TARGET ARTICLEThe Science of Cognitive Therapy☆
Highlights
► Cognitive therapy refers to a family of interventions. ► The core model assumes that cognitions causally influence emotions and behaviors. ► The model is supported by treatment studies and recent neurobiological studies. ► We discuss the cognitive models of PTSD and health anxiety as two specific examples.
Section snippets
The Model of Scientific Development
CT is not specifically linked to a particular philosophical tradition. The philosophical foundation most closely associated with CT is critical rationalism, an epistemological philosophy (Popper, 1959) that shares its philosophical roots with the natural sciences. The core assumption of critical rationalism is that knowledge can only be gained by attempting to falsify hypotheses that are derived from scientific theories. Based on this philosophy, knowledge is objective and, thereby, shows
The Interplay of Cognition and Emotion in CT
The core model of CT holds that cognitions causally influence emotions and behaviors and, in the case of dysfunctional thoughts and cognitive distortions, contribute to the maintenance of psychopathology. It should be noted that the relationship between emotions and cognitions is bidirectional because changes in emotions can also lead to changes in cognitions. The CT model simply builds on the fact that emotions are strongly, and causally, influenced by the perception of events or situations.
The Treatment Goals
Emotional disorders are typically associated with negatively valenced emotional responses, such as fear, sadness, anger, and heightened level of distress. The goal of CT is not to eliminate or regulate these emotions in general. Instead, the goal is to foster the abilities of patients to provide for themselves more realistic and accurate appraisals of the situations that they face. Cognitive techniques do not ask patients to think positively but rather more realistically.
As described above, the
Hypothesized Mechanism of Treatment Change
In its simplest form, the CT model predicts that changes in cognitions causally lead to changes in behaviors and emotions. When CT was first developed, little empirical support existed for this basic model (Hollon & Beck, 1986). However, as statisticians developed strategies to test for treatment mediation, data has since accumulated to support the cognitive model for the treatment of panic disorder (Hofmann et al., 2007), social anxiety disorder (Hofmann, 2004, Smits et al., 2006),
Relationship to the Medical Model and Its Diagnostic System
Many contemporary cognitive models of psychopathology are aligned with medical classification systems of mental disorders, such as that provided by the DSM-IV-TR (American Psychiatric Association, 2000) and the International Classification of Diseases-10 (ICD-10; World Health Organization, 1992, World Health Organization, 1993). Cognitive-behavioral researchers and clinicians have taken advantage of the semblance of order that these atheoretical classification systems offer to the field of
Efficacy of CT
A review of the efficacy of CT for mental disorders would easily fill a textbook. A recent review of 16 meta-analytic studies found large controlled effect sizes for CT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia (i.e., social anxiety disorder), PTSD, and childhood depressive and anxiety disorders, and medium controlled effect sizes for CT of chronic pain, childhood somatic disorders, marital distress, and anger (Butler et
The Biological Correlates of Cognitions and CT
The cognitive and affective neuroscience literature convincingly shows that changes in cognitions due to CT are associated with changes in brain activity. The literature on the effects of cognitions on brain activity is enormous, and we can provide only a glimpse into this exciting literature.
The Role of Cognitions in Extinction and Conditioning Processes
Even basic learning is moderated and possibly mediated via cognitions. In the case of fear learning, it has been shown that fear can be acquired without directly experiencing the conditioned stimulus (CS) and unconditioned stimulus (US). For example, Rhesus monkeys learn quickly to acquire a fear of snakes simply by observing another monkey respond fearfully to them. Similarly, observing another monkey responding nonfearfully can effectively prevent the acquisition of this fear following later
The Family of CTs
Psychology is most commonly defined in contemporary textbooks as the scientific study of behavior and mental processes. CT, which is rooted in behavioral and cognitive sciences, targets psychotherapy as the object of scientific study. Since its initial development, CT has undergone extensive scientific scrutiny through comparisons in RCTs, component analyses, and mediation analyses (as discussed above). Predictions of aspects of the intervention have been tested in laboratory experiments, and
Examples of CT Models and Treatments
CT, as with every advanced science, has many subdisciplines. All CT approaches are connected by the same basic model (i.e., cognitions causally affect emotions and behaviors), but the various techniques and models show a number of unique features, depending on the targeted disorder.
Although traditional CT protocols are more effective than placebo treatments, there is clearly still room for improvement. For example, the average effect size of CT for anxiety disorders is 0.73 (Hofmann & Smits,
Discussion
CT is a general scientific approach to psychological disorders that has been the foundation of a wide variety of psychological treatments. The overarching principle of these interventions is that cognitions causally influence emotional experiences and behaviors. We reviewed two prominent CT models to illustrate the significant variations in the basic assumptions of the maintaining factors of the disorders and the differences in the disorder-specific treatment techniques. The Ehlers and Clark
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Stefan G. Hofmann is supported by grant R01MH078308 from the National Institute of Mental Health and is a paid consultant by Organon (Schering-Plough) for issues and projects unrelated to this article and is an advisor to the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group. Gordon J. G. Asmundson is supported by a Canadian Institutes of Health Research (CIHR) Investigator Award. We thank Kelly G. Wilson, Murray Abrams, and Kelsey Collimore for their comments on an earlier draft of this manuscript.