Cognitive Behavior Therapy (CBT) - An Overview, Strengths and Limitations

This report provides an overview of Cognitive Behavior Therapy (CBT), its strengths and limitations. It discusses the mental health conditions where CBT can be utilized, analyzes its strengths and weaknesses and key outcomes of the process.

Running head: Cognitive Behavior Therapy (CBT)
Cognitive Behavior Therapy (CBT)
Name of the Student
Name of the University
Author Note

1Cognitive Behavior Therapy (CBT)
Contents
Introduction (a brief overview)..................................................................................................2
Discussion..................................................................................................................................3
Strengths and Limitations of CBT:............................................................................................6
Strengths:................................................................................................................................6
Weaknesses:...........................................................................................................................8
Present Evidence Base on CBT:..............................................................................................10
Conclusion:..............................................................................................................................12
References:...............................................................................................................................14

2Cognitive Behavior Therapy (CBT)
Introduction (a brief overview)
Cognitive Behavior Therapy (CBT) can be understood as a type of psychosocial
intervention, which is the most popular evidence based practice of addressing and managing
mental health problems. CBT focuses on improving the personal coping mechanisms which
helps to tackle current challenges in the modification of negative cognitive patterns
(involving the beliefs, thoughts and attitudes of people), behavior of people and their
emotional modulations. This process was originally designed to manage depression, however
is not utilized for many other mental health problems (Farmer & Chapman, 2016).
CBT can also be understood as a type of talking therapy, which can be useful for
individuals to manage their problems by changing the way a person thinks and behaves
regarding the problem (Wright et al. 2017). According to NHS UK, CBT can be used not
only for depression and anxiety, but also other mental health issues (nhs.uk, 2018).
According to the Royal College of Psychiatrists, CBT is a way of talking about how a person
thinks about himself/herself, the world and others; and how the thoughts and feelings in turn
affects the actions of the person. Thus CBT is a way to change how a person thinks
(cognition) and how the person behaves. These changes can be useful to make a person feel
better; focusing primarily on the ‘here and now’ issues instead of the causes of the issues, and
thus tries to improve the current state of mind of individuals. Apart from anxiety and
depression, CBT can also be used in many other cases such as panic, phobia, stress, bulimia,
obsessive compulsive disorder (OCD), post traumatic stress disorders (PTSD), bipolar
disorder and psychosis. CBT can be additionally useful in anger management, low self
esteem and even to manage physical health issues like pain and fatigue (Rcpsych.ac.uk,
2018).

3Cognitive Behavior Therapy (CBT)
CBT integrates principles from cognitive and behavioral psychology, and differs from
psychotherapy (where meanings behaving each behavior are focused on). Instead, CBT is an
action oriented and problem based approach to treat specific mental health condition that has
already been diagnosed. The practice is also based on the understanding that distorted
through and maladaptive behavior has a crucial part in the persistence of mental health
problems and psychological disorders and that the adverse facets of these conditions can be
lowered by changing how information is processed and through coping strategies (Hayes et
al. 2016).
The purpose of this report is to understand the process of CBT, the mental health
conditions where CBT can be utilized, analyze its strengths and weaknesses and key
outcomes of the process.
Discussion
CBT generally comprises of 10- 20 sessions, which can last 1 hour each and conducted
one every week. The sessions can be individually delivered or in a family or small (focus)
group setup. In the recent years, computer programs which are internet based and assisted by
clinicians, are also used in the CBT process (Wright et al. 2017). According to the John
Hopkins Psychiatry Guide, CBT can involve different types of strategies such as:
 Psycho education: Here the patients are educated on the nature of mental health
issues, helping to increase understanding of its effects on cognition and behavior
of people.
 Cognitive Restructuring: This is the process of identifying; challenging and
eliminating maladaptive thinking process and incorporate adaptive, realistic and
coping thought processes.

4Cognitive Behavior Therapy (CBT)
 Exposure to fear, and reducing avoiding behavior (since negative reinforcements
can cause anxiety. This phase encourages individuals to approach or face their
fears.
 Behavioral activation: this allows individuals to increase their engagement in
constructive or pleasurable activities like exercising and also encourage the use of
social support systems.
 Relaxation training: this helps to alleviate psychological reactivity and trigger
mechanisms through relaxation routines which can include deep breathing
practice, guided imagery, and muscular relaxation techniques and through sensory
focus.
 Homework on out of session activities to develop mastery over the coping
strategies.
 Preventing Relapse through continued practice of CBT and developing strategies
for coping with future stresses and symptoms related to it.
According to the John Hopkins Psychiatry Guide, CBT have shown positive outcomes for
different types of mental health disorders. Among adults, different disorders which can
indicate the use of CBT as a form of intervention include the following:
 Anxiety disorders (like agoraphobia, panic disorder, social phobia, generalized
anxiety problems an specific phobias)
 Obsessive Compulsive Disorder (OCD)
 Post Traumatic Stress Disorder (PTSD)
 Depression
 Eating disorders (bulimia nervosa)
 Personality disorders (borderline personality disorder)
 Substance abuse problems

5Cognitive Behavior Therapy (CBT)
 Chronic pain and conditions like insomnia and headache
CBT can also be an important adjunctive treatment for bipolar disorder and schizophrenia
(when used along with pharmacological intervention). Among children and adolescents, CBT
was also found to be effective in the treatment of anxiety disorder, OCD, body dimorphic
disorder, PTSD, depression, tic disorders, Toilette’s syndrome, eating disorder, oppositional
defiant disorder, chronic pain and medical problems like chronic abdominal pain and
headache (Goldstein et al., 2015; Mataix-Cols et al., 2017; Martin et al., 2015).
The focus of CBT is to bring about a change in the attitudes of people and also their
behavior, by understanding the through, beliefs, attitudes and images held by individuals
which are the parts of the cognitive machinery, and tries to relate these aspects to how a
person behaves in order to deal with various situations. CBT also places a significant
importance on Negative Thoughts and where they originate. The CBT model suggests that
the meaning we give to specific events and not the events themselves are the aspects that
makes us upset. That is, if we have negative thoughts about something, it can lead to
improper cognition towards it and thus lead to maladaptive behavior. Also, the source of the
negative though is an important consideration of the CBT process. According to Beck, out
thinking patterns are developed in our childhood, and over time, it becomes automatic and
relatively constant. Any dysfunctional assumption that might have been confirmed by an
individual in the early childhood can lead to automatic thoughts. CBT tries to break the
system of automatic thoughts, and clear out dysfunctional assumptions and helps an
individual to examine the real-life experiences, trying to gain a better context to the problem,
trying to analyze how other might react to the same situation. The process also considers that
negative thoughts are a common phenomenon during a disturbed state of mind, and that it can
bias our interpretation of reality. CBT attempts to correct these misinterpretations (Farmer &
Chapman, 2016; Wright et al., 2017).

6Cognitive Behavior Therapy (CBT)
The CBT sessions with the therapist can include different activities. Given below is the
work involved in a typical CBT session with a therapist:
 Each of the problems is first broken down into its constituent parts. Keeping a dairy or
journal for this process can be very useful which will allow an individual to identify
their though patterns, emotions, bodily sensations and actions, and provide scope for
reflection and retrospect.
 The therapist and the patient will then analyze the thoughts together to identify
whether they are unhelpful/unrealistic/negative and how they might be affecting the
patient or others around them.
 The therapist then helps to work out strategies to change the
negative/unhelpful/unrealistic though patterns
 After proper strategies have been identified, the therapist assists the patient to
implement them. Homework’s might be given for practicing the skills.
 In each session, the progress on the previous session will be discussed, as well as how
the patient performed between the sessions. The therapist can then analyze the
progress of the therapy.
 Deciding upon the schedule and the strategies for the next CBT session will also be
done at the end of each session.
 (Farmer & Chapman, 2016; Wright et al., 2017).
Strengths and Limitations of CBT:
Strengths:
A. Different studies have shown that CBT is an effective treatment for mental conditions
like depression and anxiety disorders, and studies suggest that CBT can be as
effective as pharmacotherapy, regardless of how severe the condition is, among non-

7Cognitive Behavior Therapy (CBT)
psychotic patients. Use of CBT is not contra-indicated by pharmaceutical prescription,
and evidence shows that using the two treatments (pharmacotherapy and CBT)
simultaneously can reinforce the effect. However, CBT therapy can be done without
the need of pharmacotherapy, and hence, is not associated with any side effects, as
seen with most pharmacotherapy (Wright et al., 2017).
B. Existence of detailed information allows the effective communication of the
technique, as well as being standardized, replicated ad evaluated. CBT therapies are
usually of shorter length and cheaper, compared to psychotherapy which can be
expensive and time consuming. CBT moreover focuses on the management of
symptom rather than creating an insight, which can allow quicker identification of
technique to cope up with the condition. The shorter duration of CBT is also helpful
for people who wants to schedule them between works, and thus does not
significantly hamper the flow of their day to day life, unlike psychotherapy
(Hoffmann et al., 2014).
C. In CBT it is important to develop the involvement of the client, and it is a hallmark
feature of this therapy. Interpreting the cognition of the client and help to tackle them
is done in CBT through an active partnership between the client and the therapist.
They can also engage in a ‘Socratic Dialogue’ which can lead to the interpretation of
their thinking. Hence most approaches of CBT puts vital focus in the development of
a good interaction between the client and therapist, which can encourage the client to
speak about their thoughts, and considers that therapeutic alliance is an important
factor of cognitive techniques and helping to reach desired outcomes in client health
(Pugh et al., 2015).
D. CBT approaches are more focused on the reduction of symptoms beyond the effects
of the condition because of more generalized factors of therapy such as empathy and

8Cognitive Behavior Therapy (CBT)
kindness. Studies show that she’s can be an effective tool for community psychiatric
nurses (CPN), and that in patients suffering from severe depression, CPN’s who did
not have any training in CBT failed to cause any improvement in the mental health
condition of the patients (Diehle et al., 2015).
E. Interviews on clients have shown that CBT is considered to be more ‘user friendly’ by
them compared to other forms of therapy (like psychotherapy or pharmacotherapy),
and also has lower dropout rates than other therapies. Also, CBT focuses on the
present, and not on hypothetical factors like the unconscious mind, resistance and
transference non-utilization (Barlow et al., 2016).
Weaknesses:
A. Critiques have pointed out that the theory of depression by Beck, in the context of stable
and dysfunctional belief is inconclusive, and has negative views regarding the causal
factors of cognition. The design of CBT is also criticized as being ‘convenient and self
serving’ which tries to place cognitive therapy against psychopharmacotherapies, and
thus can have an antibiological and propsychological point of view (Wright et al., 2017).
B. According to some authors, CBT considers the cognitive triad (which the development of
negative views about self, others and the future) and maladaptive cognition results in the
maintenance of depression. However, many authors, including Beck also suggested that
the cognitive problems are not really the cause of depression, but possibly its
characteristic symptom (Beck et al., 2015).
C. There is also a criticism about the studies that support the efficacy of CBT to treat
depression and anxiety, which suggests that the studies only points out that CBT is an
efficient therapy but does not justify its validity fully. Moreover, in CBT there is the
possibility of the therapist to develop a subjective bias while trying to find the bias in the
thinking process of the client (such as forgetting or remembering information, first

9Cognitive Behavior Therapy (CBT)
impressions, and making clinical decisions). This shows that the therapist objectivity can
be jeopardized while trying to decide which through process is rational, what cognitive
process needs to be changes and what are the dysfunctional beliefs and values in the
client. Identification of these aspects are very important in CBT especially considering
evidences that show that individuals suffering from depression can be more accurate in
their perception of reality, and more realistic in its appraisal as well as of the world,
themselves and others than non depressed individuals (Meichenbaum, 2017).
D. Some authors believe that CBT is effective in case of reactive depression, and not for
psychotic, severe depression. Also, CBT is ineffective in cases of complex mental health
conditions (Wright et al., 2017).
E. Some of the assumptions in CBT are inapplicable in cases of clients with personality
disorders, learning and intellectual disorders (Wright et al., 2017).
F. There is an inadequate level of comprehension of the mechanisms that underlie mental
health conditions, lacking the application of basic psychological researeech approaches
and there are different terminologies used to describe similar cognitive functioning, which
makes its study confusing, and lacks a theoretical unity (Farmer & Chapman, 2015).
G. CBT approaches have also been considered very restrictive, since in this therapy
emotions are considered as factors which needs to be regulated instead of experiencing
them, and the therapists put too much emphasis on rationalizing the though process
instead of focusing on the unconsciousness part of it (Ho et al., 2015).
Present Evidence Base on CBT:
De Castella (et al., 2015) pointed out that CBT can be applicable for the treatment of
Social Anxiety Disorders, and suggested that changes in the beliefs of the client regarding
their emotions has a crucial function in CBT for SAD. The authors conducted a randomized
controlled trial where they analyzed the beliefs of the participants regarding the fixed versus

10Cognitive Behavior Therapy (CBT)
variable nature of their anxiety as a key factor for CBT in SAD. According to the authors, the
cognitive models of the SAD outlines several distortions in cognitive process, and
dysfunctional beliefs associated with the aetiology and sustenance of the disorder. It is
suggested that in a cycle of destruction, these factors can cause an emotional over response,
an inability to regulate the emotions, cause avoidance behavior, all of which can further
exaggerate the symptoms of anxiety. Models of anxiety disorder highlight several
maladaptive processes that can foster the mentainance of the dysfunction. These processes
can be divided into three types: 1) beliefs about social situations which can include unrealistic
thinking and expectations, inadequate self efficacy, and dysfunctionality in beliefs regarding
the probability and costs of behaving poorly 2) Belief regarding oneself which includes a
negative perception of self, rumination and an increased self focus and attention 3) beliefs
regarding self emotions which includes a belief that one has little control over their emotions.
The Authors believe that CBT is able to address these distortions and thus are suitable
therapy for treating anxiety.
Zipfel et al. (2014) in The Anorexia Nervosa Treatment for Outpatient (ANTOP)
study analyzed two methods of treatment, namely CBT, focal psychodynamic therapy and
optimized treatment. The authors screened 727 adults, 242 of whom underwent
randomization, 80 to focal psychodynamic therapy, 80 to CBT and 82 to optimized treatment.
The study lost 54 participants during follow-ups and 30% dropout by the end of 12 months.
By the end of the treatment, an improvement in BMI was observed in all study groups;
however, in case of the CBT group the rate of improvement in BMI was seen to be the
fastest. Based on such evidences, the authors suggested that CBT can be regarded as a solid
baseline treatment for adults with anorexia nervosa. The findings from the study showed that
multicentre outpatient studies are possible for individuals with anorexia nervosa. The authors
showed that the patients can be treated safely, and that the patients can eventually gain

11Cognitive Behavior Therapy (CBT)
weight, and that a significant part of the studied population showed improvements in their
eating habits, pathology and associated psychopathology, with CBT showing evidence of
causing the fastest rate of recovery. This proves that CBT is an effective tool in the treatment
of eating disorders such an anorexia nervosa.
Gilbody et al. (2015) studied the utility of Computerised CBT to treat depression in a
primary care trial setup, as a part of a randomized controlled trial. Here the participants, all of
whom were adults with depression symptoms (scores of 10 or more on the PHQ-9
questionnaire) were given a computerized CBT therapy and the usual GP care in randomized
groups. Encouragement was given to the participants to complete the program using the
weekly phone calls. The control group was provided the usual GP care. The primary outcome
was measured using the PHQ-9 questionnaire after 4 months of treatment, and secondary
outcomes identified in the study were the quality of life related to health (measured by SF-36)
and psychological well being (measured using CORE-OM) at fourth, twelfth, and twenty
fourth months. The study showed that Computerised CBT does not cause any significant
improvement in the depressive symptoms compared to the usual GP care provided alone. The
study highlights that computerized CBT might not be an entirely efficient method for treating
mental health condition. The results of these trials were different from the developer led trials
in the aspect that these trials were conducted entirely in the primary care center, with is the
most common setup where treatment for depression can be provided. This is different from
other trails where the target participants were recruited on the internet of from a secondary
care setup, and thus the results of these trials can be applied to primary care setup.
Freeman et al. (2015) studied the effects of CBT for worry on persecutory delusions
in patients with psychosis, in a parallel, single blind, randomized controlled trial. The authors
suggested that worry can be a significant factor that contributes to the development of
persecutory delusions (illogical fear of being persecuted) among patients with psychotic

12Cognitive Behavior Therapy (CBT)
disorders, which led to the postulation that by reducing the worry using CBT, the delusions
can be reduced or controlled. The study was conducted as four assessors blinded, two armed
tests, on patients between the age of 18 and 65 years showing signs of persistent persecutory
delusions, with a score of at least 3 on the Psychotic Symptoms Rating Scale (PSTRATS).
The study found that reduction in long standing delusions were achieved through brief
interventions which focused on the worries of the patients, and thus the findings suggests that
worry can lead to paranoia, and interventions for worry can be a significant addition to the
treatment for psychosis.
Conclusion:
The overview of the analysis of CBT shows that CBT has different strengths and weaknesses,
which decides the conditions and situations in which it can be applied. The strengths of the
process includes its efficacy in the treatment of mental health conditions such as depression
and anxiety, and that it can be as effective as pharmacotherapy. The availability of sufficient
details on this process allows it to be perfectly communicated and replicated in different
studies and treatment approaches. The treatment helps in thru development of a therapeutic
relation bet went the client and the therapist CBT puts focus on reducing the symptoms of the
mental health condition and uses basic techniques like empathy to understand the thoughts of
the patients. And clients have also shown preference towards CBT compared to other forms
of treatment, stating that they found CBT to be more user friendly, and thus also was
associated with fewer dropouts on the long term. CBT also has few weaknesses; such as CBT
is based on a dysfunctional idea regarding the causal factors of cognitive dysfunction the
treatment also is unable to differentiate the symptoms of a mental health condition from its
causes in while focusing on specific issues. Also, the studies that found CBT’s efficacy in the
treatment never really proved the validity of CBT and there is also the chance that the
therapist might develop biases during the treatment while trying to identify the cognitive

13Cognitive Behavior Therapy (CBT)
distortions in the client. The usage of CBT is also found to be limited in complex mental
health issues like personality disorders, learning and intellectual disorders. The process also
does not focus on the underlying causes of mental health conditions, which is another
limitation. Moreover, some author also critiqued CBT to be very restrictive as it only
considers emotions as factors that needs to be controlled and not expressed.
Studies by De Castella et al. (2015) showed that CBT can be used to treat social anxiety
disorders, while Zipfel et al (2014) suggested that CBT can be an effective baseline treatment
for anorexia nervosa. Studies by Gilbody et al (2015) showed that computerized CBT are not
a better tool compared to treatment at GP, highlighting that they should not be depended on.
Also, Freeman et al. (2015) showed that CBT can be useful to treat even psychosis, by
reducing the level of worries in the patients, and thus reduce their persecutory delusions.
These studies show that CBT can be an effective tool for the treatment of various types of
mental health conditions.

14Cognitive Behavior Therapy (CBT)
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