong scientific theory and empirical findings, is seen as simple and easy to understand by clients, including clients who may come from cultures in which the Western medical model of depression is foreign (Kanter et al., 2012). According to this rationale, BA techniques may be helpful when a client is experiencing negative life circumstances, is feeling down as a result, and wants to reengage in life. The BA rationale often empowers clients to persevere in the face of difficult life circumstances and offers therapeutic assistance and techniques to do so. There is no need for the therapist to educate the client about the symptoms of depression per Western medicine or even to use the term “depression” for that matter. The therapeutic tasks are primarily listening to the client’s narrative of life circumstances and helping the client actively pursue personal goals and meaning with respect to their life circumstances. In its simplest form, the BA rationale can be “I’d like to help you stay active and engaged in the things that are important to you.” In its more elaborated form, the rationale can be presented as in the following exchange between a therapist and hypothetical client Alice. THERAPIST: Alice, I would like to take a few minutes now to share my views

on how you have come to feel as you do and how you can go about improving how you feel. Would that be alright? ALICE:

Yes, definitely, please.



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THERAPIST: It makes a lot of sense to me that you have been feeling as you

have been over the last few months given what you’ve lived recently. You experienced the loss of your husband—a major source of connection and support. With his loss have also come other losses and hardship. It sounds like you are experiencing financial insecurity and there is some uncertainty about how you will be able to provide for your two children now that you cannot rely on a second income. Since your husband passed, it sounds like you have been struggling with deep sadness, and as time has progressed, you have also come to feel very little interest and motivation to carry out your life as you did prior to his passing. Does this map on to what you’ve shared? ALICE:

Yeah, that’s exactly what’s happened . . .

THERAPIST: When people undergo the types of experiences you have, they

tend to feel like you are now. When they feel as you do, they often respond by disengaging from life, which I call “shutting down.” In listening to you, it sounds like you may have shut down in some important ways. I wonder if this is reflected in your decision to stop attending your bimonthly book club and in your recent decision to have your children carpool with friends to their weekend activities. What do you think? ALICE:

I hadn’t thought of things that way. I think it’s fair to say that I have pulled out of my old life. I just don’t have the energy and desire to do much of anything.

THERAPIST: Again, it makes sense to me that in the face of everything that’s

happened and the feelings that constantly come up for you, you would shut down. Now, the way I see it given my experience working with others in similar situations, we can work together to help you tackle your depression with behavioral activation. This means helping you plug back into your life in such a way that you are doing things that are important to you. For instance, we would figure out how to get you doing things that help solve problems, give you a sense of purpose, and bring about enjoyment. We would also get you doing things that you may be putting off but that are key to living your life meaningfully. In my experience, when a person plugs back into life, the changes in feelings they are looking for often follow. By getting more active, you will be able to live the life you envision for yourself, and there is a good chance your sadness will lessen and your interest and motivation will increase. We suggest that such an intuitively straightforward rationale may help therapists work cross-culturally within the BA model by presenting a rationale that is likely to resonate with culturally diverse clients while staying open to their

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cultural needs and experiences. For example, consider Rahim, a Muslim client who quit his job and became depressed after experiences of discrimination at his workplace. He subsequently stopped going to his mosque, which further isolated him since much of his social engagement came through his religious practice and community. Rahim presented primarily with somatic symptoms of depression, such as feeling tired and lacking energy, rather than emotional symptoms. The BA therapist was not Muslim but was able to recognize the sequence of losses of reinforcers in Rahim’s life, per BA’s model of depression, and provide a rationale that was consistent with Rahim’s experience, using his language rather than behavioral jargon (Mir et al., 2015). The therapist explained that BA could focus on helping Rahim reactivate to find new employment and reengage with his religious practice and social community, even though he was feeling tired and lacking energy. The therapist suggested that once Rahim started getting more active in these ways, it was expected that he would feel less tired and have more energy. Activity Monitoring and Other Assessment Techniques In the above example, the primary targets for activation were fairly clear from an initial examination of Rahim’s presenting problem. However, it is often the case that BA therapists will implement specific assessment techniques to develop a list of activation targets tailored to the client’s values and life circumstances. A primary technique, which has existed in BA since its early days (Kanter, Manos, et al., 2010), is activity monitoring. To achieve the aims of activity monitoring, the client is asked to keep a detailed record of their activities over the course of the week for the therapist to review. This record may also include ratings associated with each activity, such as the client’s mood during the activity, experience of enjoyment during the activity, and experience of mastery during the activity. Through these ratings, the client and therapist can discuss together how certain activities result in the client feeling better, experiencing more enjoyment, or experiencing more mastery and how other activities (or lack of activity) result in the client feeling more depressed, experiencing less enjoyment, or experiencing less mastery. Identifying these relations between activity and mood can be helpful for identifying activities to assign. The following is a hypothetical exchange between Alice and her therapist as they work to identify treatment targets. THERAPIST: I’m looking forward to going over your activity monitoring form

this session. As we discussed last session, one way this form will be useful is that it will help us get a clearer picture of your level of activity right now, as well as the feelings that come up for you when you carry out your activities. Another way in which it will be useful is by helping us home in on which activities we want to see more of and which activities we want to work to decrease to reverse your depression. How does that sound?



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ALICE:

Okay, that makes sense to me. At first, I was not sure what I could learn from this. Coming in, I thought I had a pretty good sense for what I’m up to, which is not much, and how I feel.

THERAPIST: Tell me, what did you learn? ALICE:

Well, I spend a lot more time on my phone than I realized.

THERAPIST: Let’s take a look at when you were on your phone throughout

the week. What was your mood like after being on your phone for a while? ALICE:

On Monday I didn’t go in to work. I woke up with a very bad headache, so I called out from work. I stayed in bed all morning and got up like at 1:00 or 2:00. I was on my phone pretty much the whole time, on and off. I felt very depressed after that.

THERAPIST: What happened on Wednesday? What was your mood like after

being on your phone for a good chunk of time that day? ALICE:

So that was 3 hours after work when I was supposed to be doing meal prep for my kids for the week . . . I felt like a terrible mother. Meal prep didn’t get done. [sigh]

THERAPIST: What came up for you? ALICE:

I felt so guilty and worthless . . . That was probably my lowest point of the week. I was extremely depressed after that.

THERAPIST: It really comes across how important it is to you that you follow

through on that task. Why is that task so important to you? ALICE:

My kids are the most important people in my life. When I don’t do things that are meant to keep them happy and healthy, it really brings me down.

THERAPIST: Alice, based on what we’ve learned from your activity form just

now, I think an important activity we could schedule is meal prepping. It sounds like a very important activity and we could develop a plan that makes it more likely you will succeed at carrying it out. What do you think of that? ALICE:

Okay, yeah, I really need to turn that around.

THERAPIST: It also sounds like we could explore your phone use a bit more.

Right now, it sounds like phone use, at least in certain situations, leads you to feel pretty down on yourself. We could work to reduce phone use and get you doing things that are important to you during that time instead. Thoughts? ALICE:

I definitely think I spend too much time on my phone. Yeah, I think that makes sense.

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Activation assignments in BA, however, generally are not solely the product of activity monitoring. In addition, the therapist is continuously informally learning about the client’s life circumstances, cultural issues, values, and goals, thereby developing ideas for activation from multiple sources of information. Per Puspitasari et al. (2013), four additional sources of influence may be considered. First, BA therapists look for behaviors and activities that clients used to do but stopped doing as they became depressed, as well as new activities that clients want to start doing. Because these activities are not in the client’s current repertoire, activity monitoring will not reveal them to the therapist, so the therapist must ask about these activities. Second, per Ferster’s (1973, 1974) focus on avoidance in depression, which is heavily emphasized in BA by Martell et al. (2001, 2013), BA therapists should assess behaviors that the client is avoiding because they feel overwhelming or aversive. These may be difficult, but important, behaviors to activate. Third, per BATD (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), BA therapists may employ a formal and structured assessment of different life areas (e.g., education, family) and the client’s values in each area (e.g., attending college, improving a relationship with a sibling) that would lead to specific activation assignments. Fourth, BA therapists may assess daily routines (e.g., exercise, sleep, personal hygiene) that have been disrupted in depression. Although the specific assessment techniques described above may be helpful to therapists in developing activation assignments, assessment in BA is an ongoing process and not restricted only to the techniques described in this section. Essentially, BA therapists are always listening for ideas from the client about which behaviors may be important to activate and which behaviors are contributing to depression. Furthermore, as activity scheduling occurs, therapists are listening for what has worked and not worked, as well as which activities have helped the client experience decreased depression and which have not. Therapists make adjustments to the conceptualization as therapy unfolds. Activity Scheduling The core technique of BA is activity scheduling. Each week, the therapist and client together develop a specific list of antidepressant activities in which the client plans to engage that week. Some of these activities may be discussed and scheduled in detail, whereas others may simply be mentioned and assigned in passing. In BATD (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), the therapist and client, early in treatment, complete a specific activity hierarchy, which is a list of all the activities identified during assessment for the client to complete over the course of treatment, ranked in terms of difficulty and priority. This hierarchy then determines the assignment of activities, although adjustments are regularly made with respect to the client’s current functioning, capacities, and goals. Other variants of BA are less structured, such as determining activities to schedule, leaving the weekly choices to the discretion of the therapist and the client.



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In our experiences, we have found that approximately three to five activities are assigned to the client each week, representing a mix of difficult and simple assignments across life areas. For example, the activities assigned to the client on a given week may involve an exercise or hygiene activity, maintaining a commitment or an obligation rather than avoiding it, searching for a job, and doing something enjoyable with a friend or family member. In a typical 50-minute therapy session, there will be time to discuss two or three of these activities in detail. Such detailed discussion involves concretely identifying what the activity will be and where, when, and with whom the activity will occur. For example, a client may decide to invite a friend for a jog around a nearby lake at 10:00 a.m. on Saturday morning. The therapist and the client will also identify and problem solve potential obstacles to successful completion of the assignment, such as the possibility that the friend will be unavailable, that the client will feel too tired to get out of bed Saturday morning, or that it will rain. Alternative plans are typically developed. The following is a hypothetical exchange between Alice and her therapist as they work to develop Alice’s activity plan. THERAPIST:

Let’s come up with a plan for helping you prepare meals for your children each week. What do you usually aim to accomplish during your meal prep sessions?

ALICE:

My goal is usually to prepare three dinner meals for the week so that I make sure that the kids are getting proper meals. I want to have different kinds of meals so that they don’t get bored of eating the same thing over and over again. I have wanted to cook the meals at once because I find it hard to cook many times during the week, but this just hasn’t worked out . . .

THERAPIST: It sounds like you are working toward a very productive

cooking session! Let’s work on helping you meet that goal as part of our work together. I often find that one way to help clients succeed at accomplishing their goals is to start off by breaking down an activity into chunks. It sounds to me that your meal prep plan involves many smaller activities. For instance, each meal can be thought of as one activity. I would suggest that we start off by scheduling a meal prep session that involves cooking one meal. Right now, it sounds like it’s very difficult to get going with things that are usually not difficult for you to do when you are feeling like yourself and not depressed. I think it’s important to take into consideration that things are difficult to do at this time. By setting a realistic plan that considers how difficult it is to do the activity, we make it more likely that you will be able to succeed at carrying it out. What do you think of starting off with preparing one meal during your cooking session?

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ALICE:

I suppose that sounds more realistic than my current plan. I’m willing to try that.

THERAPIST: Great. I recall you planned to prepare meals on Wednesdays.

How did you decide on Wednesday? ALICE:

It’s the day I get off of work early enough to cook in the evening. I have been wanting to avoid cooking on the weekends since there is a lot going on during those already.

THERAPIST: It sounds like you’ve given a lot of thought to when would be a

good day to cook. Would you like to stick to that day then? ALICE:

Yes.

THERAPIST: Okay, when on Wednesday is a good time to meal prep? ALICE:

I usually plan to do it after dinner.

THERAPIST: How has that worked? ALICE:

Well, I haven’t really meal prepped in a long time, so not very well, I suppose.

THERAPIST: What has gotten in the way of doing the activity at that time? ALICE:

After dinner, all I want to do is sit down and doze off.

THERAPIST: It sounds like you’re tired by the time meal prep time comes

along. Would it be possible to do it earlier? ALICE:

Mmm . . . I could do it as soon as we get home while the kids are doing their homework. I have protected that time to just do homework or to sit and unwind after a long day at work.

THERAPIST: Would you consider prepping meals as soon as you get home? ALICE:

Mmm . . . I suppose I could. I just really feel that I need the time for myself and to help the kids with their homework.

THERAPIST: You sound ambivalent. Would it work to switch your “me time”

to after dinner? ALICE:

Okay, that could work. I’m tired after dinner anyway.

THERAPIST: Sounds good. I assume you will want to cook at home in your

kitchen. Is that right? ALICE:

Yes.

THERAPIST:

Wonderful. Now, let’s put our heads together and think through what could get in the way of you completing this activity this week.

Activities to assign will be a function of assessment and tailored to the unique cultural and life circumstances of the client. For example, in our study wherein



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we evaluated BA at a community clinic that primarily served low-income Latino clients, a variety of activities were assigned and completed by clients over the course of the study (Kanter et al., 2015). These activities included dancing, walking, exercising, playing sports, attending community center activities (e.g., relaxation groups, stress management groups), attending a community fiesta (i.e., party), going to fun places or events (e.g., museums, seasonal free concerts, library), attending church activities and events, visiting friends, playing with children/grandchildren, reading Spanish-language magazines, listening to Spanish-language music, preparing a traditional family meal, cleaning the house, knitting, seeking employment, attending medical appointments and maintaining medical care (e.g., diabetes care), calling family and friends in their country of origin, working on social service agency problems, asking others for help, saying no to a request, spending time with family, taking English-language and computer classes, maintaining personal hygiene, and talking with a spouse/ partner about parenting issues. Clients who receive BA will be asked to monitor completion of activities as they occur, possibly using a similar form to activity monitoring. As with activity monitoring, the client may be asked to track how they felt before, during, and after the activity, using the same format they used in activity monitoring. After the initial assessment sessions in a course of BA, the typical session will involve first reviewing the previous week’s assigned activities, problem solving obstacles that occurred and celebrating successes, and developing new assignments. This process composes the bulk of the BA session. Techniques to Cope With Avoidance and Other Barriers to Activation The final set of core BA techniques concerns how to address avoidance and other barriers to activation. Techniques to address avoidance are explicated in detail by Martell et al. (2001, 2013), who suggested that a primary goal of BA is not only to activate clients as we have discussed above but also to teach clients how to proactively identify their tendencies to avoid engaging in important antidepressant behaviors because the behavior may lead to aversive feelings or other negative outcomes. For example, many individuals who do not exercise regularly avoid exercise because it requires a lot of effort and energy and potentially causes physical pain, both during and after exercise. Yet we know that exercise is antidepressant, and only over time does it become enjoyable and reinforcing. Thus, BA therapists teach clients to identify the triggers that might lead to avoidance (e.g., an assignment to exercise), the thoughts and feelings associated with the assignment (e.g., “I will feel exhausted and out of shape.”), and the tendency toward avoidance that results from this sequence. In general, the overall BA rationale presented to clients is seen as relevant to the problem of avoidance, as the belief in BA is that one can engage in behavior and do difficult activities even when one does not feel like doing so. Per Martell et al. (2001), this may be thought of as an “outside-in” approach to therapeutic change, in that one may first change “outside” behaviors, and this change will

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influence how one feels on the “inside.” This may contrast with an “inside-out” approach, with which a client may be more familiar, in which one first has to change how one feels on the inside before one can change what one does on the outside. Clients may be encouraged to think of examples in their lives when they were successfully able to do something even though they did not feel like it. Overall, avoidance is addressed in a variety of ways by BA therapists. For example, clients may be encouraged to engage others to help them complete difficult activities, such as by establishing contracts with others to complete the task. Per Martell et al. (2001, 2013), the therapist may also teach clients to engage in the present moment through mindfulness techniques that help the client disengage from aversive feelings and thoughts that control avoidance (i.e., rumination), thereby making valued behavior more likely. All told, it must be recognized that for some clients, the urge to avoid is very strong, and this remains one of the most difficult issues BA therapists face. When avoidance is an issue, the therapist must balance the provision of techniques to help the client overcome the avoidance with reconsideration of the original difficulty level of the task, in the context of exquisite validation of difficulty of activating and associated emotions and thoughts. Therapists may work with clients to make tasks less difficult and try again. Patience, persistence, and flexibility, in combination with warmth and validation, are necessary therapeutic qualities here, as is the ability to recognize small improvements in the client.

OUTCOME DATA Efficacy and Effectiveness of Integrated BA Components Although most of BA’s evidence base exists with respect to BA components integrated into stand-alone treatment packages, the efficacy and effectiveness of individual BA techniques has been demonstrated as well in many cases. Regarding BA packages, the results of multiple meta-analyses of BA trials (Cuijpers et al., 2007; Ekers et al., 2008, 2014; Mazzucchelli et al., 2009) provide clear indication that these protocols, as a group, demonstrate superior efficacy in treating depression compared with control conditions, evidenced by large effect sizes in favor of BA. A more recent meta-analysis found a small, albeit significant, short-term superiority of BA relative to antidepressant medication (Ekers et al., 2014). Data also indicate that BA is comparable to cognitive therapy and antidepressant medication with regard to maintaining gains at 2-year follow-up (Dobson et al., 2008). Given the accumulated evidence, BA has been designated a well-established, validated treatment for depression by the American Psychological Association (APA; Chambless et al., 1998). Evidence also suggests that BA strategies can reduce the burden of depression among groups taxed with chronic mental health conditions leading to hospitalization or other mental health problems that are not depression. Specifically, several studies have noted decreases in clinical symptom severity in a range of populations, including clients with posttraumatic stress disorder (PTSD; Acierno



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et al., 2016; Strachan et al., 2012; Jakupcak et al., 2010; Nixon & Nearmy, 2011), binge eating disorder (Alfonsson et al., 2015), and substance abuse (Daughters et al., 2008; Magidson et al., 2011). Additionally, several studies have demonstrated significant changes in activation and avoidance with clients in inpatient settings (Folke et al., 2015), with binge eating disorder (Alfonsson et al., 2015), and with substance abuse (Magidson et al., 2011). Also, clients with PTSD (Jakupcak et al., 2010) or substance abuse (Daughters et al., 2008) report a high level of satisfaction with BA. BA has shown promise for individuals coping with mental and physical health problems. BA has evidenced reductions in depressive symptoms in clients with cancer (Hopko, Armento, et al., 2011), HIV infection (Magidson et al., 2014), functional impairments (Wesson et al., 2014; Hellerstein et al., 2015), cognitive impairment (Snarski et al., 2011), and intellectual disabilities (Jahoda et al., 2015), as well as in clients who smoke (MacPherson et al., 2010). Additionally, BA holds promise as a depression-prevention tool, already having garnered some support to indicate prevention of depression in individuals with age-related macular degeneration (Rovner et al., 2014). BA also produces high treatment satisfaction in clients with cancer (Hopko, Armento, et al., 2011). As discussed in Dimidjian et al. (2011), BA has been researched across a wide array of depressed subpopulations, not limited to prototypical samples (i.e., White and affluent), who are diverse with regard to ethnicity, socioeconomic status, accessibility (e.g., rural vs. urban), problem profile (e.g., comorbid with psychological disorders or other health conditions), and geographical region. A substantial amount of research has been conducted on BA with lowincome Latinos, and results indicate significant changes in activation and avoidance (Collado et al., 2014), clinically meaningful depression symptom reduction (Collado et al., 2014, 2016; Kanter, Santiago-Rivera, et al., 2010; Kanter et al., 2015), and greater engagement and retention (Kanter et al., 2015). Research with Black samples has been supportive of BA’s ability to reduce depressive symptomatology (Jacob et al., 2013; MacPherson et al. 2010). BA techniques may be well suited for adaptation to address treatment disparities encountered by individuals with low mobility, geographic barriers, and other issues of access through alternative modes of delivery. BA has led to significant symptom improvement when delivered via telephone (Au et al., 2015; Gellis et al., 2014; Lyons et al., 2015), internet website (O’Mahen et al., 2014), videoconferencing (Acierno et al., 2016; Egede et al., 2015; Luxton et al., 2016), and mobile applications (Ly et al., 2014, 2015). Although some results suggest the slight benefit (i.e., reductions in depressive symptomatology) of in-person BATD (Luxton et al., 2016), other findings suggest that home-based and in-person activation treatments are comparable (Acierno et al., 2016; Egede et al., 2015). BA may be poised to address the burden of depression worldwide, both in regions with access to mental health care and regions with limited access and considerable need. Randomized and pilot trials of BA to reduce depression symptoms have been conducted in the United Kingdom (e.g., Jahoda et al.,

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2015), Sweden (e.g., Alfonsson et al., 2015; Folke et al., 2015), Japan (Takagaki et al., 2016), China (Au et al., 2015), India (Chowdhary et al., 2016), Iran (Moradveisi et al., 2013; Soleimani et al., 2015), and Iraq (Bolton et al., 2014). BA strategies led to lower depression-severity scores compared with a control after 2 months of treatment in India (Chowdhary et al., 2016); greater reductions in depression severity, particularly among the more severely depressed, compared with treatment as usual (TAU) in Iran (Moradveisi et al., 2013); and a significant effect on depression and dysfunction among survivors of systematic violence in Northern Iraq (Bolton et al., 2014). A current initiative by the APA is examining the existing research support for BA using recently recommended criteria, which consider quality of research methodologies, cost of interventions, and relevance for clinical practice (Tolin et al., 2015). We predict that BA will continue to be deemed to have strong research support, considering the accumulated empirical evidence on BA for depression and comorbid conditions when provided to diverse populations and in various clinical settings. Empirical Support for Individual BA Components Presenting the Treatment Rationale BA experts have suggested that the delivery of the treatment rationale is an indispensable initial treatment step and that a poor delivery of the treatment rationale may be a potential mechanism of BA treatment failure (Hopko, Magidson, & Lejuez, 2011). Thus, BA should be offered within a collaborative framework in which other treatment approaches are considered by the therapist and client if the client is minimally satisfied with, disagrees with, or is resistant to the rationale after presentation and discussion. In studies of CBT, acceptance of the treatment rationale (ATR) has generally been consistently linked to positive treatment outcomes. In a trial in which CBT was compared with TAU, a subset of CBT clients but not TAU clients showed a very rapid response to treatment. Rapid responders tended to more strongly endorse the treatment rationale than slow responders. Thus, ready acceptance of the treatment conceptualization appeared to be an important characteristic distinguishing rapid from slow responders (Fennell & Teasdale, 1987). In a component analysis of cognitive therapy for depression, a comparison of the BA and cognitive therapy components showed a different pattern of association between perceptions of the treatment (i.e., treatment helpfulness, measured after the session in which the treatment rationale was presented) and outcome (Addis & Jacobson, 1996). In BA, early reactions to the treatment were positively associated with outcome, whereas in cognitive therapy, the same trend was observed but did not reach significance. However, using the same data set, ATR was shown to predict change halfway through treatment and treatment outcome across treatment component conditions (Addis & Jacobson, 2000). That said, the current literature does not contain studies on the relation between ATR and outcomes for contemporary versions of BA. Kanter et al. (2015) speculated that strong agreement with the BA treatment rationale may have been an important



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mechanism for improved treatment engagement among Latinos in a community clinic setting. Given the research on presenting the rationale for treatment in CBT for depression and indications that client expectancies for improvement predict various treatment outcomes (e.g., Devilly & Borkovec, 2000), studies on the BA rationale-outcome association are needed. Assessment Techniques Traditionally, activity monitoring has been considered a necessary precursor to the achievement of behavior change, a factor that guides behavioral interventions (e.g., Kanter, Manos, et al., 2010). In fact, self-monitoring has been used as a control condition in various intervention studies, in which it has been found to be inferior to interventions that include more active components. However, there is evidence that activity monitoring alone produces increases in activity for individuals with depression (Snippe et al., 2016), and a mobile phone monitoring application was found to decrease depression in a sample of adolescents, leading the authors to recommend self-monitoring programs delivered via mobile phone as an ideal first-step intervention for adolescent depression (Kauer et al., 2012). Activity monitoring may also uniquely contribute to desirable outcomes for issues such as smoking (i.e., smoking cessation rates; McFall, 1970), binge eating (i.e., binge eating frequency; Latner & Wilson, 2002), and ruminative thinking (i.e., rumination episodes; Frederiksen, 1975), though data on whether tracking activity (e.g., physical activity) yields benefits above and beyond other interventions are mixed (e.g., McMurdo et al., 2010). Given the drawbacks of existing treatments for depression, such as poor medication adherence (Pampallona et al., 2002) and limited psychotherapy availability (Beck, 2005), researchers have been called to consider “out-of-the box” interventions for depression, such as monitoring of daily behaviors and emotional responses using momentary assessment methodologies, especially for individuals who are less likely to seek traditional care (Wichers et al., 2011). According to proponents, moment-to-moment activity monitoring may provide depressed individuals feedback through which they may gain insight into emotional and behavioral patterns that can inform concrete steps to change daily life patterns and facilitate recovery (Snippe et al., 2016; Wichers et al., 2011). Further evaluation of prospective activity monitoring via electronic technology is needed to determine whether it alone may positively impact outcomes. Activity Scheduling A meta-analysis of randomized studies of activity scheduling by Cuijpers et al. (2007) found clear-cut support for its efficacy without other BA techniques in treating depression at posttreatment, with gains maintained through follow-up periods, including comparability to a full package of CBT in a subset of 10 randomized studies. A review of more recent literature suggests the importance of diversifying activities scheduled and for emphasizing intentional and nonpassive social activity. Specifically, Riebe et al. (2012) found that older primary care individuals in successful depression care management engaged in a wide

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variety of activities, including deliberate social engagement in contrast to both passive social and solitary activities, resulting in positive scores on self-reported engagement and depression outcomes. One study has offered evidence challenging the clinically accepted practice in BA of scheduling activities according to level of difficulty (i.e., moving from the least to most difficult activity over time). Specifically, in a single-subject multiple baseline study, participants engaged in low-, moderate-, and high-difficulty activities at the start of and throughout treatment (Bailey & Arco, 2010). The authors found that participants were more likely to complete activities of moderate to high difficulty over low difficulty, suggesting the importance of scheduling activities of greater difficulty early in treatment and offering clients more therapist support for more difficult activities. Moreover, results from this study indicated that activity completion resulted in decreases in depression. Procedures Targeting Avoidance Although there is ample evidence that avoidance is positively associated with depression (e.g., Ottenbreit & Dobson, 2004; Wagener et al., 2016), including evidence that avoidance predicts future depression severity after controlling for baseline depression and activation (Shudo et al., 2017), there is no direct support for the use of techniques targeting avoidance as component interventions in BA (Kanter, Manos, et al., 2010). A primary question, for example, is whether the multifaceted and presumably more difficult-to-train version of BA by Martell et al. (2001, 2013), which targets avoidance substantially, will have a greater benefit than the simpler version of BATD by Lejuez and colleagues (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), which does not include direct techniques targeting avoidance. That said, avoidance likely is addressed in a functional way in Lejuez, Hopko, and Hopko (2001) even if no explicit techniques are discussed. BATD developers recognize that moving a client away from a lifestyle characterized by avoidance toward one characterized by an active way of life is essential for successful treatment (Hopko et al., 2003). It is unlikely that trials will be conducted to test these differences, as they would be expensive and possibly produce null results, which would be of little value to clinicians. Furthermore, we see no harm in having multiple versions of BA empirically supported and available. That said, it would be beneficial to clinicians for researchers to examine the most effective techniques for addressing and overcoming client avoidance during treatment, as it is clinically obvious that avoidance is a substantial obstacle to treatment progress and thus to improvement in the lives of clients.

MECHANISMS OF CHANGE DATA According to the theory underlying BA, depression is due to losses of, reductions in, and/or chronically low levels of positive reinforcement, which produce the behavioral and emotional changes that typify depression. In turn, BA



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techniques are designed to increase activation, which increases positive reinforcement and reverses the cycle of depression (Kanter, Manos, et al., 2010). In theory, the primary objective of BA is to increase contact with RCPR (Hopko et al., 2015), and in practice, BA is designed to increase contact with RCPR by increasing activation. Thus, RCPR and activation are two key treatment model processes theorized to account for changes in BA treatment. In contrast to research on BA’s efficacy and effectiveness, less work has been done to understand how BA works. We review empirical findings in support of these processes using recommended process measures (Mazzucchelli et al., 2016) developed over the last decade to improve on the limitations of prior measurement tools. These include the Environmental Reward Observation Scale (EROS; Armento & Hopko, 2007) and the Reward Probability Index (RPI; Carvalho et al., 2011). These measures assess environmental reward or, more specifically, the subjective experience of environmental reward and reward probability as a proxy for RCPR. Another conceptually rigorous measure is the Behavioral Activation for Depression Scale (BADS; Kanter et al., 2007), from which a short form with stronger psychometric properties has been developed (BADS-SF; Manos et al., 2011). Associations Between Purported Mechanisms and Depression Congruent with the BA model, associations between activation (measured with the BADS or BADS-SF) and environmental reward (measured with the EROS or RPI) have been observed in multiple studies (Armento & Hopko, 2007; Barraca & Pérez-Álvarez, 2010; Carvalho et al., 2011; Manos et al., 2011; Wagener & Blairy, 2015). The empirical relations between BA’s theorized mechanisms and depression have been demonstrated as well. Specifically, greater self-reported depression is associated with decreased activation (Barraca & Pérez-Álvarez, 2010; Manos et al., 2011; Petts et al., 2016; Wagener & Blairy, 2015) and increased avoidance (Petts et al., 2016). Shudo et al. (2017) demonstrated a predictive association between avoidance (but not activation) and depression severity scores 8 weeks later in the absence of intervention. Change in Mechanism Processes and Outcomes Over Time Changes in activation, environmental reward, and depression in patterns that are consistent with BA theory have been demonstrated in the context of BA treatment with diverse samples. For example, Petts et al. (2016) found that activation changes were significantly associated with depression change during an intervention phase but not during a baseline phase in a sample of adolescents treated with BA. Likewise, Gawrysiak et al. (2009) found that a BATD group showed greater increases in reinforcement and a significant reduction in depression in a randomized controlled trial comparing a single-session BATD protocol with a no-treatment control group for university students with moderate

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depression symptoms. Daughters et al. (2008) found that BATD, compared with TAU, produced greater improvements in perceived reward value of activities in a sample of illicit drug users. MacPherson et al. (2010) found that depressive symptoms reduced over time in a sample of low-income smokers with depression who received BATD; however, no treatment-linked changes in perceived reward from daily activities were observed. The same research team similarly documented that a BATD treatment targeting smoking and depression in youth produced decreases in depression and increases in activation, but no consistent changes in perceived reward value of activities were observed (MacPherson et al., 2017). Although these studies used the EROS to measure environmental reward, lack of support for environmental reward as a mediator of BA treatment has been observed with the RPI as well (e.g., Read et al., 2016). Analyses have been conducted to determine whether purported mechanisms mediate the relations between treatment and outcome. Nasrin et al. (2017) randomized depressed clients to a brief BATD intervention or control condition. BATD clients experienced significant reductions in depression and increases in activation compared with controls, and activation changes mediated the relations between treatment and symptom reduction. Dimidjian et al. (2017) evaluated the effectiveness of BA for depression in pregnant women relative to TAU. Compared with TAU clients, BA clients evidenced significantly higher levels of activation and environmental reward, and early change in these variables mediated subsequent depression change. For a sample of depressed cancer clients treated with BATD, Ryba et al. (2014) found that participant compliance with assigned activities (but not the total number of activities completed) was causally related to depression change, and the best outcome was achieved by clients who completed all assigned activities. However, perceived reward did not mediate this association between activation and depression change. Temporal Association Between Processes and Outcomes To demonstrate a treatment mechanism, the temporal sequence of change must be established, such that there is evidence that change in the mechanism variable (e.g., activation, positive reinforcement) temporally precedes change in the outcome variable, such as depression (e.g., Borckardt et al., 2008; Gaynor & Harris, 2008; Kazdin, 2007). Therefore, support of a robust nature for BA’s mechanisms would be provided by studies showing that when clients make less contact with positive reinforcement or are less active, they subsequently are more depressed, and when clients contact more positive reinforcement or are more active, they subsequently are less depressed. Gaynor and Harris (2008) conducted an early evaluation of this more rigorous mechanism hypothesis with a small, within-subject sample. They concluded that for two of four BA clients, temporal precedence was established, such that increased activation could plausibly explain improvements in depression. Similarly, in an analysis of two BA clients, Manos et al. (2011) showed



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that change in activation preceded change in depression for one client, but change in activation and depression co-occurred within the same time window for another client. Folke et al. (2015) investigated BA’s mechanisms with six individuals in inpatient psychiatry using a multiple-baseline design. Once the BA treatment phase was initiated, activation behaviors gradually increased in five of six inpatients and avoidance decreased in four of six inpatients. However, although changes in activation and avoidance preceded or occurred concurrently with changes in depression symptoms, results of hourly diary ratings showed that changes in mood preceded changes in activation in several instances. Folke et al. suggested that the BA model allows for such variability in the timing of changes between activation, avoidance, and mood. For example, although the effect of activation on mood may be instant given immediate contact with positive reinforcement, the effect on mood also may be delayed. A person may need to engage in an activation behavior (e.g., studying) multiple times before contacting natural reinforcement and improving mood (e.g., getting desired score on a test at end of term). In a pilot trial of BATD for Latinos with limited English proficiency with no control condition, Collado et al. (2014) observed significant decreases in depression symptoms and increases in activation and environmental reward over the course of treatment, and they found that changes in activation occurred concurrently with changes in depression whereas changes in perceived reward preceded changes in depression. Collado et al. (2016) replicated their findings that activation and environmental reward increased over the course of treatment in a larger study of BATD for Spanish-speaking Latinos compared with supportive counseling. However, findings on whether changes in BA mechanisms temporarily preceded change in depression were not reported. Santos et al. (2017) used cross-lagged correlations to test whether change in behavioral activation predicted, co-occurred with, or was predicted by depression scores in a study of BA for Latinos with depression (BAL) compared with TAU. Forty-three percent of BAL clients, but no TAU clients, demonstrated cross-lagged correlations that were supportive of BA theory. Specifically, these clients reported increases in activation that temporally preceded decreases in depression. Further, 71% of BAL clients, but no TAU clients, showed significant concurrent correlations that were consistent with BA theory. Specifically, these participants reported increases in activation that corresponded with decreases in depressive symptomatology during the same window of time. Moreover, only 21% of BAL clients evidenced correlations that did not support BA theory. Overall, the results suggested that activation was a plausible mechanism of change for 79% of BAL clients and no TAU clients. The evidence base for BA’s treatment model is growing. The extant literature lends empirical support for activation as a mechanism of change in BA treatment for many but not all successful BA clients, as data consistently suggest that changes in activation appear to temporally precede changes in depression for many but not all BA clients. This literature base, although nascent, is

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strengthened by its inclusion of diverse samples and methodologies. Research that examines whether environmental reward drives change in BA treatment is less convincing and generally not supportive of it as mechanism of change for most clients.

DISSEMINATION AND IMPLEMENTATION According to traditional translational science models in health (Sussman et al., 2006), most BA research is considered Type 1 (i.e., translational research that uses discoveries generated through controlled laboratory research or efficacy trials) and Type 2 (i.e., translational research that focuses on the enhancing use of efficacious interventions by the target group). However, whereas Type  2 research includes effectiveness, diffusion, and dissemination studies, most existing BA trials only examine effectiveness. Considering the limited amount of dissemination and implementation research on BA, there is still much to learn about how to best scale up BA in “real-world” clinical practice. To facilitate discussion of current efforts to disseminate and implement BA in clinical practice, it is important to define several key terms. Dissemination is defined as the targeted distribution of information and intervention materials to a specific public health or clinical practice group, and dissemination research is the systematic study of processes and factors that lead to widespread use of an evidence-based intervention by the target group (Johnson et al., 1996). Implementation, in turn, is the use of strategies to adopt and integrate evidencebased health interventions and change practice patterns within specific settings (National Institutes of Health, 2009). Clinical guidelines have been published in the United States and internationally that list BA as one of the recommended treatments for major depression. For example, the U.S. Department of Veterans Affairs recommends BA as one of the first-line treatments for uncomplicated mild-to-moderate depression and combining pharmacotherapy and BA for severe, chronic, or recurrent depression (Management of MDD Working Group, 2016). Similarly, the U.K. National Institute for Health and Care Excellence (NICE) identified BA as one of the recommended psychotherapies for mild-to-moderate depression (National Collaborating Centre for Mental Health, 2010). The World Health Organization (WHO) has recommended BA as one of the psychotherapies for mild-to-moderate depression for people who live in both high- and low-resource settings (WHO, 2016). However, these guidelines do not prescribe methods for disseminating BA to target groups or ensure effective implementation. The most commonly used BA dissemination efforts are the publication of scientific journal articles and treatment manuals based on efficacy and effectiveness trials (e.g., Kanter et al., 2009; Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011; Martell et al., 2013; McCauley, Schloredt et al., 2016). These literatures mainly target mental health providers and academic faculty who provide psychotherapy and research



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training. Although some resources are available for free, practicing mental health providers mostly need to have subscriptions to academic journal publications or independently purchase the published treatment manuals. Thus, cost might be a significant barrier for providers to learn specific BA techniques to implement with their clients. Another BA dissemination effort targets the consumers or psychotherapy clients directly. For instance, a self-help book was published to help clients with depression practice BA skills in conjunction with psychotherapy (Addis & Martell, 2004). With the advancement of technology, several new mobile phone applications for BA have been developed and are available to the public. For example, the U.S. Department of Veterans Affairs (2016) developed Mood Coach, which is intended for service members and veterans to learn and practice BA. Another self-help phone application that is currently under study in a clinical trial is Moodivate (Behavioral Activation Tech, 2016b), which is intended for individuals who have been experiencing some depressive symptoms but are not yet interested in enrolling in individual therapy. Along these lines, a clinical support phone application, called Behavioral Apptivation, has been developed to support successful BA treatment (Behavioral Activation Tech, 2016a). This phone application allows clients to record their moods and activities, which can be immediately accessed by their providers. Efforts to translate BA from research into clinical practice are encouraging initial steps. Yet most of these efforts have not been studied empirically, so their effectiveness is unknown. Furthermore, they rely heavily on passive dissemination strategies (e.g., publication of scientific articles and treatment manuals and clinical guidelines; Rabin et al., 2006), which assume that mental health organizations and providers will actively seek the most recent evidence on BA (or other evidence-based practices [EBPs]), purchase the published treatment manuals, and learn and implement BA techniques independently. However, numerous EBP implementation barriers exist. Some commonly reported barriers include lack of financial and human resources to support successful EBP implementation, limited training that could be costly, negative attitudes toward new EBPs, and organizational climates and cultures that are not fully conducive to implementation of new EBPs. In fact, research has shown that scaling up new evidence-based interventions requires a more active and systematic approach to facilitate adoption, implementation, and sustainment of these interventions in clinical practice. It could take up to 17 years to translate 14% of health care research and innovations to benefit patient care, especially without additional support and effective strategies to implement interventions successfully (Balas & Boren, 2000). Whereas there are several emerging BA dissemination strategies, there are few implementation strategies documented in the BA literature. Continuing education (CE) training is the most commonly used strategy to support BA implementation in clinical practice. In the context of effectiveness trials, Ekers et al. (2013) found that health care providers with no previous psychotherapy experience could be trained in BA with CE-style training, yielding comparable

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outcomes to providers who were more experienced in providing psychotherapy. A large randomized controlled, noninferiority trial was recently conducted in the United Kingdom and concluded that BA can be delivered by less experienced mental health providers who have undergone less intensive and costly training, and they still produced the same results compared with CBT (Richards et al., 2016). Puspitasari et al. (2013) examined trainer-led BA training strategies that can be effectively delivered online to increase access for providers in diverse geographical locations. Guided by learning principles, this BA training protocol included active learning strategies (e.g., modeling, practicing, and feedback) and focused primarily on building providers’ skills for delivering BA in clinical practice. When compared with a self-paced BA online training, mental health providers who received the trainer-led BA online training showed greater increases in BA skills at posttraining and 6-week follow-up (Puspitasari et al., 2017), suggesting the potential effectiveness of this training as an evidencebased implementation strategy for BA. However, further research is needed to examine whether receiving BA training is adequate to support successful adoption, implementation, and sustainment of BA in diverse clinical settings.

CONCLUSION AND FUTURE DIRECTIONS In summary, we propose that BA is a promising treatment for depression, suitable for large-scale implementation. Effectiveness trials point out several features of BA that might increase feasibility and appropriateness of BA when delivered to diverse populations and in various settings. First, BA effectiveness remains when delivered to clients with comorbid depression and other psychological (Acierno et al., 2016; Papa et al., 2013) and medical conditions (Alfonsson et al., 2015; Hopko, Armento, et al., 2011; Lyons et al., 2015; Magidson et al., 2014). Second, BA has been tested across developmental ages and shown to be effective for adolescents (McCauley, Gudmundsen, et al., 2016; Ritschel et al., 2011), adults (Dimidjian et al., 2006), and older adults (Katon et al., 2006). Third, BA protocols have been adapted culturally and shown to be effective when delivered to clients with diverse cultural backgrounds, from both developed and developing countries (Bolton et al., 2014; Chowdhary et al., 2016; Collado et al., 2016; Kanter, Santiago-Rivera, et al., 2010; Kanter et al., 2015; Moradveisi et al., 2013). Fourth, BA can be flexibly delivered in either individual or group settings (Chu et al., 2016), as a guided self-help treatment (Soucy Chartier & Provencher, 2013), and remotely using online or phone technology (Carlbring et al., 2013; Eisma et al., 2015; Huguet et al., 2016). Fifth, BA has also been shown to be compatible with other evidence-based strategies and treatments such as mindfulness (McIndoo et al., 2016), motivational interviewing (Balán et al., 2016), exposure (Eisma et al., 2015), and acceptance and commitment therapy (Carlbring et al., 2013). Lastly, evidence highlights the ease of BA training whereby paraprofessionals or those with less experience in



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mental health and psychotherapy can be trained in BA and produce desirable clinical outcomes. Future research should examine various implementation strategies that might facilitate the translation of BA from research to practice, including creating learning collaboratives, building implementation teams within a clinical setting, providing incentives, and identifying and preparing local champions (Powell et al., 2015). Research should also be guided by existing implementation science theoretical frameworks and models (e.g., Aarons et al., 2012; Damschroder et al., 2009). Existing BA efficacy and effectiveness trials have focused primarily on client-level outcomes. When the goal is to scale up and implement BA in clinical practice, other integral outcomes should be measured, such as acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability (Proctor et al., 2011). We know little about how to scale up BA in clinical practice. Increasing access to evidence-based treatments for depression, such as BA, is crucial given that the majority of individuals with depression do not receive adequate treatment for depression (Olfson et al., 2002). Current dissemination and implementation efforts are still limited in numbers, mostly rely on passive dissemination strategies, and have not been empirically studied. Future studies should examine strategies to successfully implement BA in clinical settings, and current knowledge from implementation science may be used to guide the development of BA implementation research and practice.

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Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B., & Munizza, C. (2002). Patient adherence in the treatment of depression. British Journal of Psychiatry, 180(2), 104– 109. https://doi.org/10.1192/bjp.180.2.104 Papa, A., Sewell, M. T., Garrison-Diehn, C., & Rummel, C. (2013). A randomized open trial assessing the feasibility of behavioral activation for pathological grief responding. Behavior Therapy, 44(4), 639–650. https://doi.org/10.1016/j.beth.2013.04.009 Petts, R. A., Foster, C. S., Douleh, T. N., & Gaynor, S. T. (2016). Measuring activation in adolescent depression: Preliminary psychometric data on the Behavioral Activation for Depression Scale–Short Form. Behavior Analysis: Research and Practice, 16(2), 65– 80. https://doi.org/10.1037/bar0000036 Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21. https://doi.org/10.1186/ s13012-015-0209-1 Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 38(2), 65–76. https://doi.org/10.1007/s10488-010-0319-7 Puspitasari, A., Kanter, J. W., Murphy, J., Crowe, A., & Koerner, K. (2013). Developing an online, modular, active learning training program for behavioral activation. Psychotherapy, 50(2), 256–265. https://doi.org/10.1037/a0030058 Puspitasari, A. J., Kanter, J. W., Busch, A. M., Leonard, R., Dunsiger, S., Cahill, S., Martell, C., & Koerner, K. (2017). A randomized controlled trial of an online, modular, active learning training program for behavioral activation for depression. Journal of Consulting and Clinical Psychology, 85(8), 814–825. https://doi.org/10.1037/ ccp0000223 Rabin, B. A., Brownson, R. C., Kerner, J. F., & Glasgow, R. E. (2006). Methodologic challenges in disseminating evidence-based interventions to promote physical activity. American Journal of Preventive Medicine, 31(4 Suppl.), S24–S34. https://doi. org/10.1016/j.amepre.2006.06.009 Read, A., Mazzucchelli, T. G., & Kane, R. T. (2016). A preliminary evaluation of a single session behavioural activation intervention to improve well-being and prevent depression in carers. Clinical Psychologist, 20(1), 36–45. https://doi.org/10.1111/cp. 12084 Rehm, L. P. (1977). A self-control model of depression. Behavior Therapy, 8(5), 787–804. https://doi.org/10.1016/S0005-7894(77)80150-0 Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., O’Mahen, H., Watkins, E. R., Wright, K. A., Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K. (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): A randomised, controlled, non-inferiority trial. Lancet, 388(10047), 871–880. https://doi.org/10.1016/S0140-6736(16)31140-0 Riebe, G., Fan, M. Y., Unützer, J., & Vannoy, S. (2012). Activity scheduling as a core component of effective care management for late-life depression. International Journal of Geriatric Psychiatry, 27(12), 1298–1304. https://doi.org/10.1002/gps.3784 Ritschel, L. A., Ramirez, C. L., Jones, M., & Craighead, W. E. (2011). Behavioral activation for depressed teens: A pilot study. Cognitive and Behavioral Practice, 18(2), 281–299. https://doi.org/10.1016/j.cbpra.2010.07.002 Rovner, B. W., Casten, R. J., Hegel, M. T., Massof, R. W., Leiby, B. E., Ho, A. C., & Tasman, W. S. (2014). Low vision depression prevention trial in age-related macular degeneration: A randomized clinical trial. Ophthalmology, 121(11), 2204–2211. https://doi.org/10.1016/j.ophtha.2014.05.002

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Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal of Consulting and Clinical Psychology, 82(2), 325–335. https://doi.org/10.1037/a0035363 Santos, M. M., Rae, J. R., Nagy, G. A., Manbeck, K. E., Hurtado, G. D., West, P., Santiago-Rivera, A., & Kanter, J. W. (2017). A client-level session-by-session evaluation of behavioral activation’s mechanism of action. Journal of Behavior Therapy and Experimental Psychiatry, 54, 93–100. https://doi.org/10.1016/j.jbtep. 2016.07.003 Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 45(4), 543–551. https://doi.org/10.1037/0022-006X.45.4.543 Shudo, Y., Yamamoto, T., & Sakai, M. (2017). Longitudinal predictions of depression symptoms using the activation and avoidance subscales of the Japanese Behavioral Activation for Depression Scale–Short Form. Psychological Reports, 120(1), 130–140. https://doi.org/10.1177/0033294116680794 Snarski, M., Scogin, F., DiNapoli, E., Presnell, A., McAlpine, J., & Marcinak, J. (2011). The effects of behavioral activation therapy with inpatient geriatric psychiatry patients. Behavior Therapy, 42(1), 100–108. https://doi.org/10.1016/j.beth.2010.05.001 Snippe, E., Simons, C. J. P., Hartmann, J. A., Menne-Lothmann, C., Kramer, I., Booij, S. H., Viechtbauer, W., Delespaul, P., Myin-Germeys, I., & Wichers, M. (2016). Change in daily life behaviors and depression: Within-person and between-person associations. Health Psychology, 35(5), 433–441. https://doi.org/10.1037/hea0000312 Soleimani, M., Mohammadkhani, P., Dolatshahi, B., Alizadeh, H., Overmann, K. A., & Coolidge, F. L. (2015). A comparative study of group behavioral activation and cognitive therapy in reducing subsyndromal anxiety and depressive symptoms. Iranian Journal of Psychiatry, 10(2), 71–78. Soucy Chartier, I., & Provencher, M. D. (2013). Behavioural activation for depression: Efficacy, effectiveness and dissemination. Journal of Affective Disorders, 145(3), 292– 299. https://doi.org/10.1016/j.jad.2012.07.023 Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C. W., & Acierno, R. (2012). An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: Preliminary findings. Behavior Therapy, 43(3), 560–569. https://doi.org/10.1016/j.beth.2011.03.003 Sussman, S., Valente, T. W., Rohrbach, L. A., Skara, S., & Pentz, M. A. (2006). Translation in the health professions: Converting science into action. Evaluation & the Health Professions, 29(1), 7–32. https://doi.org/10.1177/0163278705284441 Takagaki, K., Okamoto, Y., Jinnin, R., Mori, A., Nishiyama, Y., Yamamura, T., Yokoyama, S., Shiota, S., Okamoto, Y., Miyake, Y., Ogata, A., Kunisato, Y., Shimoda, H., Kawakami, N., Furukawa, T. A., & Yamawaki, S. (2016). Behavioral activation for late adolescents with subthreshold depression: A randomized controlled trial. European Child & Adolescent Psychiatry, 25(11), 1171–1182. https://doi.org/10.1007/ s00787-016-0842-5 Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122 Wagener, A., Baeyens, C., & Blairy, S. (2016). Depressive symptomatology and the influence of the behavioral avoidance and activation: A gender-specific investigation. Journal of Affective Disorders, 193, 123–129. https://doi.org/10.1016/j.jad.2015. 12.040 Wagener, A., & Blairy, S. (2015). Validation and psychometric properties of the French versions of the Environmental Reward Observation Scale and of the Reward Probability Index. Psychologica Belgica, 55(2), 71–86. https://doi.org/10.5334/pb.bg



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Wesson, M., Whybrow, D., Gould, M., & Greenberg, N. (2014). An initial evaluation of the clinical and fitness for work outcomes of a military group behavioural activation programme. Behavioural and Cognitive Psychotherapy, 42(2), 243–247. https://doi.org/ 10.1017/S135246581300043X Wichers, M., Simons, C. J. P., Kramer, I. M. A., Hartmann, J. A., Lothmann, C., MyinGermeys, I., van Bemmel, A. L., Peeters, F., Delespaul, P., & van Os, J. (2011). Momentary assessment technology as a tool to help patients with depression help themselves. Acta Psychiatrica Scandinavica, 124(4), 262–272. https://doi.org/10.1111/ j.1600-0447.2011.01749.x World Health Organization. (2016). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (Version 2.0). http://www.who.int /mental_health/mhgap/mhGAP_intervention_guide_02/en/ Zeiss, A. M., Lewinsohn, P. M., & Muñoz, R. F. (1979). Nonspecific improvement effects in depression using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of Consulting and Clinical Psychology, 47(3), 427–439. https://doi.org/10.1037/0022-006X.47.3.427

10 Exposure Therapy Lauryn E. Garner, Emily J. Steinberg, and Dean McKay

E

xposure therapy has been demonstrated as a highly efficacious intervention, used primarily in the treatment of anxiety and obsessive-compulsive disorders (McKay, 2016) and posttraumatic stress disorder (PTSD; Courtois et al., 2017). Its application has been evaluated as a stand-alone intervention and as a component of a broader program of cognitive behavioral therapy (CBT). This chapter has the following aims: first, to briefly review the history and underlying theory of exposure therapy; second, to provide a description of the primary procedures in exposure; third, to summarize the outcome data associated with the approach and highlight the mechanisms of change; and finally, to cover the application of exposure to diverse populations.1 The chapter concludes with future directions in the applications of exposure therapy.

HISTORY Exposure as a method for reducing anxiety is predicted from the original experimental work of Pavlov (summarized in Pavlov, 1927). Specifically, with repeated presentation of a conditioned stimulus in the absence of the unconditioned stimulus, the conditioned response should weaken and ultimately result in habituation. Application of this procedure implies, however, that the individual will experience an adverse emotional state en route to experiencing relief. Accordingly, proper application requires gradual presentation of portions Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-010 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  275 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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of the stimulus, referred to as the stimulus complex (discussed later in the Underlying Theory section). The earliest documented use of exposure as a therapeutic method comes from Jones (1924) in the treatment of fear of small animals in a 2-year-old boy. In this case illustration, Jones carefully detailed the process of gradually presenting small furry animals to the child and, under different conditions, successfully eliminating his fear. The gradual approach adopted closely resembles that employed in exposure therapy, as will be shown in this chapter. Jones’s intent was to illustrate that principles of behaviorism could be demonstrated through the elimination of problem behavior, which stood in contrast to the conditioned fear experiment by Watson and Rayner (1920). Extensive experimental work was conducted to demonstrate the efficacy of exposure for treating specific phobias. After years of laboratory research detailing the applicability of exposure in alleviating fear in analogue and client samples, Krasner (1971) described exposure therapy as a component of desensitization. However, desensitization was associated with a procedure that paired deep muscle relaxation with the aversive stimuli as a means to reduce the fear in a process of competition between incompatible responses (Wolpe, 1958). Specifically, in systematic desensitization (also referred to as reciprocal inhibition), the client is first taught cued deep muscle relaxation. This entails practicing muscle relaxation procedures, whereby the relaxation is associated with specific words like “relax.” The intention is that the client may produce the relaxation response independently through this learning experience. Once this is mastered, the clinician then develops a hierarchy of feared stimuli and situations (hierarchies are discussed later in this chapter). Through imagery, the client is asked to visualize the feared stimuli, based on the hierarchy, and, when anxiety is experienced, they are then instructed to engage in muscle relaxation. In this way, the desensitization process is hypothesized to counter the anxiety experience through an incompatible response (relaxation). Since the time systematic desensitization was developed, it has been found that exposure, without relaxation, is more efficient in reducing anxiety and maintaining change (Marks, 1987). Relaxation training remains a part of comprehensive treatment protocols for anxiety disorders, but systematic desensitization would not generally be recommended as a primary treatment modality. Concurrent with the developing laboratory models of fear reduction through exposure, treatment research began on what was otherwise an intractable problem, namely obsessive-compulsive disorder (OCD). Meyer (1966) first reported on a case series of individuals with OCD treated with exposure with response prevention (ERP). ERP consists of exposure to the specific feared stimuli that serve as the impetus for compulsive behaviors; continued exposure through the prevention of compulsive responses, therefore, was shown to reduce symptoms. Shortly following this case series, controlled experimental research began in earnest to examine the applicability of ERP to different symptom presentations of OCD, such as checking or washing (i.e., Rachman et al., 1973).



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Recognizing the role of exposure in anxiety reduction, practitioners extended the intervention to alleviate the fear reactions in trauma survivors. The earliest case description by Keane and Kaloupek (1982) was the treatment of a 36-yearold Vietnam veteran, conducted over a 3-week period of inpatient hospitalization, with 19 total sessions where exposure focused on memories of combat trauma. Since that time, extensive research has accumulated to support the application of exposure for PTSD, and exposure is one of the recommended interventions in the American Psychological Association’s practice guidelines for trauma (Courtois et al., 2017).

UNDERLYING THEORY The theory underlying the effectiveness of exposure treatments has changed over the years. The early model emphasized presentation of the conditioned stimuli (CS) in the absence of the unconditioned stimulus (US) in order to achieve extinction (the cessation of the CS eliciting the conditioned response [CR]). This was the guiding principle in early tests in phobic individuals (e.g., Gelder et al., 1967) and was based on the original conceptualization of the extinction process from Pavlov. This early conceptualization was predicated on how any CS can be extinguished without regard for the specific psychopathology related to anxiety. However, anxiety theorists had asserted that the emotional state, when at pathological levels, was a result of a reinforcement process that strengthened avoidance (i.e., Mowrer, 1960). Further, the original model anticipated spontaneous recovery of CS activation of CR, often occurring following a long rest period between exposure sessions (discussed in Domjan, 2018). In order to explain the efficacy of exposure for anxiety and describe the underlying mechanisms of the procedure, Foa and Kozak (1986) highlighted how to maximize successful fear reduction. Specifically, they suggested that avoidance resulting from anxiety management leads to memories of fear and its management. In order to effectively disrupt this process, exposure must be of sufficient intensity to engage the fear structure but not so great that new emotional learning is formed. This model of fear reduction was the first to articulate a way in which exposure could be harmful if conducted improperly (i.e., too quickly or with too high an intensity). This model is explicitly oriented to the neuroscience underlying anxiety, where the focus is on specific brain structures and their role in classical conditioning of fear, and has been supported extensively in laboratory and clinical research (see Dębiec & LeDoux, 2009). This model set the stage for recommended parameters for the conduct of exposure, such as session duration. Because engagement of the fear structure is essential and the elicitation of fear must be of sufficient intensity to promote change, one would need to ensure the therapy session is long enough that extinction occurs during the session. Otherwise, given the propensity to avoidance

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that is associated with anxiety, session termination before anxiety alleviation would lead to avoidance of therapy itself. More recently, it has been observed that provocation of fear during exposure is not a necessary condition for anxiety reduction. This perspective is articulated in the inhibitory learning model (Abramowitz, 2013; Craske et al., 2014), in which the aim of exposure therapy is to disconfirm the feared outcomes articulated by anxious individuals. This means that under this perspective, there is an implicit recognition of cognitive processes, namely prediction of outcomes following exposure to the CS. This builds on basic experimental research that had previously been underappreciated by clinicians but nevertheless was foundational in basic learning theory (Rescorla, 1987, 1988). Specifically, laboratory research suggests that CSes permit for predictions of what will follow, and without prior experience, the predictions of outcomes are crystallized. With repeated presentation of the CS, these predictions weaken, assuming the feared outcome fails to materialize. Interestingly, the concept of exposure being effective in the absence of fear elicitation was demonstrated experimentally by Foa and her colleagues long before the Foa and Kozak (1986) model was articulated (Foa et al., 1977). In some ways, the practice of exposure from the inhibitory learning perspective is in line with how most successful clinicians likely operated already. In-session elicitation of fear is challenging, and doing so repeatedly can make for substantial reluctance to engage in treatment. Indeed, the reputation of exposure therapy as intense and scary has created barriers to clients arriving at the clinicians’ offices and has led some to remark that there is a public relations problem for the approach (Richard & Gloster, 2006). Figure 10.1 lays out a basic schematic depicting each of the theoretical models described above.

DESCRIPTION OF MAIN PROCEDURES Although seemingly straightforward and deceptively simple in its basis, exposure therapy is a highly complex treatment procedure. In order to carry it out properly, the clinician must carefully assess the nature of the fear, develop a hierarchy of fears, and consider different avenues for best presenting the feared stimuli as well as the setting for conducting the treatment. Hierarchy Development Before initiating exposure therapy, a fear hierarchy must be constructed. While most anxiety sufferers will report fears in broad terms (e.g., spiders, contaminated places/situations, social encounters), these fears can be broken into smaller components. Thus, most fears are described in terms of components of the stimulus complex. To make this explicit, consider the case of spider fear. The most obvious and intensely anxiety-evoking stimulus would be a live spider. However, it is likely that a spider-fearful individual would find a photo of a



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FIGURE 10.1. Theoretical Bases of Exposure: Three Perspectives

spider less anxiety producing than a live one that is physically present. Likewise, seeing a spider 10 feet away would be less anxiety provoking than one that is 6 inches away. Using the concept of a stimulus complex, a hierarchy can be constructed that depicts components of the feared stimuli from least to most anxiety provoking. A detailed discussion of hierarchies in the context of OCD for children is available in McKay (2018). This exercise requires recognition that a CS is really composed of a multitude of components that collectively refer to the stimulus complex. In order to begin developing a fear hierarchy with a client, it is essential to establish the anchor points for a rating scale that will be used by the client in estimating the fear that would be experienced for each component of the stimulus complex. This scale is known as the Subjective Units of Distress Scale (SUDS; see Wolpe, 1958, 1990). The range for this scale is typically either 0–10 or 0–100. Establishing the anchor for the lowest point might include asking the client to imagine the feeling of greatest comfort they can picture, such as when imminently going to sleep, and then setting that as 0. Next, the clinician may ask the client to picture the time when they felt the highest level of fear in their life and set this at 100 (or 10 if that is the clinician’s preference; for the purposes of this chapter we will retain a 0–100 scale). Once this is established, the clinician identifies aspects of the stimulus complex that elicit different levels of fear as rated by the client under hypothetical exposure. That is, during the construction of the hierarchy, no exposure occurs, only the presentation of the idea of different components of the stimulus complex. This places a responsibility on the clinician to identify components of the stimulus complex that might be anticipated to produce anxiety that the client

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might not notice. Construction of the hierarchy is a phenomenological process, the clinician visualizing situations and objects that might elicit anxiety based on the primary presenting fear (see McKay, 2018, for a discussion of this process in relation to childhood OCD). Developing the hierarchy can be challenging, therefore, if there is insufficient awareness of the client’s environment, insufficient experience with aspects of the stimulus complex, or a limited familiarity with the objects and situations associated with the feared stimuli. To illustrate the variety of stimuli that may be associated with even basic phobic objects, Figure 10.2 shows components of the stimulus complex for spider phobia. To help the reader appreciate further the extent to which one might delve into the stimulus complex even for putatively straightforward feared stimuli and experiences, Figure 10.3 shows a range of items that might appear on a hierarchy for contamination fear associated with OCD. Using the items from Figure 10.3, a hypothetical fear hierarchy is displayed in Table 10.1. Initiating Exposure Once the hierarchy is established, it is advisable to start exposure gradually in order to guarantee that the client will be successful in completing the exercise. It is often useful to inform clients that the anticipated anxiety (as predicted for construction of the fear hierarchy) is typically greater than the actual experience of anxiety when faced with individual stimuli. This phenomenon has been demonstrated in two experiments (Arntz et al., 1994). In the first experiment, over FIGURE 10.2. Basic Stimulus Complex



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FIGURE 10.3. Detailed Stimulus Complex

TABLE 10.1. Illustrative Fear Hierarchy for Contamination Fear Situation/object

Anticipated SUDS (0–100)

Dirty undergarments

10

Washing machine

10

Bathroom odor

15

Bathroom soap dispenser

20

Bathroom door handle

25

Observed fecal consistency, firm

30

Hospital/medical patient waiting areas

40

Child with sticky food on fingers

50

Child with dirt on shirt

50

Child with runny nose

60

Customers appearing sick in drug store

65

Pharmacy counter

70

Toilet seat

75

Fecal consistency, loose

80

Door handle, drug store

85

Door handle, hospital

90

Note. SUDS = subjective units of distress.

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10 exposure sessions, 37 individuals with a range of primary anxiety disorders (i.e., panic disorder, social anxiety, OCD, specific phobia) consistently rated their anticipated anxiety higher than the experienced anxiety, with anticipatory anxiety mean range of 43.2–57.9 versus experienced anxiety mean range of 37.5– 51.5 (with SUDS scale maximum of 100). This finding was replicated in a second experiment with 11 anxiety-disorder patients (i.e., panic disorder, generalized anxiety disorder [GAD], social anxiety), with mean predicted anxiety of 69.1 and mean experienced anxiety of 47.3 (again with SUDS maximum of 100). As noted previously, each session should end with the client experiencing less anxiety than when the session began in order to prevent treatment dropout. In Vivo Exposure In vivo exposure occurs when the stimuli are presented directly to the client. To illustrate, in the case of a client with contamination fear associated with OCD, direct contact with stimuli such as those listed in Table 10.1, beginning with lower items on the hierarchy (e.g., washing machines, bathroom soap dispensers), should occur. This is the most common means of presenting stimuli in experimental evaluations of exposure given that the stimuli can be operationalized and effectively described. It also forms the basis for behavioral avoidance tests (BATs), whereby the client comes closer and closer to the feared stimuli and improvement can be quantified. In Imagery (Plus Implosion) Early proponents of exposure conducted the procedure by creating imagery of situations where the feared stimuli were present, relying on the hierarchy to develop scenes to move to more intense situations. This was in line with the approach developed by Wolpe (1958), such that the feared stimuli was presented in imagery but paired with muscle relaxation. Implosion entails incorporating additional aspects of the feared situation that are inferred to contribute to the persistence of anxiety. For example, socially anxious clients might report that they are most concerned with embarrassment, but the therapist may also infer that the fear is a result of rejection by potential romantic partners. Accordingly, the implosive scene might incorporate additional feared components. Therapists should use implosion with great caution given problems in memory formation during intense emotional arousal (discussed in McNally, 2003)2 and instead adhere more closely to manifest content when conducting exposure exercises with imagery. The use of imagery also allowed clinicians to develop scenes that were not physically possible to experience in vivo. For example, the clinician may take Excitement around the potential of procedures like implosion to “unlock” repressed memories reached a peak in the late 1990s, when clinicians would employ the procedure to attempt to resolve traumatic events for clients. However, research accumulated showing that, when under intense emotional duress, individuals may be more susceptible to developing recall for events that did not likely occur (Kaplan et al., 2016). As a result, unless approached with care, implosion and associated exposure methods where clinicians might engage in a type of “pattern completion” approach with clients can lead to “false memory syndrome” (reviewed in McNally, 2003).

2



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liberties in the imagery to develop scenes associated with assumed functional relations between the feared stimuli and outcomes, such as fears of death, illness, or other outcomes. This was first articulated as an intervention that permitted behavior therapists to address underlying concerns that clients might not be capable of articulating, such as in unconscious processes (Stampfl & Levis, 1967). Modern applications of imagery procedures often take the form of therapeutic recordings that clients develop with the therapist and then listen to between sessions. These typically involve images with items on the hierarchy that are carried to some extreme that might not be possible in vivo. In Vivo and in Imagery When conducting exposure in vivo, it is sometimes unclear what role the clinician plays while the client is processing the situation. However, it is entirely possible that the client is engaged in a cognitive process of avoidance. Foa and Kozak (1986) illustrated this process well when they described a contaminationfearful client who engaged in “freezing” during exposure where the contaminant was cognitively isolated to minimize the experience of anxiety. In order to circumvent this process, the clinician may provide additional imagery during the in vivo exposure and thereby enhance the outcome of treatment. In the aforementioned example from Foa and Kozak (1986), the client had a contaminant on his forearm. If imagery were included, the clinician might have stated how the contaminant was penetrating the skin as through a semipermeable membrane, entering the bloodstream and contaminating the entire soma. Exposure With Response Prevention (In Vivo, in Imagery, Combined) Individuals with OCD engage in compulsions as a means of avoiding the feared stimulus after they experience it in the environment. For example, in contamination fear, exposure to a contaminant leads to excessive handwashing in order to prevent experiencing anticipated feared consequences. Therefore, the response-prevention portion of ERP is a continuation of exposure. Although ERP is most frequently associated with treatment for OCD, it is generally recommended for any occasion where the client engages in systematic efforts to avoid or undermine the exposure to the feared stimulus. For example, individuals with panic disorder might check for the presence of anxiolytics (e.g., as needed anxiety medications, water). The availability of these items may serve to reduce any anxiety evoked in session prematurely, thus diminishing the benefit of treatment. Accordingly, blockage of these anxiety-reducing rituals would enhance the therapeutic effort of the exposure procedures. Prolonged Exposure for Trauma Models of psychopathology associated with trauma have relied on bioinformational theory, which suggests that in the face of overwhelming experiences, individuals systematically avoid memories and other reminders of trauma as a means to process the events (discussed in Drobes & Lang, 1995). Presently, prolonged exposure (PE) for trauma, along with several associated interventions (i.e., cognitive processing therapy; Resick et al., 2010; narrative exposure

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therapy; Schauer et al., 2011) is one of the recommended interventions in the recently published clinical practice guidelines (Courtois et al., 2017). Common to each variant of exposure treatment for trauma involves recalling specific aspects of the traumatic event, including the physical experiences, and recalling aspects of the event that might have been suppressed through strategic avoidance (see Green et al., 2017, for a detailed summary). Exposure Therapy With Children Recall that the first documented case of therapeutic exposure was conducted by Jones (1924) in treating fear of small animals in a child. Since that time, the application of exposure to childhood psychopathology has covered all the major anxiety problems present in youth. Carrying out exposure with children calls for highly specific skills by the clinician, including efforts to make exposure a game and rely on altering expectancies as described in the inhibitory learning model. The approach has documented efficacy in outpatient GAD clinics (Whiteside, Deacon, et al., 2016; Whiteside, Sattler, et al., 2016) and is a component of a major treatment program for child anxiety disorders (Coping Cat; Hourigan et al., 2012). Interoceptive Exposure Many anxiety sufferers are acutely aware of physical sensations and react to changes in these physical sensations as dangerous. This is referred to as anxiety sensitivity, and although it was originally conceptualized to account for panic disorder (Reiss et al., 1986), extensive research has shown it to be elevated in all anxiety disorders. Olatunji and Wolitzky-Taylor (2009) showed that, across all anxiety disorders, there was a large difference compared with nonanxious controls (d = 1.61) and that individuals with panic disorder had the highest anxiety sensitivity compared with other anxiety disorders. More recent investigations have emphasized a role for anxiety sensitivity in PTSD and associated substance use (i.e., Vujanovic et al., 2018). Measures of anxiety sensitivity suggest that there are three broad domains for the construct: (a) fear of physical symptoms, (b) fear of publicly observable symptoms, and (c) fear of loss of cognitive control. These factors have been observed across ethnic and racial groups (e.g., Jardin et al., 2018) and in children and adolescents (Bernstein et al., 2007). Interoceptive exposure targets these manifestations of anxiety sensitivity. Virtual Reality Exposure Exposure therapy is highly efficacious, particularly so when conducted in vivo. Some common fears, however, do not readily lend themselves to in vivo exposure. This could be due to either low access to the situations associated with the feared stimuli, potential concerns with safety, or lack of feasibility to conduct therapy in a repeated manner. To illustrate, a common fear, acrophobia, would necessitate exposure in an elevated location, which could pose serious logistical problems to conduct in vivo (e.g., access, time demands) and safely (e.g., conducting exposure in a place where the feared situation might involve limited



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barriers to the edge). These feared situations with these logistical challenges would also frustrate any effort to conduct the exposure therapy repeatedly, often a necessary component of successful therapy. Virtual reality therapy has become relatively accessible in light of the increased speed and memory of modern computer technology. This approach to therapy involves a computer “environment” that represents a set of feared situations, such as heights, flying, public speaking, agoraphobia (e.g., in a supermarket), and other settings where therapists would struggle to develop replicable and graded exposure situations. Virtual reality exposure has an added advantage in that the feared situation can be terminated, if the therapist inadvertently proceeds too rapidly up the hierarchy, and restarted at a lower level. To illustrate, in the treatment of fear of flying, virtual reality exposure may be initiated in a session, and should the client find it too challenging, it can be stopped and restarted at a level associated with less anxiety. Additionally, virtual reality exposure allows for multiple exposure trials of otherwise complicated situations in a single session. For example, in fear of public speaking, a virtual “audience” can be assembled for the client to deliver a speech several times in a session. Research suggests that virtual reality applications of exposure are efficacious in PTSD (Motraghi et al., 2014), flying fear (Cardoş et al., 2017), and specific phobias (Côté & Bouchard, 2008), as well as social anxiety and panic with agoraphobia (reviewed in Krijn et al., 2004). Further, research has shown that therapist alliance and treatment expectancies (i.e., anticipation of benefiting from the procedure) were high in virtual reality-based exposure (Meyerbröker & Emmelkamp, 2010). Inhibitory Learning To this point, it has been emphasized that a necessary mechanism of successful exposure therapy is activation of the fear memory network, which in turn leads to corrective processing (Foa & Kozak, 1986). Recent research has suggested that this may not be a necessary ingredient and that instead several other facets of exposure may successfully lead to fear reduction. The original model depicting the way in which a conditioned response ceases to produce its response considered it to be through inhibition of the neural connections that were formed in the CS-CR learning association (discussed in Rescorla & Wagner, 1972). This means that exposure to the feared stimulus is the crucial element, not necessarily fear activation. Interestingly, this had been shown previously, where phobia reduction was demonstrated experimentally through the use of pleasant imagery (Foa et al., 1977). With this new perspective, termed the inhibitory learning model, there are several important distinctions regarding how exposure may be delivered and how exposure produces its effects (Craske et al., 2014). These fall into the following broad categories: • Expectancy violation: Rescorla (1988) described the process of classical conditioning as one predicated on the formation of expectations around the outcome for a stimulus. Accordingly, exposure should set the stage for individuals to have a new prediction of outcome when exposed to the feared

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stimulus.3 Clinicians can facilitate this process through the imagery produced during exposure (e.g., by making humorous remarks) or through in vivo exercises that are contrary to the anticipated outcome (e.g., in fear of dogs and conducting exposure to puppies). • Exposure in multiple contexts: By the time clients seek treatment, their fear has likely generalized to multiple settings and situations. Accordingly, in order to produce enduring change, exposure should be conducted in numerous settings. • Deepened extinction: Moving up the hierarchy with clients often involves selecting a single component of the feared stimulus. Once all the single or small set of feared stimuli are mastered, then one might conclude that treatment was successful. However, in order to fully alleviate fear, exposure to multiple features of the feared stimuli, together, can produce lasting fear reduction. • Occasional reinforced extinction: “Real-life” experience of phobic stimuli does not necessarily mean there will not be any adverse consequences. For example, with the fear of contamination, at the end of treatment, the client still may develop minor illnesses when taking the ordinary precautions that unaffected individuals take. This would mean that in order for the benefits of exposure to fully accrue, the client (when appropriate) would also come into contact with the feared outcome. Recent work employing this facet has been shown to be instrumental in improving outcome for social anxiety disorder, through “social mishaps” (clinical application discussed in Fang et al., 2013, and elaborated on below in our consideration of social anxiety disorder). • Removal of safety cues: Safety cues signal that even if the feared stimulus is present, the feared outcome will not occur. For example, many panic disorder sufferers keep antianxiety medication on hand as a signal that should a panic attack happen, there is ready access to a relaxant. These safety signals serve as an impediment to full fear reduction that might be realized in the course of exposure, and, hence, practice in exposure in the absence of maladaptive safety cues is necessary. • Variability: Once a client has mastered much of the hierarchy, practice in exposure to varied feared stimuli along the hierarchy in turn fosters more enduring fear reduction.

The Rescorla and Wagner model was derived from animal models of learning. At the time, there was intense interest in evaluating how animals (up to and including humans) form expectancies (Bolles, 1972). One concern was that this perspective prematurely introduced cognition, as it requires organisms to predict outcomes through hypothetical mental structures (discussed in Jenkins, 1984). Since that time, cognition has been embraced as part of a comprehensive system of treatment and has been fully integrated in the movement of CBT.

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• Affect labeling: In the course of exposure, it is assumed that clients experience fear. However, clients may not recognize the emotional experience, may mislabel the experience, or may have an emotional reaction other than fear. Practice in labeling the experience and its associated change in the course of exposure facilitates the process of fear reduction and, more importantly, alleviates the urge to avoid feared situations. The inhibitory learning model has been the focus of considerable recent clinical conceptualization and is drawn largely from experimental lab research (discussed in Craske et al., 2014; Frank & McKay, 2019). Research on the efficacy of specific components of the inhibitory learning conceptualization of exposure in alleviating clinically significant fear has not yet been demonstrated.

Delivery Methods Treatment using exposure approaches can be conducted in several different settings or through different delivery modes. The most common is in an outpatient office. However, it can also be conducted in inpatient and residential settings, in the client’s home environment, or remotely. In Office In office is the most common delivery method, and it typically relies heavily on imagery methods described earlier. Treatment using this method is also instructional, in that clients are given specific between-session homework exercises aimed at fostering exposure outside the office, which is not therapist guided. Inpatient and Residential Specialized inpatient and residential treatment programs for anxiety disorder have been developed where more intensive exposure can be conducted. This would entail practicing exposure for multiple hours per day over consecutive days in order to alleviate symptoms. Prominent examples include programs for OCD (Shikatani et al., 2016), trauma in youths (Cohen et al., 2016), and panic with agoraphobia (Pollard et al., 1987). Out in the Field As noted earlier, in vivo exposure is generally more effective than in imagery and often necessitates leaving the office to conduct therapist-assisted exposure. Although this is the most effective approach to conducting exposure, it is also the approach that prompts the greatest hesitancy among providers and stands as a barrier to proper dissemination (Powers & Deacon, 2013). The benefit of leaving the office to conduct exposure allows for an enhanced ability to practice the kind of exposure that clients need to conduct as part of between-session behavioral homework, and it provides the clinician with opportunities to observe potential barriers to exposure that the client might encounter but would not recognize to report.

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Remote Treatment Delivery (Telehealth) In the event that there are institutional restrictions on conducting therapistguided exposure outside the office, advances in computer technology have allowed for treatment to take place remotely. The research in this area is still in active development, so specific methods to optimize delivery have not been fully described. However, the research thus far is encouraging. In the case of OCD, for example, telemental health approaches have large effect sizes for symptom reduction (Herbst et al., 2012). This has likewise been shown for obsessive-compulsive related disorders (Brand & McKay, 2012) and PTSD (Acierno et al., 2016). In addition to guided exposure through telemental health approaches, treatment can be delivered through internet-guided methods (e.g., via email; see Jacob & Storch, 2015).

OUTCOME DATA Research has established CBT, including an exposure component, as a firstchoice treatment for anxiety and as a more efficacious intervention for anxiety disorders than a number of other therapies (Hofmann et al., 2012; Tolin, 2010). In addition, there is strong evidence suggesting the efficacy of CBT as a method to treat a wide array of other mental health issues including bulimia, somatoform disorders, anger control issues, and overall stress, pointing to the widespread benefits of CBT across disorders and symptoms (Hofmann et al., 2012). As most CBT models for anxiety disorders include exposure or some variant such as behavioral experiments, this component has been described as the one accounting for the greatest amount of variance in outcome data. For example, Abramowitz, Taylor, and McKay (2005) showed that behavioral experiments were effectively exposure-based interventions when applied in OCD and were the primary means of prompting symptom improvement.

Phobias Exposure therapy is the preferred treatment for specific phobias (see Barlow et al., 2002). In a meta-analysis conducted by Wolitzky-Taylor et al. (2008), exposure therapy for phobias led to greater symptom improvement at posttreatment (d = 0.44) as well as at follow-up (d = 0.35) compared with nonexposure treatment, with the average individual who received exposure outperforming 64% of those given a nonexposure treatment. Additionally, this meta-analysis revealed that exposure alone is as efficacious as the combination of exposure and cognitive techniques. Furthermore, in vivo exposure for phobias has been found to be superior to other forms of exposure, such as the use of imagery, and to nonexposure and placebo conditions when results are evaluated at posttreatment (for review, see Choy et al., 2007; Olatunji et al., 2010). However, in vivo exposure may only be superior to other forms of exposure immediately following treatment (d = 0.38), as these different forms of exposure were found to



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have similar outcomes at follow-up (Wolitzky-Taylor et al., 2008). Additional methods for administering exposure have developed with new technology, including the use of virtual reality. In a meta-analysis conducted by Parsons and Rizzo (2008), virtual reality exposure therapy was shown to significantly reduce symptoms of specific phobias, with effect sizes (d) ranging from 0.92 to 1.59. Finally, exposure therapy has had remarkable effects on fear reduction for many different types of phobias. For example, 79% to 92% of participants treated for animal phobia, height phobia, driving phobia, or claustrophobia were able to complete a fear-inducing activity (e.g., handling an animal) without fear following treatment compared with only 0% to 18% of participants who were in a control condition (for a review, see Choy et al., 2007). Panic With and Without Agoraphobia The use of interoceptive exposure (i.e., exposure to somatic cues) in treatment for panic disorder, with and without agoraphobia, is common practice and often increases symptom improvement. A combination of cognitive restructuring and interoceptive exposure was found to be most efficacious when treating panic disorder (d = 0.88) compared with multiple other combinations of CBTs (Gould et al., 1995). Gould et al. (1995) also found that CBT in general had a larger impact on panic disorder symptoms (d = 0.68) compared with pharmacological treatments or combination treatments, which were characterized by effect sizes of d = 0.47 and d = 0.56, respectively. Though there is scant research directly comparing exposure therapy to cognitive therapy (without exposure or behavioral experiments4), there is some evidence that exposure therapy and cognitive therapy may be equally as efficacious for panic disorder (Arntz, 2002; Bouchard et al., 1996). In one study conducted by Arntz (2002) that compared cognitive therapy to interceptive exposure, 75% to 92% of individuals in both conditions improved, with no significant differences in symptom improvements across conditions. Although it is clear that using interoceptive exposure in treatment is central for panic disorder, additional evidence is necessary to determine the benefit of using exposure alone. Beyond treating panic disorder, exposure is also particularly helpful for treating agoraphobia (Gloster et al., 2011; Jansson & Öst, 1982). In a study conducted by Gloster et al. (2011), therapist-guided exposure (compared with exposure that was prescribed) led to greater improvements in agoraphobic avoidance and in panic attacks. For individuals with panic disorder with agoraphobia, one study revealed that following exposure therapy, 68% of participants were no longer experiencing panic following treatment (Fava et al., 2001). More specifically, when comparing cognitive restructuring combined Behavioral experiments, in the context of anxiety disorders, entail creating situations whereby situations that are typically avoided are faced with the aim of eliciting unhelpful cognitions. These cognitions are then subject to direct modification in vivo. However, given the exposure component inherent in behavioral experiments, many scholars suggest that behavioral experiments are effectively exposure exercises (for a review, see McMillan & Lee, 2010).

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with either interoceptive exposure or breathing retraining in individuals with panic disorder with agoraphobia, those who received interoceptive exposure had better outcomes for panic frequency and severity as well as functioning at posttreatment (Craske et al., 1997). Thus, individuals suffering from panic with agoraphobia may benefit the most from the use of exposure within treatment, supporting the benefit of combining cognitively based techniques with exposure. Follow-up research on panic disorder with agoraphobia has shown that a high percentage of individuals who receive exposure therapy maintain their gains at follow-up. Follow-up data in one longitudinal study revealed that only 23% of exposure treatment responders relapsed during a 2- to 14-year followup period (Fava et al., 2001). For individuals treated with both exposure and cognitive therapy in another longitudinal study, 81% were panic-free after 2 years (Craske et al., 1991). Generalized Anxiety Disorder As with other anxiety disorders, exposure therapy is also an important component of CBT for GAD, although the exact impact of exposure alone on outcomes for GAD is understudied. Often, imagery is used to expose individuals to anxiety-related cues and worries. In one study comparing applied relaxation and CBT with imaginal exposure, generally anxious individuals who received CBT demonstrated better long-term outcomes (Borkovec & Costello, 1993). Because applied relaxation does not include exposure, this finding provides evidence that exposure may be central in promoting long-lasting change in GAD. Additionally, Dugas and Robichaud (2012) highlighted the importance of using exposure procedures for GAD to combat the intolerance of uncertainty, a core component of excessive worry. Specifically, they described the use of imaginal exposure to address worries surrounding hypothetical scenarios with uncertainty-inducing elements and to limit cognitive avoidance. In one study evaluating the efficacy of CBT that included exposure to uncertainty, CBT fared better at posttreatment than applied relaxation, with pretest to posttreatment effect sizes of d = 0.74 and d = 0.34 for CBT and applied relaxation, respectively (Dugas et al., 2010). Social Anxiety Disorder CBT is the most studied intervention for social anxiety disorder and has been found to be very beneficial for symptom reduction. Empirical research has found that exposure on its own can be as efficacious as, or even superior to, cognitively based treatments or their combination, particularly for social anxiety (Feske & Chambless, 1995; Gould et al., 1997; for a review, see Deacon & Abramowitz, 2004). For example, in a meta-analysis conducted by Gould et al. (1997), exposure therapy alone produced an effect size of d = 0.89, but when combined with cognitive restructuring, it produced an effect size of d = 0.80. Cognitive restructuring alone yielded an effect size of d = 0.60. Exposure therapy, therefore, is considered a highly effective treatment for social anxiety disorder.



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Recent advances in technology as well as developments in exposure procedures have expanded the format and techniques by which exposure is conducted. For example, virtual reality has been found to be efficacious for those with social anxiety around public speaking (for review, see Krijn et al., 2004). Recent research emphasizes a specific facet of exposure for social anxiety that involves social mishaps, which entails exposure to situations that may involve fearing a negative social outcome (also referred to as “social cost” exposure; Fang et al., 2013). This facet of exposure bridges the divide between behavioral practice and cognitive dimensions in the treatment of social anxiety, whereby individuals hold catastrophic beliefs regarding the consequences of social mishaps (Hofmann, 2007). Obsessive-Compulsive Disorder There is strong evidence demonstrating the efficacy of CBT consisting of ERP for OCD. Research has shown the best outcomes in CBT for OCD (d = 1.37) relative to many anxiety and related disorders, such as social anxiety (d = 0.62), panic disorder (d = 0.35), and PTSD (d = 0.62; Hofmann & Smits, 2008; Hofmann et al., 2012). Of note, this evidence challenges the common perception that OCD is among the most treatment-resistant disorders in clinical practice, even if it is the case that practitioners indeed come across treatment-resistant cases in clinical settings. The findings in research settings and in clinical practice may seem particularly discrepant due to the extreme heterogeneity of symptoms and severity that is typical of OCD (Hofmann & Smits, 2008). A number of individual studies have examined the efficacy of CBT and its components. Within a medication-refractory sample, the combination of cognitive restructuring and ERP was found to produce greater improvement in OCD symptoms than ERP alone (Rector et al., 2005, in Butler et al., 2006). Although some research has found ERP to be comparable to cognitive therapy for OCD (Abramowitz, 1997), more recent findings suggest that behaviorally based treatments, such as ERP, may actually be more beneficial than cognitively based treatments and their combination. For example, for self-reported symptoms of OCD, behaviorally based treatment produced an effect size of d = 1.46, cognitive therapy yielded an effect size of d = 1.09, and combined cognitive and behavioral therapy yielded an effect size of d = 1.30 (for a review, see Deacon & Abramowitz, 2004; McKay et al., 2015). It is important to note that OCD is a highly complex and heterogeneous condition. There are several subtypes of the disorder in adults (McKay et al., 2004) and children (McKay et al., 2006), and these subtypes have different expected outcomes (see, for example, Abramowitz et al., 2003). There are different models of subtypes, though the most consistently identified are checking and obsessions (aggressive, sexual, religious, or somatic); symmetry, ordering, and counting obsessions and repeating compulsions; and contamination obsessions and cleaning obsessions (Abramowitz, McKay, & Taylor, 2005). In general, when conducting specialized ERP for OCD, clients and therapists can achieve good outcomes for all subtypes, but duration of treatment may vary in

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part based on the symptom presentation in adults (McKay et al., 2015) and children (Franklin et al., 2015). In the case of children, behavioral effort may necessitate exposure sessions of shorter duration but with more frequent practice, whereas in adults, sessions often call for 90 minutes or more in order to ensure adequate within-session habituation. This is particularly the case for complex symptoms, symptoms with a long lag between exposure and feared consequences (e.g., in obsessions for blasphemy), or where in vivo practice is necessary to ensure adequate contact with the full stimulus complex.

Posttraumatic Stress Disorder There is also strong evidence supporting the efficacy of exposure therapy for PTSD (Bradley et al., 2005; Jonas et al., 2013; Watts et al., 2013), and it is a first-line recommended intervention for the disorder in the practice guidelines of the American Psychological Association (Courtois et al., 2017). In one study, participants receiving exposure therapy demonstrated a greater decrease in symptoms involving avoidance and reexperiencing, and more participants no longer met criteria for PTSD, compared with those receiving other forms of treatment, including relaxation training and eye-movement desensitization and reprocessing (EMDR; Taylor et al., 2003). Exposure therapy yielded the greatest percentage of participants exhibiting clinically significant symptom reductions. By both posttreatment and follow-up, 73% of those who had received exposure therapy maintained clinically significant reductions in reexperiencing symptoms; this percentage was significantly more than that of both the relaxation training group (33%) and the EMDR group (27%). Additionally, 67% of those in the exposure therapy group maintained clinically significant reductions in avoidance, which was a significantly greater percentage of participants than that of both the relaxation training group (27%) and the EMDR group (27%; Taylor et al., 2003). Further support for exposure therapy in PTSD comes from research on one specific type of exposure therapy, PE. When PE was compared with stressinoculation training (SIT) and a combination thereof in a sample of women with chronic PTSD, comparable reductions in symptoms were found across treatments. However, PE resulted in lower anxiety and had the largest impact on PTSD severity (in the completer sample, d = 1.92), depression (d = 1.47), and anxiety (d = 1.44) compared with SIT (d = 1.61, 1.00, and 0.89, respectively) and combined treatment, (d = 1.50, 0.91, and 0.67, respectively; Foa et al., 1999). This finding is notable because SIT includes several components of CBT such as relaxation training, coping strategy role playing, and cognitive restructuring, but it de-emphasizes exposure (see Meichenbaum, 2009). However, other research has suggested that, while efficacious, exposure-based treatment for PTSD is not substantially more efficacious than cognitively based treatment (Bradley et al., 2005) or a combination of the two treatment types (Olatunji et al., 2010), indicating that further research is warranted.



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Childhood Anxiety Similar to findings in adult samples, CBT has been found to be efficacious for children and adolescents and is considered the treatment of choice for anxiety and depressive disorders in youth (Albano & Kendall, 2002; Compton et al., 2004; Silverman et al., 2008). CBT for youth commonly utilizes both imagined and in vivo exposure and often emphasizes parental involvement in exposure practice, particularly with young children (Crowe & McKay, 2017). Although some studies have found CBT to be as efficacious for youth anxiety disorders as various other psychotherapies, there is strong evidence that CBT is superior to both passive and active control groups for youth with anxiety (Compton et al., 2004; Reynolds et al., 2012). Findings from a meta-analytic review of psychotherapy for youth anxiety indicated a small yet significant effect size when comparing CBT to passive control groups among 34 studies (d = −0.39) and a moderate-to-large effect size when comparing CBT to active control groups among 17 studies (d = −0.77; Reynolds et al., 2012). In another recent review of meta-analyses examining CBT for youth anxiety and depressive disorders, CBT was again deemed an efficacious treatment in comparison to active control groups (e.g., supportive counseling, psychoeducation; d = 0.40) and even more superior passive control groups (e.g., wait-list control; d = 0.76). A similar trend occurred for youth PTSD, with largest effect size occurring when CBT was compared with passive control (d = 1.40), followed by when CBT was compared with mixed control (d = 0.67), and the smallest effect size when CBT was compared with an active control (d = 0.47). For youth OCD, a large weighted effect size was also found when comparing CBT to mixed control groups (d = 1.37; Crowe & McKay, 2017). CBT for youth anxiety has also been modified to target specific disorders, with disorder-specific CBT showing greater effectiveness than generic CBT (whereby cognitive restructuring may be a significant focus of treatment). Whereas generic CBT for youth anxiety disorders has demonstrated a moderate overall effect size (d  =  −0.53), disorder-specific CBT has demonstrated a moderate-to-large overall effect size (d = −0.77; Reynolds et al., 2012). Disorder-specific CBT has been studied among many anxiety and related disorders, including social anxiety disorder, OCD, and PTSD (Reynolds et al., 2012). Disorder-specific CBT for PTSD is superior to generic CBT, with a moderate effect size (d = −0.68), as is disorder-specific CBT for social anxiety disorder, which has a moderate-to-large effect size (d = −0.79). For youth with OCD, CBT for OCD is particularly superior over generic CBT, with a large overall effect size (d = −1.79) compared with both generic CBT and other psychotherapy for anxiety, which aligns with findings among adults with anxiety disorders (Hofmann & Smits, 2008; Reynolds et al., 2012). Although the efficacy of CBT in the short term has been established for youths, as well as its efficacy in the short-term posttreatment, further research including longer follow-up periods is needed to understand the long-term impact of CBT for youth with anxiety and depression (Crowe & McKay, 2017).

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Separation Anxiety Disorder With an age of onset aligning with the occurrence of the normative developmental fear of separating from parents, separation anxiety disorder (SAD) tends to have an early onset, commonly around ages 6 to 9 years (Albano & Kendall, 2002). Because GAD, social anxiety disorder, and SAD are all common among children and tend to co-occur, they have often been studied together. In the largest randomized controlled trial of youth anxiety disorders, 488 youth with GAD, SAD, or social anxiety disorder received CBT, sertraline, a combination, or placebo. Findings suggest that CBT, sertraline, and their combination are all efficacious over placebo and that combined treatment is most efficacious for these disorders, as it yielded the largest effect size (g = 0.86), followed by sertraline alone (g = 0.45) and CBT alone (g = 0.31). Of note, there was no significant difference in efficacy between CBT and sertraline (Walkup et al., 2008). Further research comparing standard CBT to exposure-focused CBT has indicated that focusing on parent-coached exposure therapy early in treatment for SAD can lead to better outcomes, in fewer sessions, than treatment that emphasizes anxiety-management strategies early on (Whiteside et al., 2015). Selective Mutism While selective mutism (SM) is among the least studied of all anxiety disorders, a comprehensive review of psychosocial interventions for SM indicated that behavioral and cognitive behavioral treatments are most effective for youth with this disorder (Cohan et al., 2006; Fung et al., 2002). Specifically, within behavioral treatment, systematic desensitization—combining relaxation skills with graduated exposure, both imaginal and in vivo—has been found to be effective for youth with SM (for a review, see Cohan et al., 2006). For younger children, the graduated exposure component alone, focusing on in vivo exposure, may be most effective, due to developmental difficulty with relaxation and the use of imagery (Cohan et al., 2006; Compton et al., 2004). Because SM can be difficult to recognize in youth and is less prevalent than many other anxiety disorders, many studies on the disorder are based on case studies and few include large samples and comparison treatment groups. More recently, however, there has been an increase in better controlled studies of SM. One controlled study with a slightly larger sample found improvement of speaking in public for eight of nine youths and found better outcomes from child-focused exposure-based practice than from parent-focused contingency management (Muris & Ollendick, 2015; Vecchio & Kearney, 2009). In a larger randomized study of 24 youths with SM, those who received an intervention consisting of defocused communication (i.e., sit next to, instead of opposite, the child; joint attention on an activity instead of focus on the child) and behavioral methods (i.e., exposure) demonstrated significantly increased speech at school in comparison to wait-list control (Muris & Ollendick, 2015; Oerbeck et al., 2014). Another treatment exhibiting positive outcomes among youth with SM is integrated behavioral therapy (IBT), a newly



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developed treatment that involves the child, parent, and teacher and includes exposure activities as well (Bergman et al, 2013; Muris & Ollendick, 2015). In a randomized controlled trial assessing the efficacy of IBT among youth with SM, youth were randomized to receive IBT, consisting of exposures to take place in home, school, and clinic settings, as well as behavioral techniques, or were assigned to wait-list control. Whereas 67% of those who received IBT no longer met criteria for SM at posttreatment, all in the wait-list control group still met criteria. Further, 75% of those who received IBT were deemed treatment responders, compared with none among the wait-list control group. Moreover, according to parent and teacher reports on standardized measures, youth in the IBT group had increased functional speaking, compared with none in the wait-list control group (Bergman et al, 2013; Muris & Ollendick, 2015). In addition, improvements among those in the IBT group were maintained at 3 months posttreatment, which strengthens support for this intervention for youth with SM (Bergman et al, 2013; Muris & Ollendick, 2015).

MECHANISMS OF CHANGE DATA Experimental research has accumulated to show that exposure produces beneficial changes at the neural level in pathways associated with learning. Pavlov (1927) postulated that conditioning occurs in specific neural pathways and, further, that habituation is the learning of responses that inhibit the previously learned CR. This means that once a CS is established, it is not lost, but instead new learning blocks the previously learned response. In this way, Pavlov anticipated findings from neuroscience related to neural connections for fear learning, such as the N-methyl-D-aspartate (NMDA) pathways. This pathway is significant, as basic animal and human research has shown its involvement in new learning, particularly during fear reduction (Baker et al., 2018; Lee & Kim, 1998; Myskiw et al., 2014). Recent translational work examining the facilitation of habituation by including the NMDA agonist D-cycloserine (DCS) has shown that when DCS was administered approximately 2 hours before exposure, improvement occurred faster in several anxiety disorders (i.e., phobias, social anxiety, and OCD) but also that, over time, individuals who were not administered DCS achieved the same level of symptom improvement (e.g., Hofmann et al., 2006; reviewed in Norberg et al., 2008). Laboratory experimental findings suggest that extinction is facilitated when practiced in multiple settings and under multiple contexts (i.e., under varied threat potential), such that it leads to lower risk of recovery of fear (Dunsmoor et al., 2015). On the other hand, under conditions of heightened arousal (i.e., elevated noradrenergic response), fear responses may be consolidated rather than alleviated (Dębiec et al., 2011). This suggests that exposure should be conducted in varied settings and under varied conditions, but while the client is at a comparably normal mood state (i.e., not under acute fear) in order to facilitate the benefits of exposure.

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In addition to the neural changes observed in laboratory experiments, several different cognitive changes have been identified as mechanisms of change in anxiety reduction with exposure therapy. For example, Hofmann (2008) reviewed the literature on cognitive processes in exposure therapy and concluded that exposure reduces harm expectancy in anxiety disorders and thus could be a mechanism by which exposure therapy causes symptom reduction. In the aforementioned research on reduced fear recovery in multiple contexts of exposure (Dunsmoor et al., 2015), it was also observed that intolerance of uncertainty decreased. Individuals with combat-related trauma who had positive outcome in exposure showed a reduction in trauma-related guilt (Trachik et al., 2018). In addition, a general reduction in panic-related cognitions was observed in individuals who showed sudden gains in exposure treatment (Nogueira-Arjona et al., 2017), and changes in panic-related cognitions led to changes in the severity of panic symptoms (Hofmann et al., 2007). Other research has demonstrated that cognitions related to physical consequences of anxiety changed in the successful treatment of both agoraphobia and social anxiety (Vögele et al., 2010). Moreover, changes in an individual’s estimation of social cost were related to symptom change following CBT for social anxiety (Hofmann, 2004). Finally, it has been shown that individuals with compulsive checking showed changes in the perceived need to control thoughts, intolerance of uncertainty, and perception of danger in general following successful treatment (Overton & Menzies, 2005). This is not an exhaustive review of the cognitive mechanism of change data, but it illustrates that when exposure is conducted and there is clinically significant symptom reduction, cognitions change as a consequence (reviewed in Hofmann et al., 2018). The experimental findings also suggest that cognitive restructuring is not required in order to achieve cognitive change. One of the key means of achieving cognitive change is through shifts in expected outcomes following exposure and through experiencing the stimuli with different emotional states. When individuals encounter feared stimuli in the natural environment before treatment, they strategically avoid the full stimulus complex (i.e., Huijding & de Jong, 2006). During clinician-guided exposure, the full stimulus complex is presented (and elaborated on in imagery), leading to the aforementioned changes in expectancies through direct experience. These processes are consistent with the mechanisms of change predicted by the inhibitory learning model (Craske et al., 2014; see also Jacoby & Abramowitz, 2016).

DISSEMINATION As noted earlier, clinicians are generally reticent to practice exposure, often out of concerns that there is litigation risk or that clients will decompensate and then drop out of treatment instead of experiencing beneficial outcome. These attitudes have profound consequences for the dissemination of exposure. Indeed, recently, blog posts have been posted that decry the application of PE



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for trauma following the recommendations of the clinical practice guidelines. These blog posts often report erroneously on the dangers of exposure and state that clients will be harmed rather than helped by the procedures (see, for example, Shedler, 2017; see also response, McKay & Lilienfeld, 2017). The concerns over litigation and dropout are greatly inflated. Exposure therapy is on firm footing as an appropriate and acceptable form of treatment, leaving clinicians with little fear of litigation stemming from its use (Olatunji et al., 2009). As for dropout, there is little evidence that it is higher than for other psychotherapies (in PTSD, Imel et al., 2013; in OCD, Ong et al., 2016). Najavits (2015) identified several significant factors contributing to premature dropout from exposure, including client factors, such as severity, which can make exposure difficult to tolerate, and other mental illness, which could complicate information processing of exposure. Important clinician factors play a role in dropout as well, such as confidence the provider holds in the procedure, depth of familiarity with behavioral principles of change, and deviation from exposure protocol. The deviation from the procedure is a problem that exists more generally (Waller, 2009) but is exacerbated in the case of PTSD, given the complexity of the disorder and sensitivity to intensity of exposure that is specific to this group. In addition to improving the training that clinicians receive in conducting exposure, a move to conduct direct-to-consumer marketing of evidence-based treatments has been proposed. These efforts focus on educating consumers in the benefits of evidence-based treatment (e.g., symptom alleviation, efficiency of interventions), reducing stigma, and educating consumers regarding the core features of proper treatment (Gallo et al., 2013). Although CBT’s empirical support is strongly established, most individuals seeking treatment for a psychiatric disorder receive suboptimal CBT or do not receive CBT at all. One study demonstrated that only 33% of individuals treated for a psychiatric disorder received minimally adequate treatment, providing evidence that empirically supported treatments (ESTs) are rarely used (Wang et al., 2005). Furthermore, behavioral methods (e.g., exposure), which are an integral part of CBT, are used less often than other treatment approaches such as supportive therapy and medication (Goisman et al., 1993). One study demonstrated that only 17% of clinicians reported using exposure to treat individuals with PTSD, despite its established efficacy (Becker et al., 2004). Yet even among a sample of individuals who did receive CBT, less than half received the exposure component, demonstrating that clinicians often suboptimally implement CBT (Stobie et al., 2007). Further, even when exposure therapy is utilized, therapist-assisted exposures are rarely employed, and imaginal exposures are more commonly used than in vivo despite strong empirical support for in vivo exposure (Goisman et al., 1993; Hipol & Deacon, 2013). Inadequate dissemination and implementation of CBT including exposure is a widespread issue, particularly affecting populations with the greatest unmet need for mental health treatment. Racial minorities, the elderly, residents of rural areas, low-income individuals, and those without insurance are most likely to be underserved by current mental health services (Wang et al., 2005).

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There are a variety of barriers challenging the maximization of CBT in community settings. Among the most considerable are clinicians’ lack of CBT-specific training and available resources. Lack of training in CBT is common among clinicians, as only approximately 20% of social work and PsyD programs require supervision in CBT (Weissman et al., 2006). Clinicians, therefore, must seek out supplementary training opportunities to become well versed in CBT, which can be time consuming and costly and thus not feasible for many (Addis, 2002; Stewart et al., 2012). Research indicates that mental health counselors use CBT infrequently and usually do not have adequate training to correctly implement ESTs (Addis, Hatgis, et al., 1999; Addis, Wade, & Hatgis, 1999). This may, in part, explain why ESTs are less effective in clinical settings than in research settings (Weisz et al., 2014). Master’s-level clinicians tend to make up the majority of mental health providers, especially among community mental health centers. This is of particular concern, as master’s-level clinicians in community settings are often providers for low-income and minority populations. Even when clinicians are knowledgeable and well trained in CBT, it is common for them to worry about their ability to master EST implementation, especially when adequate supervision is unavailable when they are learning to refine new skills (Addis, Wade, & Hatgis, 1999; Cook et al., 2009). Despite these barriers, there is promising evidence that ESTs can be implemented adequately in community mental health centers, creating a recent push in the field to increase dissemination efforts and thereby eliminate barriers to treatment (Shafran et al., 2009; Wade et al., 1998). An increase in dissemination and adherent implementation of ESTs in community clinics would help provide better mental health treatment, most notably benefiting elderly and minority individuals who are currently underserved by mental health providers overall (Harvey & Gumport, 2015; Wade et al., 1998). Novel technological advances may help increase access to ESTs for these populations. In particular, computerized and internet-based CBT have shown positive outcomes (Craske et al., 2009). One study offering computer-assisted CBT for anxiety disorders in primary-care settings found that participants using this program not only rated it highly and found it beneficial but also were able to understand the material, fully participate, and develop skills in CBT (Craske et al., 2009). Moreover, this method of CBT implementation yielded positive results among novice clinicians, perhaps suggesting this treatment modality as a suitable starting point for clinicians lacking experience providing CBT. For example, in this study, the clinicians’ overall opinion regarding the computer program was positive, with a mean score of 6.08 out of 7. For anxiety disorders in particular, computer-based treatment can offer a unique opportunity to incorporate both still images and video of anxiety-provoking stimuli in hierarchies during exposure treatment, while allowing for careful control of the progression of exposure to such stimuli (Khanna et al., 2007). Treatment modalities involving the use of technology may provide more widespread care to individuals who cannot afford care at treatment centers or cannot engage in such care in person due to geographic location or scheduling logistics. Reducing addi-



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tional barriers, such as a lack of financial resources, childcare, and transportation, is important when trying to increase the application of ESTs to diverse populations (Harvey & Gumport, 2015).

APPLICATION TO DIVERSE POPULATIONS Efforts to disseminate exposure-based procedures to a wide range of settings have been hampered by the negative attitudes many clinicians hold toward the procedure. Dissemination and implementation research has suggested that community mental health centers in particular do not adopt exposure procedures, that they are more likely to employ relaxation methods in lieu of exposure, and that the negative attitudes permeate up through the administrative layers of the settings (Becker-Haimes et al., 2017). Although it is widely expected that exposure is effective with underrepresented groups, it has also been acknowledged that the research on diverse populations has lagged far behind work with majority members. For example, although OCD is known to affect ethnic and racial minorities, there is comparably low recruitment and participation in treatment trials, limiting the extent that demographic variables may be studied to determine ways to optimize treatment delivery, if necessary, for different patient samples (Williams et al., 2010). Despite the limited availability of work with underrepresented groups, there are some emerging efforts to develop culturally sensitive approaches. For example, Pina et al. (2009) described a culturally sensitive model of exposure treatment, with an illustration with Mexican American youth that included key modifications such as specifically building rapport with the family, sharing culturally personal anecdotes, adopting values-based approaches to exposure, considering economic- and social-based goals, and relying on metaphors to facilitate exposure. Owing to the assumptions held around the risks of conducting exposure, many clinicians assume that the presence of different medical conditions precludes the conduct of exposure. The assumption that provoking anxiety as part of a therapeutic intervention will lead to complications in a patient with a known medical condition is embraced as common clinical lore. However, the evidence generally does not support this belief. For example, it has been shown that exposure therapy with pregnant women neither leads to complications in pregnancy nor increases risk of miscarriage (see Arch et al., 2012). Research in older adults suggests that exposure is as suitable for them as it is for younger adults with comparably few health complications (Flint, 1998; Jayasinghe, et al., 2017). Although less extensive, a large clinical trial (N = 60) demonstrated that PE for PTSD was safe when conducted with individuals who had experienced prior myocardial infarctions (Shemesh, et al., 2011). In each of these illustrations, it was strongly recommended that clinicians consult with medical providers about the possible risks to clients before initiating treatment.

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In summary, although research has lagged with underrepresented groups and with medical populations, it appears that exposure can be conducted across populations. These may require modifications to address the unique needs of the presenting client, but nonetheless exposure can be safely practiced and clinicians can expect comparable outcome to research conducted with majoritymember samples.

CLINICAL EXAMPLE Janet, age 37, reported severe fears of contracting illnesses. This fear led to a wide range of compensatory behaviors including making frequent doctor visits, checking her body for possible tumors, washing to ensure limited contact with pathogens, and seeking reassurance from family members regarding the association between minor aches and pains and likelihood of significant health risks. When she presented for treatment, she was married and had two young children. She reported that she spent much of each day worrying about contracting illnesses, checking, or washing, leaving little time for other activities. She was unemployed, despite a desire to resume her professional career that she had put on hold when she had her children. Assessment Before initiating treatment, Janet completed a battery of measures aimed to assess severity of anxiety and associated anxiety-disorder symptoms and to rule out other potential diagnoses. Following this assessment, it was determined that she had clinically severe OCD but also had met criteria for panic disorder. On further evaluation, a functional analysis was developed that suggested the panic symptoms took priority and that the obsessive-compulsive symptoms were a consequence of interoceptive awareness that prompted illness anxiety. Hierarchy Development Janet’s hierarchy focused on several dimensions. The first was centered on interoceptive experiences that prompted anxiety reactions. The second focused on contamination sources that were associated with washing rituals. The third was on images of particular illnesses that caused her anxiety. However, the latter two were later revised following the targeting of Janet’s panic symptoms, as will be described. Initiating Exposure Janet’s treatment plan was described to her, and after some collaborative discussion of what she could expect, it was determined that interoceptive exposure was the most effective starting point for intervention. It is essential to note



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that in clients with no health risks, interoceptive exposure is considered harmless. Clinicians reluctant to engage in interoceptive exposure are encouraged to practice some of these exercises themselves in order to experience the physical sensations engendered. This allows for the clinician to more accurately address the resultant responses clients will experience when practiced in session. The first exposure session with Janet focused on a hyperventilation challenge. This was chosen because she reported that her panic symptoms were most centered on heart rate and pulmonary sensations (see Kircanski et al., 2009, for a discussion of panic subtypes). Janet was then guided through the lowest level item on the hierarchy for hyperventilation, namely breathing at a rate of 30 breaths a minute into a paper bag for 1 minute. The mechanics of this exercise involved specifically instructing Janet to stand, with feet together, and then breathe into a paper lunch bag for 1 timed minute. When completed, she was instructed to close her eyes and focus on the physiological sensations (slight dizziness, wobbly feeling, shortness of breath) and to open her eyes only when the sensation passed. Her peak fear rating for this exercise was a 5 out of a possible 10. Because this was her initial exposure session, she was instructed to practice the hyperventilation exercise one to two times each day. The next two sessions focused on continued hyperventilation exposure, increasing to a maximum of 4 minutes. During this period, Janet reported significant declines in panic experiences and a corresponding reduction in illness anxiety generally. Exposure Progress Janet’s panic symptoms largely subsided after the third session of hyperventilation. However, she reported continued residual contamination concerns. As she reported to the clinician, “Well, I’m less panicky, but the world is still filled with all kinds of germs that could harm me. And, now I wouldn’t feel it in my chest, so I might not be on guard for the risk!” This led to additional discussion of the role exposure plays in anxiety management generally, and treatment then shifted to her contamination and illness anxiety fears. However, since it was determined that panic symptoms elevated her anxiety in other areas, the hierarchy was revisited and updated to reflect the changes in her perceived fears. Exposure With Response Prevention In addressing Janet’s contamination and illness anxiety, exposure was initiated for contaminants. As the research has shown that in vivo exposure is most effective when practiced in conjunction with imagery, Janet’s first exercise involved touching the door for the single-occupant bathroom in a less frequently used corridor in the clinician’s office. Once Janet came into contact with this door, the clinician then proceeded to guide her in developing an image of contracting a minor illness (a head cold). The selection of an image involving a minor illness was in line with the hierarchy. Janet was also instructed

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to refrain from any handwashing for at least one hour and, when she did wash, to then recontaminate by touching a doorknob in her home. This proceeded for five additional sessions, building in intensity to the final exposure session, whereby Janet touched the sink top in the more widely used restroom in the clinician’s office building and imagined contracting a severe illness (hepatitis) and requiring hospitalization. By the end of this process, Janet’s panic symptoms did not return, and she reported a significant reduction in OCD symptoms. It is worth noting that Janet’s exposure course of treatment was followed by ongoing exposure for illness concerns. However, her treatment then moved to other areas, such as returning to work, which aroused contamination-based anxiety that was not reported in the initial phase given that it was not salient. Following 6  months of treatment, her symptoms had receded such that she resumed working, which was a primary goal she wished to attain with therapy.

CONCLUSION Exposure therapy is a major evidence-based intervention that is either a standalone treatment or part of comprehensive treatment programs for anxiety disorders. The accumulated evidence suggests that the intervention produces large effect sizes for symptom reduction, has indirect benefits for other psychopathology, and changes core cognitive biases associated with anxiety disorders. The biggest barrier to wider adoption of exposure rests with the negative attitudes clinicians hold toward the approach (i.e., risk of litigation, conflict with theoretical orientation) and assumptions about the ability of clients to tolerate anxiety. At the present time, major initiatives in funding agencies stress “personalized medicine.” This approach stresses the identification of multiple patient characteristics and the determination of a multipronged approach to treatment that draws on psychosocial interventions as well as biomedical ones. This model in mental health is derived from the movement in medicine generally, in which patient care is understood holistically (e.g., Hamburg & Collins, 2010). Exposure therapy has been characterized by its detractors as a one-size-fits-all approach to treatment (e.g., Shedler, 2017). However, as has been shown in this chapter, we could easily characterize exposure as a personalized medicine approach. Treatment is specifically tailored to the needs of the client, it is embedded in a culturally appropriate context, medical variables are accounted for, and consultation with appropriate medical providers is suggested. These factors should all be considered before clinicians conclude that multiple interventions are necessary. Personalized medicine calls for the identification of the full range of salient variables while determining the most efficient course of treatment. This means that treatment requires not necessarily more interventions, only the most targeted ones. In many instances, exposure can serve that purpose when crafted properly.



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