Cognitive and Behavioral Therapies: Treatment

Selection of this Modality

Selection of CBT for an individual patient should be based on the appropriateness of CBT for the treatment situation. Relevant questions include: Is the patient psychotic? If so, are there spe-cific target behaviors and has psychopharmacological treatment been optimized? Does the patient suffer from a disorder known to be responsive to CBT? Within groups of patients with poten-tially treatable disorders, other indicators of responsivity include chronicity, severity and comorbidity (Whisman, 1993; Thase et al., 1993). A good general rule is that patients with acute, mild to moderately severe, mood and anxiety disorders are the best candidates for treatment with CBT alone (Thase, 1995). Patients with more chronic, severe, or complicated illnesses may be better candidates for combined treatment strategies than for CBT alone (Wright and Thase, 1992; Thase and Howland, 1994; Friedman, 1997). McCullough (2000) has developed a variant of CBT for chronic depression that has shown much promise alone and com-bined with antidepressant medication.

Preparation of the Patient

The cognitive and behavioral therapies explicitly incorporate strat-egies to increase involvement and preparedness of the patient for therapy. Patients are typically encouraged to read relevant written materials describing the theory and strategies of the therapy; for common disorders, such as major depressive disorder and panic disorder, self-help manuals for patients are now available (Burns, 1990; Greenberger and Padesky, 1995; Wright and Basco, 2001). Patients beginning CBT need to become acculturated to the follow-ing: 1) they will be active participants in trying out new strategies; 2) they will be expected to do homework; 3) the outcome of therapy will be measured and strategies will be altered if they are not help-ing; 4) therapy will be focused on symptoms and social functioning and generally will be time limited in nature; and 5) the chances of success after treatment termination can be gauged by the patients’ incorporation of the therapy into their day-to-day life.

Phases of Treatment

Most cognitive and behavioral therapies may be viewed as us-ing a three-stage process. The initial phase includes the proc-esses of clinical assessment, case formulation, establishment of a therapeutic relationship, socialization of the patient to therapy, psychoeducation and introduction to treatment procedures. The middle stage involves the sequential application and mastery of cognitive and behavioral treatment strategies. The second stage ends when the patient has obtained the desired symptomatic out-come. The final phase of therapy is characterized by preparation for termination. The frequency of sessions is reduced, and there is a steady transfer of the responsibility for the continued use of therapeutic strategies from the therapist to the patient. The third stage of treatment also focuses on relapse prevention. Strategies used at this point include anticipation of reaction to future stres-sors or high-risk situations, identification of prodromal symp-toms, rehearsal of self-help procedures and establishment of guidelines for return to treatment (Otto et al., 1993; Thase, 1993). The failure to achieve a remission of depressive symptoms after 16 to 20 weeks of treatment may indicate a need for continuation phase treatment to achieve these goals and maintenance phase treatment for relapse prevention. Incomplete symptomatic remis-sion after 20 weeks of CBT may also indicate the need for adding pharmacotherapy to the treatment plan as we discuss in greater detail below.

Intensity of Treatment

Outpatient CBT is normally conducted once or twice a week. In selected cases, three-times-weekly or even daily sessions may be useful, but the cost-effectiveness of such a labor-intensive ap-proach is uncertain. Therapists should adjust the frequency and intensity of treatment in concert with the needs of patients as well as the therapy resources that are available.

Duration of Treatment

In most cases, treatment is conducted in a period of 3 to 6 months. For those who begin therapy as inpatients, a similar period of aftercare is strongly recommended (Thase, 1993). Unsuccessful therapy (e.g., failure to effect significant symptomatic improve-ment) should generally not continue past 12 to 16 weeks for out-patients. Therapy should not be terminated until patients have achieved symptomatic remission. Ideally, at least two or three sessions are planned on an every-other-week basis in preparation for termination.

Outcome Assessment

Cognitive and behavioral therapies are, in part, distinguished by their integrated use of objective assessment methods. For de-pression and the anxiety disorders, a number of well-established rating scales are available. Therapist-administered scales include the Hamilton Anxiety Rating Scale (Hamilton, 1959) and the Hamilton Depression Rating Scale (Hamilton, 1960) as well as the Yale-Brown Obsessive–Compulsive Scale (Goodman et al., 1989). Self-report assessments of symptoms include the Beck Depression Inventory (Beck et al., 1961), the Beck Anxiety Inventory (Beck et al., 1988), the Fear Survey Schedule (Wolpe and Lang, 1964), the Fear Questionnaire (Marks and Matthews, 1979) and the Hopkins Symptom Checklist (Derogatis et al., 1974). These scales are typically administered before treatmentand repeated periodically (e.g., weekly or monthly) to monitor progress. The Dysfunctional Attitudes Scale, the Attributional Style Questionnaire and the Automatic Thoughts Questionnaire may be used to evaluate distorted cognitions (Dobson and Shaw, 1986). As suggested earlier, high residual levels of cognitive symptoms most likely convey an increased risk for relapse af-ter termination of treatment (Thase et al., 1992; Simons et al., 1986). Similarly, high scores on the Hopelessness Scale (Beck et al., 1974) have been associated with a high risk for subsequent suicidal behavior (Beck et al., 1985b).

Augmentation of Therapy

One of the major methods of augmenting a cognitive and behav-ioral therapy is to add an appropriate form of pharmacotherapy. For example, a depressed or agoraphobic person who has not ben-efited much from 8 weeks or more of CBT alone should probably be considered for pharmacotherapy. There are no contraindica-tions to combining CBT and pharmacotherapy (Hollon et al., 1991; Wright and Thase, 1992).

Continuation and Maintenance Phase CBT

Because some patients do not completely achieve a remission of symptoms (their return to premorbid well state) and because many patients experience depression as a recurring illness, there is a need for longer-term treatment methods for major depres-sion (Kupfer et al., 1986). Furthermore, incomplete remission of depression leads to recurrence, and this has many adverse eco-nomic, interpersonal and medical consequences (Thase, 1992).

Efficacy of CBT

The cognitive and behavioral therapies are, as a class, the best studied type of psychotherapy. Numerous research studies have demonstrated the efficacy for a variety of Axis I DSM IV dis-orders including mood disorders (Thase, 1995; Dobson, 1989; Depression Guideline Panel, 1993), anxiety disorders (Wolpe, 1982; Clum et al., 1993; Beck and Zebb, 1994; Chambless and Gillis, 1993; Durham and Allan, 1993; Butler et al., 1991; Barlow et al., 2000) and eating disorders (Agras et al., 1992, 1994, 2000; Fairburn et al., 1991, 1992, 1993, 1995; Garner 1992; Goldbloom et al., 1997; Walsh et al., 1997; Wilson, 1999; Ricca et al., 2000). CBT approaches have also been used to treat personality disor-ders and as part of multimodal treatments for schizophrenia and bipolar disorder.