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in Cognitive
Innovations in Cognitive Behavioral Therapy provides clinicians with a powerful
arsenal of contemporary, creative, and innovative strategic interventions for use
in cognitive behavioral therapy (CBT). This book goes well beyond standard CBT
texts by highlighting new developments in the field and advancing a new definition
of CBT that reflects the field’s evolution. Throughout these pages, clinicians will
find empirical research to back up recommended strategies and discussion of ways
to translate this research into their clinical practice. Readers can also turn to the
book’s website for valuable handouts, worksheets, and other downloadable tools.

Amy Wenzel, PhD, ABPP, is owner of Wenzel Consulting, LLC, clinical assistant
professor of psychology in psychiatry at the University of Pennsylvania School
of Medicine, and adjunct faculty member at the Beck Institute for Cognitive
Behavior Therapy. She is author or editor of twenty books and approximately
one hundred peer-reviewed journal articles and book chapters. She is a certi-
fied trainer-consultant with the Academy of Cognitive Therapy and trains and
supervises clinicians internationally in their acquisition of cognitive behavioral
therapy skills. Her research has been funded by the National Institute of Mental
Health, the American Foundation for Suicide Prevention, and the National
Alliance for Research on Schizophrenia and Depression (now called Brain and
Behavior Research Foundation). She has been featured in many American Psy-
chological Association videos demonstrating cognitive behavioral therapy for
depression and anxiety.
“Amy Wenzel is a wonderful story teller. Reading this book gives one the taste of
going through the complexities of cognitive-behavior therapy in a very pleasant
learning experience. I invite you to sit back, relax, and enjoy this book as though
you were listening to a pleasant story of CBT innovations.”
Irismar Reis de Oliveira, MD, PhD, professor of psychiatry,
Department of Neurosciences and Mental Health,
Post Graduation Program, Federal University of Bahia, Brazil

“Innovations in Cognitive Behavioral Therapy by Amy Wenzel deserves high praise

for its original and truly integrative approach to CBT. This well-written and inci-
sive text is replete with clinically rich descriptions of both enduring and recent evi-
dence-based methods, and it will be valued by novice and expert therapists alike.”
Keith S. Dobson, PhD, professor of clinical
psychology, University of Calgary
in Cognitive
Strategic Interventions
for Creative Practice

Amy Wenzel
First edition published 2017
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© 2017 Amy Wenzel
The right of Amy Wenzel to be identified as the author of this work has been
asserted by her in accordance with sections 77 and 78 of the Copyright,
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List of Figures vii

List of Exhibits viii
Preface ix
Acknowledgments xiii

1 Evolution of Cognitive Behavioral Therapy 1

2 Case Conceptualization 19

3 Motivational Interviewing 40

4 Cognitive Restructuring of Automatic Thoughts 56

5 Cognitive Restructuring of Beliefs 73

6 Behavioral Activation 92

7 Exposure 107

8 Affect Management 126

9 Acceptance and Mindfulness 141

vi Contents

10 Cognitive Behavioral Therapy: A Redux 163

References 174
Index 204

2.1 Basic Premises of Cognitive Theory 20

2.2 Ginny’s Cross-Sectional Case Conceptualization 32
2.3 Ginny’s Cross-Sectional Case Conceptualization With Strengths 33
5.1 Living a Valued Life 87
5.2 Actual Versus Ideal Pie Chart 89
8.1 Continuum of Emotion Regulation to Distress Tolerance 127
9.1 Balance Between Acceptance and Change 142
10.1 Integrative Cognitive Behavioral Therapy 169
10.2 Overlap Among Cognitive Behavioral Therapy Approaches 171


2.1 Traditional Case Conceptualization for Ginny 25

3.1 Common Motivational Interviewing Techniques 43
4.1 Manifestations of Cognition 61
5.1 Young’s Early Maladaptive Schemas 79
7.1 Sample Exposures to Social Mishaps 121
8.1 Targeted Muscle Groups in Progressive Muscle Relaxation 129
8.2 Innovative Dialectical Behavior Therapy Affect Management Skills 134
9.1 Mindfulness-Based Cognitive Therapy Exercises and Practices 146
9.2 Tools for Achieving Acceptance of Emotions 150
9.3 Domains in Hayes et al.’s (2012) Values Assessment Exercise 153


This book was very challenging to write. Educational, invigorating, and growth
enhancing but challenging all the same. It is perhaps the “messiest” book I have
ever written, given the substantial differences in the way in which scholarship has
evolved for each of the topics I have chosen to cover. At the same time, I am a bet-
ter scholar and clinician because of it. And I hope this sentiment extends to my
readers, such that they will be better scholars and clinicians because of it as well.
My original vision for this book was for it to be a compilation of new, creative,
and exciting cognitive behavioral therapy (CBT) strategies and corresponding
techniques—in other words, a focus away from the tried-and-true strategies
and techniques that are described in countless textbooks and instead a focus on
what is happening in the field that is innovative. I expected to follow a format
in which I would devote approximately one quarter of each chapter to a sum-
mary of traditional or standard CBT strategies and techniques and then focus
the remainder of each chapter on innovations. For the most part, I believe that
what follows is true to this vision.
However, when I began to delve into my thinking about the proposed topics,
as well as scholarly reviews and empirical data, at nearly every juncture I encoun-
tered fundamental issues that I needed to resolve for myself and, ultimately, for
my readers.
For example, what is innovative? To me, the word innovative implies that some-
thing is new and creative. But as the book unfolded, I saw the need to give due
attention to some very creative CBT approaches that have been around for decades
and that were the result of so much original thought that by not acknowledging
them as innovative, the book would be sorely lacking. Thus, Jacqueline Person’s

x Preface

case formulation approach, Jeffrey Young’s schema therapy, Marsha Linehan’s dia-
lectical behavior therapy, and Mark Williams, Zindel Segal, and John Teasdale’s
mindfulness-based cognitive therapy (to name but a few) are examples of well-
established approaches that, in this book, are all regarded as innovations, even
though they have been around for many years and have, themselves, spawned
innovative work in the field. Even behavioral activation, which has its roots in
behavioral approaches to the treatment of depression that were described in the
1970s, is regarded as innovative on the basis of the resurgence of attention it has
received beginning in the late 1990s.
I am a scholar-practitioner who truly values evidence-based practice. As such,
I pay close attention to the empirical data when I write about specific strategies
and techniques, and I use the empirical data to guide my clinical decisions in prac-
tice. I would have welcomed a straightforward threshold for deciding whether to
include a particular technique in this book (e.g., “I will only include this technique
in my book if at least two empirical studies have demonstrated that it is effica-
cious in reducing symptoms of mental health and adjustment problems.”). Wishful
thinking. There was much inconsistency regarding the degree to which new CBT
packages, consisting of innovative strategies and techniques, have been subject to
empirical scrutiny. For example, the contemporary approach to behavioral acti-
vation (see Chapter 6) has received so much attention in the empirical literature
that, at present, it is safe to say that it, by itself, can be considered a stand-alone
treatment for major depression. On the other hand, although there is impressive
and sophisticated scholarship on the rationale for an inhibitory learning-based
approach to the delivery of exposure for anxiety-related disorders, a true inhibitory-
learning exposure-based treatment has not been evaluated using a randomized con-
trolled trial (RCT) design. Nevertheless, the principles of the inhibitory learning
paradigm are grounded in much empirical research—not only research in clinical
psychology but also research in cognitive and experimental psychology. Accordingly,
it is also allotted a great deal of attention in this book (see Chapter 7). Other CBT-
based treatment packages have preliminary empirical evidence supporting their
efficacy on the basis of open trials (e.g., emotion regulation therapy; see Chapters 8
and 10) or one or more small RCTs (e.g., capnometry-assisted respiratory training;
see Chapter 8). Still other innovations described in this volume have their basis in
clinical experience, such as my application of activity monitoring and scheduling to
a client with a gambling addiction (see Chapter 6). Some of the innovations I refer-
ence are actually flexible adaptions of traditional CBT techniques, such as many of
the suggestions I make to incorporate innovation into cognitive restructuring (see
Chapter 4). Although seasoned cognitive behavioral therapists would likely argue
that they have been implementing some of these adaptations for years, I included
them in the section on innovations to reinforce the notion that CBT can be delivered
in a flexible, creative manner and that clinicians need not be limited to the tradi-
tional ways in which these interventions are portrayed in classic texts.
In the absence of a consistent standard for an evidence base that could guide my
selection of strategies and techniques described in this volume, I elected to take an
“above-board” approach throughout. When findings from RCTs and open trials
Preface xi

exist, I make mention of them. When an innovation is based on an extension of

theory and data in the empirical literature, but has not yet, itself, been subjected
to empirical scrutiny, I point this out. On occasion, I describe an innovation that
is based on clinical experience only, and again, I am clear about this. Innovations
need to start somewhere. Thus, my decision to include even the innovative strate-
gies and techniques that have yet to accumulate evidence supporting their efficacy
rests in my commitment to respect and showcase innovation and stimulate direc-
tions for future research.
Moreover, as is stated on many occasions throughout the book, I encourage all
therapists to conduct themselves as scientist-practitioners. This means that, in the
absence of data from the empirical literature, we, as clinicians, can collect our own
“data” with individual clients and use those data to inform treatment. This also
means that we base our clinical interventions on established principles of human
behavior (as Michelle Craske and her colleagues have done in developing their
inhibitory learning approach for the delivery of exposure therapy; see Chapter 7).
In these ways, we are taking a reasoned, strategic approach to treatment rather
than being swept away in the moment in our clients’ crises or changing course due
to assumptions that may or may not be valid.
At times, there were inconsistencies encountered in terminology. The most
salient example of this occurs in Chapter 8, where I focus on emotion regula-
tion and distress tolerance under the general rubric of affect management. The
renowned Marsha Linehan, developer of dialectical behavior therapy (DBT), goes
to great lengths in differentiating between emotion regulation and distress toler-
ance. The former pertains to techniques for modulating the frequency and inten-
sity of negative emotional experiences over time, whereas the latter pertains to
techniques for surviving moments of extreme distress without engaging in self-
defeating behavior. In reality, however, the distinction between the two is often
blurred. To take but one small example, muscle relaxation is regarded as one spe-
cific distress tolerance skill in Linehan’s (2015) skills training manual, but it is also
included in Douglas Mennin and David Fresco’s emotion regulation therapy for
generalized anxiety disorder (GAD; Mennin & Fresco, 2014). How do we reconcile
this? Is muscle relaxation best viewed as a short-term technique for managing
distress or as a longer-term technique for achieving emotion regulation? I believe
both to be true. Thus, I view strategies geared at “affect management” to be on a
continuum with emotion regulation at one end of the pole and distress tolerance
at the other end of the pole, with most strategies falling somewhere in between.
Chapter 8 is devoted to the strategies that fall on this continuum.
At the most fundamental (and perhaps most jolting) level, I began to philosophize
around the question “What is CBT?” Although many would regard the prototype of
CBT to be Aaron T. Beck’s cognitive therapy, it is accepted that CBT is actually a
family of treatment packages, with cognitive therapy being a quintessential example
and one that has exerted perhaps the greatest influence on the others (Greenberg,
McWilliams, & Wenzel, 2014). But even if we accept this definition of CBT, the outer
boundaries are still unclear. For example, Keith Dobson and David Dozois (2010),
in their excellent chapter on the historical and philosophical basis of CBT, clearly
xii Preface

indicated that for a treatment to be considered cognitive behavioral, a basic premise

underlying its use is that cognition mediates behavior change, even if the primary
intervention is behavioral in nature. They stated that a therapeutic approach like
applied behavioral analysis would be outside the purview of CBT because classi-
cal and operant conditioning, rather than cognitive mediation, would be regarded
as the mechanisms by which its interventions work. Nevertheless, applied behav-
ioral analysis is increasingly being included in handbooks on cognitive behavioral
approaches (such as Nezu & Nezu, 2016, as well as my own forthcoming two-volume
Handbook of Cognitive Behavioral Therapy). Moreover, evidence supporting the
mediational model is inconsistent, at best (Longmore & Worrell, 2007). In addition,
there is great debate in the literature regarding the degree to which mindfulness
and acceptance-based approaches should be considered members of the CBT family
or are theoretically and empirically distinct (Hayes, 2004; Hofmann & Asmundson,
2008). The title of Linehan’s (1993a) DBT textbook (describing a mindfulness and
acceptance-based approach) is Cognitive Behavioral Treatment of Borderline Per-
sonality Disorder; yet, the theoretical underpinnings are much more aligned with
applied behavioral analysis and acceptance than with cognitive mediation. Accep-
tance and commitment therapy (ACT; see Chapter 9) was clearly developed as an
alternative to CBT on the basis of a systematic series of studies demonstrating that
factors other than change in cognitive contents mediate the association between
upsetting situations and emotional distress (Hayes, 2004; Hayes, Strosahl, & Wilson,
2012), and yet, many consider it as belonging to the family of cognitive behavioral
therapies. In the final chapter of this volume on challenges (Chapter 10), I propose
a scheme for making sense of the tension inherent in this issue and offer a recom-
mendation for a way to move toward a reconciliation.
In the end, I compiled a volume of CBT treatment packages, strategies, and
techniques that are meant to stimulate critical thought, creativity in clinical
practice, and directions for scholarly research. The strategies and techniques
included in this book are the result of one person’s read of the scholarly litera-
ture, with a corresponding application to her clinical practice. Though I am one
who perseveres until the job is done, it was impossible to read the entire CBT lit-
erature (which is what I set out to do at the inception of this book, and which, if
I realized this dream, would delay the publication of this book by several years).
It is certain that many of the strategies and techniques included in this volume
are ones that the reader would not have identified on his or her own, and it is
also certain that the reader will wonder why a particular strategy or technique
was omitted (in fact, one major type of CBT strategy—problem solving—had to
be omitted due to the sheer volume of the other innovations that I had accumu-
lated). I encourage the reader to approach the volume from a broad perspective
and to take away a challenge from the volume: How can I develop or implement
strategic CBT interventions with creativity and innovation while simultaneously
maintaining integrity to CBT’s traditional theory, structure, and principles? It is
my view that scholarship and practice conducted in light of this question will
guide the next generation of cognitive behavioral intervention.

Like most projects of this magnitude, it took a village to cultivate this book from
its inception to its completion.
First, I would like to acknowledge the assistance of several colleagues who
patiently answered questions and provided their perspectives on several issues as I
drafted this volume. Pamela Hays, Jennifer Lish, Deborah Van Horn, Irismar Reis
de Oliveira, Alicia Meuret, Donald Meichenbaum, Aaron T. (Tim) Beck, and Judy
Beck, your time and expert consultation were invaluable.
Second, I would like to acknowledge the tremendous support and patience pro-
vided by senior editor Anna Moore. I delayed the submission of this volume on
(at least) two occasions, as “life got in the way” and as I saw just how expansive
the current cognitive behavioral therapy (CBT) literature in which I needed to
immerse myself has become. You never doubted that I would complete the project,
and you never questioned my progress. For that, I am grateful. And you have even
recruited me to write another book for Routledge! I look forward to continu-
ing our productive working relationship. On a related note, I would also like to
acknowledge the talent and patience of editorial assistant Nina Guttapalle, whose
work on this project substantially improved its quality.
Third, I would like to acknowledge the many experts in the broad CBT field,
including (but not at all limited to) Aaron T. Beck, Albert Ellis, Donald Meichen-
baum, Joseph Wolpe, Isaac Marks, Marvin Goldfried, Steven Hollon, Steven Hayes,
David Barlow, Richard Heimberg, Edna Foa, Keith Dobson, Michelle Craske, Mar-
sha Linehan, Arthur Nezu, Lars-Goran Öst, David M. Clark, Paul Salkovskis, Mark
Williams, Zindel Segal, John Teasdale, Stanley “Jack” Rachman, Arthur Nezu,
James Herbert, Jacqueline Persons, and Christine Padesky. Similarly, I would

xiv Acknowledgments

like to acknowledge many experts in the motivational interviewing field, includ-

ing (but not at all limited to) William Miller, Steven Rollnick, Teresa Moyers, Hal
Arkowitz, and Henny Westra. What a pleasure and treat it was to read (and, in
many cases, reread) your seminal pieces and to update myself on your careful and
innovative scholarship. It is your shoulders on which we stand, and your work has
truly set the stage for the innovations that the field is witnessing today.
Fourth, I would like to acknowledge my clients, many of whom I educated
about these innovations as I learned about them and delivered strategic and cre-
ative interventions on the basis of their principles. I have a caseload of clients who
have proactively sought out CBT after careful investigation of available mental
health treatments and who are hungry for the latest developments that will help
to prevent relapse and recurrence. It is you all who inspire me to continue forg-
ing ahead with my scholarship, and I am committed to using this scholarship to
provide the utmost in clinical care.
Finally, I would like to thank my husband, Tim Von Dulm. Through his posi-
tion as head of the reference department at one of the University of Pennsylvania’s
premier libraries, he played an essential role in helping me to acquire the resources
that I needed to write the book. I also thank my mother, Dotti Wenzel, for her
support and for wanting a signed copy of every single book I write, no matter
how many copies it sells. Last, but not least, I would like to acknowledge my sweet
daughter, Vanessa, who was oblivious to the fact that I was writing this book (and
who, quite honestly, does not fully believe that I am a published author) but who
nevertheless serves as inspiration on a daily basis to be the best mother, role model,
community member, and person that I can be.
Evolution of Cognitive
Behavioral Therapy

Cognitive behavioral therapy, or CBT for short, is an active, semi-structured, time-

sensitive approach to psychotherapy that aims to alleviate mental health and
adjustment problems by addressing problematic cognitive and behavioral pat-
terns that cause life interference and/or excessive emotional distress. By active, it is
meant that the client and therapist both come prepared for the session, contribute
to discussion, and work collaboratively together to address the client’s life prob-
lems. By semi-structured, it is meant that the therapist typically brings some sort of
flexible but organized scheme to each session, as well as to the course of treatment,
in order to ensure that therapeutic work is targeted and efficient. By time-sensitive,
it is meant that clients enter treatment with the anticipation that treatment will
eventually end, that the work done in each and every session is meant to advance
treatment and to make a difference in their lives in between sessions, and that they
will have the ability to implement therapeutic tools on their own, without the need
to have a therapist coaching them in doing so.
What does it mean to address problematic cognitive and behavioral patterns?
From a cognitive perspective, therapists help clients to recognize aspects of their
thinking that are unhelpful and that could be exacerbating their emotional dis-
tress. This thinking could be thoughts or images that run through clients’ minds
in particular situations, ways in which they interpret events in their lives, expecta-
tions that they hold for themselves or others, or underlying beliefs that developed
from key developmental experiences. Intervention at the cognitive level can mean
many things, from helping clients to modify their cognitions, to helping them
to distance themselves from their cognitions and to live their lives the way they
value in spite of their cognitions, or to coaching them to do something skillful
to address their life problems so that a change in cognition will follow. From a
behavioral perspective, therapists help clients to overcome avoidance, engage in
healthy self-care habits, respond skillfully in the face of challenges and adversity,
and participate in activities that they find meaningful and that give them a sense
of positive reinforcement.
Many CBT strategies include both cognitive and behavioral components. For
example, to implement effective problem solving, clients must have a centered
cognitive orientation from which they approach problems, and they must enact

2 Evolution of Cognitive Behavioral Therapy

effective behaviors in order to obtain a solution to their problems. As will be seen

throughout the remainder of this volume, it is overly simplistic to limit cogni-
tive behavioral interventions to only those that intervene at the level of cognition
and behavior, as they are often targeted simultaneously as the session unfolds.
Moreover, cognitive behavioral therapists are increasingly working at the level
of emotion (e.g., Hofmann, 2016; Thoma & McKay, 2015) as well as at the level of
large-scale environmental forces, such as discrimination (e.g., Hays, 2008).
The term cognitive behavioral therapy often evokes a noticeable reaction in
mental health professionals. Some clinicians, like myself, are passionate about it,
believing that it is a therapeutic approach that brings rapid and sustained relief
from emotional distress and that it arms people with tangible strategies for pre-
venting future relapse and recurrence. Other clinicians roll their eyes, indicating
that claims about the efficacy of CBT are overstated, that the cognitive behavioral
approach is too simplistic and does not get at the “real” underlying issues, or that
CBT is “old hat” and that the field has moved on. Of course, as the purpose of this
book is on innovations in CBT, I hope to disabuse the reader of these notions.
Whatever a clinician’s reaction toward CBT may be, the fact is that CBT is cur-
rently a central, if not the dominant, psychotherapeutic approach in both the con-
temporary psychotherapy research literature and in clinical practice. It is the
psychotherapeutic approach that has the most extensive empirical base, demon-
strating that it is associated with positive outcome relative to receiving no treatment
at all and relative to receiving placebo conditions, such as minimal contact with a
mental health professional (Butler, Chapman, Forman, & Beck, 2006). Results from
survey studies indicate that more clinicians identify themselves with a cognitive
behavioral orientation than with any other therapeutic orientation (Jaimes, Larose-
Hébert, & Moreau, 2015; Norcross & Karpiak, 2012; Thoma & Cecero, 2009) and
that rates of identification with the cognitive behavioral orientation have increased
over time, whereas rates of identification with other theoretical orientations have
decreased over time (Norcross & Karpiak, 2012; Norcross & Rogan, 2013). It is
the psychotherapy that is taught most often to graduate students in psychology
doctoral training (Heatherington et al., 2013). It is increasingly being viewed as
the treatment of choice for many mental health disorders by insurance companies
because of its time-sensitive (and thereby cost-saving) nature. There are also mas-
sive efforts to disseminate CBT to large treatment agencies, such as Veterans Affairs
Medical Centers (Karlin, Ruzek et al., 2010; Karlin, Brown et al., 2012; Wenzel,
Brown, & Karlin, 2011) and community mental health agencies in large urban
areas (e.g., Stirman, Buchhofer, McLaulin, Evans, & Beck, 2009). Thus, there is no
question that CBT has a firmly established place in the fields of clinical psychology,
psychiatry, and other mental health-related disciplines.
This being said, the beauty of science and practice is that they evolve, and an
approach that is stagnant runs the risk of becoming obsolete. Clinicians who
practice from any theoretical orientation must have updated knowledge of rel-
evant scientific findings, and they must translate that knowledge into their clini-
cal practice. They must be in tune with societal trends that have the potential to
affect the clinical presentations of their clients. They must have interaction with
Evolution of Cognitive Behavioral Therapy 3

other professionals to obtain fresh perspectives on the way in which they approach
complex cases. They must be open to consideration and evaluation of therapeutic
approaches outside the mainstream of their typical practice.
Fortunately, cognitive behavioral therapists value these very points. Cognitive
behavioral therapists consider themselves scientist-practitioners (or practitioner-
scientists). This means that they truly value science, as evidenced by the fact that
they keep up with the scientific literature and practice in a way that is consistent
with what the literature says is efficacious. This also means that they use a scientific
approach in their clinical work with clients, such that they find quantitative and
observable ways to measure progress and to determine whether adjustments need
to be made. In addition, cognitive behavioral therapists view environmental fac-
tors as important when they develop conceptualizations of clients’ clinical presen-
tations. For example, the well-known cognitive behavioral therapist Robert Leahy
has written extensively about applying cognitive behavioral principles to cope with
and thrive during unemployment in response to the economic woes experienced
by many during the most recent recession (Leahy, 2014). Moreover, cognitive
behavioral therapists place great value on consultation with other professionals,
at times viewing it as an essential part of the treatment package for clients with
chronic mental health problems or for those who are at risk for suicidal and self-
harm behavior (Linehan, 1993a; Wenzel, Brown, & Beck, 2009). Finally, cognitive
behavioral therapists integrate techniques from other therapeutic approaches into
their practice. A terrific example of this is the cognitive behavioral schema ther-
apy approach, spearheaded by Jeffrey Young and his colleagues (Young, Klosko, &
Weishaar, 2003), who have integrated many Gestalt, psychodynamic, and social
constructivist interventions into their treatment. More about schema therapy is
found in Chapter 5.
The purpose of this book is to highlight innovations in the science and prac-
tice of CBT, painting a picture of the flexible and contemporary study and practice
of CBT. As is likely evident from its name, this book will not simply be another
description of traditional cognitive behavioral strategies and techniques that are
outlined in countless other CBT texts. Instead, this book briefly describes these tra-
ditional strategies and techniques in order to set the stage for consideration of the
innovations that have stemmed from those traditional strategies and techniques, as
one can only appreciate innovations if they understand the traditional approaches
from which they developed. However, much of the focus of the volume is on new
treatment packages, strategies, and techniques that have been evaluated in the
research literature as well as ideas of the application and adaptation of standard
and innovative techniques that have been tested in clinical practice but that must
be verified by empirical research. It is hoped that after reading this volume, the
reader will be able to answer the questions: Where has CBT been, where is it now,
and where is it going? Although a detailed how-to description of each individual
technique is beyond the scope of this volume, the ensuing discussion will provide a
framework for understanding the ways in which these techniques are implemented,
evaluating their effectiveness, obtaining more detailed information when needed,
and thinking broadly and creatively about cognitive behavioral change.
4 Evolution of Cognitive Behavioral Therapy

The remainder of this introductory chapter is devoted to a consideration of the

historical context in which CBT developed. It describes the predominant climate
that characterized the fields of psychology and psychiatry at the time of CBT’s
inception, and it highlights the independent contributions made by many giants
in CBT’s history. It describes the expansion of CBT from a treatment for depres-
sion and anxiety to a treatment for a vast array of mental health disorders and
adjustment problems as well as to its delivery in varied formats, settings, and pop-
ulations. This chapter concludes with a glimpse of the traditional and innovative
strategies that will be discussed in the remainder of this volume.

Origins of CBT
Many forces converged to form the “perfect storm” that provided the impetus for
the development of CBT. In 1952, Hans Eysenck published a now classic paper criti-
cizing one prevailing model of psychotherapy—psychodynamic psychotherapy—
and proposing behavior therapy as an alternative. Eysenck provocatively raised
the notions that neurosis need not stem from a deep-seated psychological con-
flict and that it can be treated in full by intervening directly at the level of symp-
toms (Eysenck, 1960; Rachman, 1997). The late 1950s and 1960s, then, witnessed
increased attention on behavioral approaches to treatment that relied on prin-
ciples of behavior modification, with British researchers primarily focusing on
classical conditioning-based approaches to target fear reduction, and American
researchers primarily focusing on operant conditioning-based techniques to tar-
get severe psychopathology in institutionalized patients (Rachman, 1997, 2015;
Thoma, Pilecki, & McKay, 2015). However, as time progressed, it became evident
that a strictly behavioral conceptualization was insufficient to account for the full
range of clinical presentations that therapists see in their practices and that strictly
behavioral interventions often left major components of problems unaddressed
(e.g., obsessions; K. S. Dobson & Dozois, 2010; Rachman, 1997, 2015). According
to Rachman (2015), “the dependence on conditioning processes . . . gradually ran
out of steam” (p. 4).
Also happening at this time was that the field of psychology was going through
a “cognitive revolution,” such that information processing models were being
advanced (e.g., Neisser, 1967), and high-quality research was designed to mea-
sure many aspects of cognition, such as learning and memory. This is not to say
that innovators developed cognitive behavioral approaches specifically to apply
advances in cognitive psychology in clinical practice; in fact, a direct tie between
the cognitive revolution and the incorporation of a focus on cognition into thera-
peutic intervention is often overstated (Rachman, 2015; Teasdale, 1993). Never-
theless, the field’s fresh focus on cognition created a climate that was ripe for the
inclusion of cognition into traditional behavioral interventions. By the mid-1970s,
scholar-practitioners were beginning to propose a mediational model, advancing
the notions that cognition affects emotion and behavior and that intervening at
the cognitive level would affect behavior change (e.g., Mahoney, 1974). According
to Rachman (1997), “cognitive therapy [supplied] content to behaviour therapy,”
Evolution of Cognitive Behavioral Therapy 5

and “cognitive concepts have widened the explanatory range of behaviour therapy
and helped to fill in the picture” (p. 18). In the next sections, early cognitive behav-
ioral treatment approaches are described.

Albert Ellis’s Rational Emotive Behavior Therapy

Beginning in the late 1940s and 1950s, Albert Ellis developed rational emotive
behavior therapy (REBT, formally called rational therapy and then rational-
emotive therapy) after questioning basic premises of the psychoanalytic model in
which he was trained, observing that clients could develop sophisticated insight
into their psychological problems but yet were still struggling (Ellis, 1962). The
basic premise of REBT is that irrational cognition plays a large role in explain-
ing people’s emotional and behavioral responses. Ellis developed the well-known
ABC model, such that (A) inferences that people make about activating events
stimulate an (B) irrational belief system, which leads to (C) consequences, which
can be emotional (e.g., shame), behavioral (e.g., withdrawal), or cognitive (e.g.,
hopelessness) in nature (Dryden, 2012). The aim of REBT is to challenge (B) a per-
son’s irrational belief system, characterized by rigidity and extremity, and shape
it into a flexible and non-extreme belief system indicative of psychological health
(Dryden, 2011). Ellis assumed that a person would experience decreased emo-
tional distress and behave in a more adaptive manner if he or she substituted
irrational beliefs with more realistic beliefs. The primary process through which
this change occurred was through disputation, including questioning, challeng-
ing, and debating (Ellis, 1979). During the course of this process, Ellis actively
encouraged clients to address directly the (largely self-imposed) obstacles that
were keeping them from meeting their goals (Backz, 2011).
Ellis was a colorful personality and prolific writer whose clinical acumen
exerted tremendous influence in the field. At a time when the prevailing model
of psychotherapy was one in which the therapist was nondirective and even pas-
sive, Ellis blazed new trails by developing active, direct interventions and by ask-
ing his clients to complete homework in between sessions (DiGiuseppe, 2011).
At times, he was provocative and confrontational—characteristics that very well
might have turned some clinicians away from embracing this approach—but, nev-
ertheless, it was an approach that his clients came to appreciate due to the hard
work he exerted on their behalf and the timely progress they made (Backz, 2011;
DiGiuseppe, 2011). Importantly, Ellis assembled a conference at his institute of
like-minded clinicians (many of whom are described in this section) who believed
in the central importance of cognition in understanding and treating mental health
problems. As a result, he played a large role in solidifying a movement that pro-
vided a viable alternative to the more dominant psychodynamic and humanistic
approaches that pervaded the practice of psychotherapy at the time (DiGiuseppe,
2011). However, Ellis was first and foremost a clinician, and although he encour-
aged outcome research, he did not pursue it with the same vigor as some of the
other innovators described in this section. Thus, though REBT was perhaps
the first CBT approach that was described in print, it plays a smaller role in the
6 Evolution of Cognitive Behavioral Therapy

evolution of modern CBT than Aaron T. Beck’s cognitive therapy, described next
(Backz, 2011; DiGiuseppe, 2011).

Aaron T. Beck’s Cognitive Therapy

Like Albert Ellis, Aaron T. Beck was trained in psychoanalysis and became disil-
lusioned by it, observing that there was little empirical evidence for key unobserv-
able psychoanalytic constructs and that a more parsimonious way to understand
clients’ emotional distress was to examine the role of the meaning they were mak-
ing from their life circumstances (A. T. Beck, 2006). He developed a cognitive the-
ory in which he mapped particular cognitive distortions onto various emotional
disorders (A. T. Beck, 1976) and published a seminal treatment manual on cogni-
tive therapy for depression (A. T. Beck, Rush, Shaw, & Emery, 1979). The term
cognitive therapy suggests that A. T. Beck gave central importance to the role of
cognition in understanding emotional and behavioral problems. In fact, he later
stated that “cognitive therapy is best viewed as the application of the cognitive
model of a particular disorder with the use of a variety of techniques designed to
modify the dysfunctional beliefs and faulty information processing characteristic
of each disorder” (A. T. Beck, 1993, p. 194). Nevertheless, the treatment included
a broad array of strategies, many of which were behavioral in nature, in order to
create cognitive change and enhance emotional well-being.
Unlike REBT, cognitive therapy was subjected to rigorous empirical research to
establish its efficacy. As is described in the subsequent section on the evolution of
CBT, A. T. Beck expanded the empirical investigation of cognitive therapy from
the treatment of depression to a host of other mental health conditions. More-
over, he also pursued rigorous examination of the tenets of his cognitive theory,
simultaneously advancing cognitive theories of various manifestations of psycho-
pathology. At the time of the writing of this volume, A. T. Beck is one of the most
highly cited scholars in psychiatry and psychology.

Other Early Cognitive Behavioral Approaches

The 1970s was clearly an exciting time for scholars who were moving beyond psy-
chodynamic, humanistic, and strictly behavioral approaches to the treatment of
mental health disorders. At the same time that Ellis and A. T. Beck were molding
their cognitive approaches, other innovators were assembling treatment packages
that focused on the modification of problem behavior and cognition. Though these
cognitive behavioral approaches did not have as pervasive an influence on the field
or were applied to as many clinical conditions, they nonetheless deserve mention
for their place in the history of this dynamic field. For example, early in his career,
Donald Meichenbaum discovered that teaching people with schizophrenia to
engage in “healthy talk” was associated with significant improvements in adaptive
behavior, such as less distractibility and better task performance (Meichenbaum,
1969). He reasoned that when a person internalizes verbal commands, he or she
is better able to exert self-control over his or her behavior. Thus, Meichenbaum
Evolution of Cognitive Behavioral Therapy 7

concluded that covert behaviors, like cognition, could be modified using the same
behavioral modification principles as overt behaviors (Meichenbaum, 1973).
He elaborated his approach into self-instructional training (SIT), which involved
a process in which clients learned to generate internal coping statements, self-
correct errors, and reinforce themselves for successful task completion (Kendall &
Bemis, 1983; Meichenbaum, 1985). Although SIT is not generally used as a stand-
alone CBT today, the SIT framework continues to be used in helping people focus
on a sense of self-efficacy, such as youth with disabilities (K. S. Dobson & Dozois,
2010). Meichenbaum later continued his thoughtful integration of cognitive and
behavioral approaches and developed stress inoculation training, a more elaborate
approach to self-control, stress management, and the development of generalized
coping skills (Meichenbaum, 1985, 1993, 2007). In fact, Meichenbaum’s evolu-
tion as a scholar-clinician represents a microcosm of the evolution of the field as
a whole, as he acknowledges overlap between SIT and stress inoculation training
but states, “The stress inoculation training goes beyond SIT by including a psycho-
educational training, imaginal training, behavioral training, and a greater focus on
emotional and environmental interventions” (D. Meichenbaum, personal com-
munication, July 27, 2016). As will be seen in the subsequent section, many other
cognitive behavioral approaches followed a similar evolution.
Other innovative cognitive behavioral approaches were published in the early
empirical literature as well. Suinn and Richardson (1971) described an anxiety
management training approach, which aimed to help anxious clients develop cop-
ing skills (e.g., relaxation) that would help them achieve a greater sense of com-
petence in managing their anxiety. Goldfried, Decenteceo, and Weinberg (1974)
developed an approach called systematic rational restructuring that combined cog-
nitive restructuring and exposure to anxiety-provoking situations, reasoning that
misinterpretation of stimuli as being threatening plays a key role in the mainte-
nance of anxiety and that the aim of therapy is to help anxious clients enhance
their ability to cope with anxiety. Rehm (1977) constructed an elaborate self-control
model of depression, proposing that depression is associated with deficits in
(a) selective monitoring of negative events, (b) accurate self-evaluation, and (c) self-
reward (coupled with an excess in self-punishment). His model served as the basis
for self-control therapy for depression (Fuchs & Rehm, 1977), which incorporated
an array of behavioral and cognitive strategies to help depressed clients manage
their emotions. The implications of this early body of research are that rich treat-
ment packages could be assembled on the basis of behavioral and cognitive prin-
ciples of change and that they held great promise for developing into efficacious
treatments for mental health problems.

Emergence of CBT
It is difficult to pinpoint the precise time at which the field of CBT solidified.
Some scholars in the 1970s called their approach cognitive behavioral modifica-
tion (e.g., Mahoney, 1974; Meichenbaum, 1977), and many of the treatment pack-
ages described in the previous section indeed included cognitive and behavioral
8 Evolution of Cognitive Behavioral Therapy

components. According to Rachman’s (2015) historical analysis, the true field of

“cognitive behavioral therapy” was brought together by David M. Clark’s (1986)
elegant cognitive theory of panic. In this theory, D. M. Clark emphasized the
importance of catastrophic misinterpretations as being central in the conceptual-
ization of panic attacks—an idea that was quite innovative at the time, when panic
was regarded as simply a by-product of agoraphobia and was expected to decrease
with the successful behaviorally oriented treatment of agoraphobia. Other key fig-
ures who merged cognitive and behavioral constructs into theory and interven-
tions into treatment were David Barlow in the cognitive behavioral understanding
and treatment of anxiety disorders (Barlow, 1988, 2002) and Paul Salkovskis in the
cognitive behavioral understanding and treatment of obsessive compulsive disor-
der (OCD; Salkovskis, 1985). According to Rachman (2015),

In the process of merging behaviour therapy and cognitive therapy, the behav-
ioural emphasis on empiricism was absorbed into cognitive therapy. The
behavioural style of conducting empirical outcome research was adopted,
with its demands for rigorous controls, statistical designs, treatment integrity
and credibility, and so forth. In turn, cognitive concepts were absorbed into
behavior therapy, and cognitive therapists made greater use of behavioural
(p. 6)

Because of the speed at which CBT proliferated, as well as the number of separate
but overlapping approaches that quickly emerged, it can be difficult to answer
the question “What makes a treatment a cognitive behavioral therapy?” K. S. Dobson
and Dozois (2010) indicated that a central assumption across all cognitive behav-
ioral therapies is that cognition mediates behavior change. Other similarities
include (a) the targets of change (i.e., cognition and behavior); (b) the empha-
sis on self-control; (c) the time-sensitive nature of treatment; (d) the problem-
focused nature; (e) the structure; (f) the psychoeducation that is provided by
therapists to clients; (g) the central role of homework; (h) collaborative empiri-
cism (i.e., the therapist and client, together, drawing conclusions on the basis
of actual evidence and experiences); (i) technical eclecticism; (j) the delivery
of treatment with an eye on prevention; and (k) the emphasis on parsimony
in theoretical explanation (K. S. Dobson, 2012; K. S. Dobson & Dozois, 2010;
Herbert & Forman, 2011; Kendall & Kriss, 1983). Herbert and Forman (2011)
further indicated that it is also helpful to characterize what CBT is not, such as
a primary focus on the development of insight into intrapsychic conflicts or an
exclusive focus on the therapeutic relationship as the curative factor, alone, for
clients’ problems. In the final chapter, I offer two additional observations from
my own scholarship and clinical practice regarding key components of CBT as
it is currently understood and practiced. On the basis of this analysis, I advance
a definition of integrative CBT, which captures the contemporary, strategic, and
comprehensive practice of CBT with the vast array of clients seen in everyday
clinical practice.
Evolution of Cognitive Behavioral Therapy 9

Evolution of CBT
Since the 1970s, the family of CBTs has expanded greatly to the treatment of many
mental health problems; to its delivery using various modalities; to a movement in
which it is delivered with increasing flexibility; to its evaluation not only in tightly
controlled academic laboratories but also in “real-world” settings with “real” clini-
cians and “real” clients who struggle with clinical presentations that do not neatly
fit into a research protocol; to cultural adaptations that take into account impor-
tant racial, ethnic, religious, socioeconomic, and other individual differences; and
to an increased focus on acceptance. These expansions are considered in the fol-
lowing section.

Expansion in Status for the Treatment of Depression

A. T. Beck’s cognitive therapy was met with much skepticism when it was devel-
oped, as it was such a departure from the prevailing view of the way in which
depression was conceptualized and treated (i.e., the psychodynamic approach, the
humanistic approach, the pharmacological approach). However, he was commit-
ted to empirical scrutiny and ran clinical trials early on designed to demonstrate
the efficacy of this treatment package. He made a notable impression with the
publication of his first clinical trial (Rush, Beck, Kovacs, & Hollon, 1977), in which
he compared the efficacy of cognitive therapy and imipramine in depressed out-
patients. Results indicated that almost 80% of participants who received cogni-
tive therapy showed marked improvement or complete remission of symptoms
relative to approximately 23% of the participants who received imipramine. More
clients dropped out of the imipramine condition than in the cognitive therapy
condition. Moreover, 68% of the clients who received imipramine later reentered
treatment for depression relative to only 16% of the clients who received cogni-
tive therapy. For the first time, health-care professionals began to consider psy-
chotherapy as being an alternative (not simply an adjunct) to medication in the
treatment of depression.
However, debate continued as to whether it was seen as first-line treatment for
depression, equal to antidepressant medications. To further address this question,
the massive Treatment of Depression Collaborative Research Program (TDCRP;
Elkin et al., 1989) was initiated, which compared cognitive therapy, interpersonal
psychotherapy (IPT), imipramine plus clinical management, and placebo plus
clinical management at five different sites around the United States. Contrary
to the findings reported by Rush et al. (1977), results for cognitive therapy were
disappointing: Only 36% of clients receiving cognitive therapy met study crite-
ria for recovery posttreatment relative to 43% and 42% for IPT and imipramine,
respectively. Moreover, all treatments, including placebo plus clinical manage-
ment, performed similarly for less severely depressed clients, and imipramine plus
clinical management outperformed the other conditions for severely depressed
clients. On the basis of these findings, it was widely concluded that psychotherapy,
including cognitive therapy, was appropriate for people with mild to moderate
10 Evolution of Cognitive Behavioral Therapy

depression but that antidepressant medication was necessary for moderate to

severe depression. This attitude persisted for many years, despite the preponder-
ance of outcome studies demonstrating the efficacy of cognitive therapy that were
accumulating and despite the fact that concern was raised about the quality of
cognitive therapy that was delivered in some of the sites included in the TDCRP
(N. S. Jacobson & Hollon, 1996).
This attitude shifted after the publication of research by Robert DeRubeis, Ste-
ven Hollon, and their colleagues (DeRubeis et al., 2005), in which clients with
moderate to severe depression were randomly assigned to receive antidepressant
medication (paroxetine, with the possibility of augmentation with lithium or
desipramine in cases in which clients did not meet established response criteria
by week 8), cognitive therapy, or pill placebo. At the 8-week assessment, both the
medication (50%) and the cognitive therapy (43%) groups had higher response
rates than placebo (25%), and at posttreatment, both the medication and the cog-
nitive therapy groups had achieved response rates of 58%. Even more compelling
are the results from their 12-month follow-up period, in which the investigators
followed the clients who had completed cognitive therapy, the clients who had
completed their medication trial, and a subset of clients who continued on with
their medication trial (Hollon et al., 2005). Clients who had completed cognitive
therapy had much lower relapse rates than clients who had completed their medi-
cation trial (31% vs. 71%, respectively), and they were no more likely to relapse
than patients who were continuing to take medications (47%). These results sug-
gest that cognitive therapy is indeed efficacious for moderate to severe depression
and that its effects are much more enduring than the effects of taking medications
(cf. Hollon, Stewart, & Strunk, 2006). Cognitive therapy, or CBT, is now seen as
a viable alternative to antidepressant medication in the treatment of depression.

Expansion to Various Mental Health Problems

As has been seen to this point in the chapter, much of the early evaluation of CBT
(A. T. Beck’s cognitive therapy in particular) was focused specifically on the treat-
ment of depression. Both A. T. Beck’s cognitive therapy and Ellis’s REBT have since
been expanded to the treatment of anxiety disorders (A. T. Beck & Emery, 1985;
Warren & Zgourdies, 1991), anger (A. T. Beck, 1999; Dryden, 1990), substance
abuse (A. T. Beck, Wright, Newman, & Liese, 1993; Ellis, McInerney, DiGieseppe, &
Yeager, 1988), eating disorders (Fairburn, 2008), personality disorders (A. T. Beck,
Davis, & Freeman, 2015; Ellis, 1999), and suicidal behavior (Brown et al., 2005;
Ellis, 1989; Wenzel et al., 2009). More recently, CBT, broadly speaking, has been
developed as an adjunctive treatment for serious psychiatric conditions, such as
bipolar disorder (Basco & Rush, 2005) and schizophrenia (A. T. Beck, Rector, Sto-
lar, & Grant, 2009). CBT has also been adapted for the treatment of clients whose
salient feature is not necessarily a diagnosis of a mental health problem but other
difficulties including (but not at all limited to) medical illnesses (Kyrios, 2009),
chronic pain (Winterowd, Beck, & Gruener, 2003), obesity (Cooper et al., 2010),
and sexual dysfunction (ter Kuile, Both, & van Lankveld, 2010).
Evolution of Cognitive Behavioral Therapy 11

Thus, it is very quickly becoming true that CBT has been adapted for the treat-
ment of as many types of emotional distress, unhelpful approaches to coping, and
adjustment difficulties that one can imagine. Similarities across these approaches
include the active, problem-focused nature of treatment, the structure that
cognitive behavioral therapists bring to each session and the overall course of
treatment, the integration of both cognitive change and behavior change strat-
egies, and some of the basic cognitive behavioral interventions (e.g., cognitive
restructuring; see Chapter 4). What makes each of these approaches unique is
not only the content focused on in session but also the inclusion of specific tech-
niques that are tailored to the problem at hand. For example, clients with eating
disorders who participate in CBT often weigh in at the beginning of each session;
obviously, this practice would be unnecessary for a client who is being treated for
anxiety or depression.

Expansion to Various Modalities of Delivery

Early forms of CBT were primarily delivered in the context of in-person indi-
vidual psychotherapy. However, today, CBT is delivered in the context of a num-
ber of modalities. For example, cognitive behavioral group therapy is regarded
as a treatment of choice for several clinical presentations (cf. Bieling, McCabe, &
Antony, 2006; Norton, 2012a). One of the most rigorous and thoughtful adap-
tions of cognitive behavioral group treatment was advanced by Richard Heim-
berg and his colleagues in the treatment of social anxiety disorder (Heimberg &
Becker, 2002). It is logical that a group treatment approach would be particu-
larly attractive for socially anxious clients, as the group setting, itself, could pro-
vide a form of exposure and corrective learning experience for clients as they
acquire other important cognitive behavioral tools. However, today, group CBT
approaches can be found for nearly any clinical presentation; a subset of the
group CBT approaches recently published at the time of this writing include but
are not limited to group CBT for psychosis (Owen, Sellwood, Kan, Murray, &
Sarsam, 2015), for comorbid anxiety disorders and personality disorders (Holas,
Suszek, Szaniawska, & Kokoszka, 2015), for perfectionism (Handley, Egan, Kane, &
Rees, 2015), for specific phobias as distinctive as emetophobia (Ahlen, Edberg,
Di Schiena, & Bergström, 2015), and with male prison inmates (Brazão, Rijo,
Pinto-Gouvelea, & Ramos, 2015).
There are a number of features of group therapy that make it an attractive
modality in which to deliver CBT. One obvious feature is the potential cost effec-
tiveness of group treatment, as groups can be implemented for as little of half
the cost of individual therapy (Morrison, 2001). Although meta-analytic work
indicates that individual CBT is slightly more efficacious than group CBT (cf.
Bieling et al., 2006), this difference is often seen at the level of a statistical trend,
and its clinical significance is questionable. Another attractive feature of CBT
groups is the ability to capitalize on the distinctive features of the group modal-
ity in general (cf. Yalom & Leszcz, 2005), including the promotion of a sense of
universality, the ability to demonstrate altruism toward others, and a forum for
12 Evolution of Cognitive Behavioral Therapy

corrective learning experiences to emerge as a function of interactions among

fellow group members.
CBT is also readily delivered in the context of couples and family therapy
(cf. Dattilio, 2010; Ellis, 1993; Ellis & Wilde, 2001). Cognitive processes often
targeted in cognitive behavioral couples and family work include (a) selective
attention, or the tendency to focus on certain aspects of relational behavior
while ignoring other aspects; (b) malicious attributions that are used to pro-
vide an explanation for a partner’s or family member’s behavior; (c) probabil-
ity overestimations for events that are predicted to happen in the relationship;
(d) unrealistic assumptions about general characteristics of people and their
relationships; and (e) unrealistic standards about characteristics that “should”
operate in relationships (Baucom, Epstein, Sayers, & Sher, 1989). Common
behavioral processes that are targeted in cognitive behavioral couples and fam-
ily work include (a) communication skills deficits, (b) problem-solving skills
deficits, and (c) excesses in negative behavior coupled with deficits in posi-
tive behavior (Epstein & Baucom, 2002). Dattilio (2010) also emphasized the
importance of incorporating a focus on affect in cognitive behavioral couples
and family work, allowing space for partners to experience and express emo-
tion. Outcome research suggests that cognitive behavioral couples therapy
is associated with significant improvement posttreatment, such that couples
engage in more positive behaviors and report greater adjustment in the rela-
tionship (R. L. Dunn & Schwebel, 1995).
Since the turn of the century, a rapidly developing and innovative field of study
has been the delivery of CBT via the Internet (iCBT; Andersson, 2014). iCBT
includes standard content, such as psychoeducation; “lessons” that build progres-
sively in a sequence to help clients acquire skill in modifying unhelpful think-
ing, emotions, and behaviors; and homework that serves to consolidate learning
and allows the client to practice what has been learned (Andrews & Williams,
2014, 2015). Typically, iCBT programs are paced so that they mimic the course
of progression in face-to-face CBT. Therapist support and guidance are provided
through e-mail correspondence, video chat, and/or telephone consultations in
order to promote treatment engagement and prevent dropout (Andersson, Rozen-
tal, Rück, & Carlbring, 2015; Andrews & Williams, 2014). There are many advan-
tages of iCBT, including that it is available whenever an individual wants to access
it, that it has an array of attractive interactive features (Andersson et al., 2015),
and that fidelity, or the reliability and validity of the psychotherapeutic approach,
is guaranteed (Andrews & Williams, 2014). Accumulating research suggests that
iCBT is highly efficacious; for example, when iCBT is compared to either no treat-
ment or treatment that consists of minimal support, effect sizes are moderate to
large and comparable to effect sizes obtained in studies examining the efficacy of
face-to-face CBT (Andersson, 2014; Andersson, Cujpers, Carlbring, Riper, & Hed-
man, 2014; Andrews & Williams, 2014, 2015). It has even been shown to be highly
efficacious for clients with severe clinical presentations, such as severe depression
with persistent suicidal ideation (A. D. Williams & Andrews, 2013).
Evolution of Cognitive Behavioral Therapy 13

Expansion to Flexible Protocols

As CBT garnered an increasing amount of attention and following, treatment
manuals describing step-by-step CBT protocols for various mental health disor-
ders were developed. This was a great accomplishment for the field, as it laid out
the specific interventions that cognitive behavioral therapists deliver for specific
mental health problems so that these interventions could be replicated and eval-
uated using scientific methods (Wenzel, Dobson, & Hays, 2016; Wilson, 2007).
Manualized treatments were not without critics, however. For example, concerns
were expressed that manualized treatments are stagnant and promote the delivery
of psychotherapy in a robotic manner that leaves little room for clinical wisdom
and collaboration with the client (Gaston & Gagnon, 1996; Westen, Novotny, &
Thompson-Brenner, 2004). Furthermore, because most manuals focused on one
particular mental health diagnosis (e.g., major depression, bulimia nervosa), there
was concern that clinicians would have to learn an unwieldy number of protocols
to treat the array of clients typically seen in clinical practice (Beutler, 2000).
Treatment manuals have significantly advanced the practice of CBT, and I
anticipate that they will serve as essential resources for practitioners for many
years to come. Nevertheless, even the protocols described in manuals, themselves,
will continue to evolve. For example, many CBT protocols have moved away
from session-by-session prescriptions and instead include “modules” that can be
administered on the basis of the conceptualization of the client’s clinical presen-
tation and the client’s needs (e.g., Dugas & Robichaud, 2007). Moreover, there
is movement toward the development of transdiagnostic protocols that can be
applied to clients that target the mechanisms that underlie related clinical presen-
tations rather than the diagnosis per se (e.g., eating disorders, Fairburn & Coo-
per, 2014; emotional disorders, Barlow et al., 2011). Such developments in the
field reflect recognition of the similar psychological processes that underlie many
diagnoses of mental health disorders as well as the importance of customizing
treatment for each client’s clinical presentation and circumstances and for incor-
porating essential ingredients that cut across therapeutic approaches (e.g., cultiva-
tion of a therapeutic alliance).

Expansion From Efficacy to Effectiveness

Efficacy is the degree to which the delivery of a treatment results in positive out-
comes under optimal, tightly controlled circumstances, such as a high degree of
homogeneity among clients enrolled in the study (e.g., no comorbidity), the use
of highly trained therapists who receive extensive supervision (e.g., postdoctoral
fellows or seasoned PhD-level therapists), or a setting like a principal investigator’s
research laboratory. Effectiveness, in contrast, is the degree to which the delivery
of a treatment results in positive outcomes in real-world settings and under real-
world circumstances, such as a community mental health center that uses mas-
ter’s level therapists and serves clients with a range of mental health problems and
14 Evolution of Cognitive Behavioral Therapy

needs. It is typical for psychotherapy packages to first be evaluated using research

methods that establish efficacy, and, once efficacy is established, to be subjected to
research designs that target effectiveness.
Since the 1970s, a body of research has accumulated that clearly establishes
CBT’s efficacy (see Butler et al., 2006; Driessen & Hollon, 2010; and Epp & Dob-
son, 2010, for reviews). Nevertheless, critics have questioned the degree to which
the efficacy research applies to “real-life” clients, reasoning that there is a difference
between the types of clients who are enrolled in efficacy trials and the types of cli-
ents who therapists typically see in their clinical practices (Pagato et al., 2007; Per-
sons & Silberschatz, 1998). Thus, it has been observed that there is a gap between
psychotherapy researchers in academia and practicing clinicians, often mani-
festing in an us-versus-them mentality (cf. Lilienfeld, Ritschel, Lynn, Cautin, &
Latzman, 2013). To, in part, address this gap, whether real or perceived, research-
ers are increasingly turning their attention to effectiveness. Some researchers have
compared outcome data obtained in community outpatient settings with results
reported in efficacy studies (i.e., a benchmarking strategy) and found that rates of
treatment gains and treatment maintenance are comparable (Björgvinsson et al.,
2014; Merrill, Tolbert, & Wade, 2003; Stuart, Treat, & Wade, 2000; Wade, Treat, &
Stuart, 1998). Others have conducted randomized controlled trials (RCTs) in
clinical practice settings for mental health problems such as depression in older
people (Serfaty et al., 2009), eating disorders (Byrne, Fusland, Allen, & Watson,
2011), and psychosis (Lincoln et al., 2012). Collectively, these data are demonstrat-
ing that CBT is generalizable to real-life clinical settings with real-life therapists
and clients, which, through dissemination, will increase the accessibility of this
psychotherapeutic approach to treatment-seeking individuals around the globe.
More about dissemination is considered in the final chapter.

Expansion to Cultural Sensitivity

Cognitive behavioral therapists have, traditionally, emphasized case conceptual-
ization and the unique understanding of each client in the context of his or her
environment, communicating a great respect for individual differences. At the
same time, some have noted that CBT was developed from the basis of Western,
individualistic values such as autonomy, independence, and achievement and
questioned the degree to which the fundamental tenets of CBT are applicable
across cultures (Hays, 2009). In fact, many empirically supported treatments for
mental health disorders, including CBT, are evaluated using samples drawn from
predominately white, middle-class backgrounds, making their relevance to indi-
viduals of ethnic minorities unclear (Bernal & Scharrón-del-Rio, 2001).
Cultural sensitivity is increasingly receiving attention in the field. For example,
Pamela Hays is a leading cognitive behavioral clinician whose scholarly work cen-
ters on culturally responsive cognitive behavioral treatment (e.g., Hays, 2008;
Hays & Iwamasa, 2006). She developed the ADDRESSING framework to be aware of
the multiple influences that affect clients’ clinical presentations, including influ-
ences relevant to age/generation, developmental and other disabilities, religious
Evolution of Cognitive Behavioral Therapy 15

and spiritual orientation, ethnic and racial identity, socioeconomic status, sexual
orientation, indigenous heritage, national origin, and gender (Hays, 2008, 2009).
According to Hays (cf. Wenzel et al., 2016), cognitive behavioral therapists take
care not to assume that clients’ clinical presentations result solely from distortions
or abnormalities in cognition and behavior but that they consider the ways in
which environmental factors (e.g., racism, oppression) existing outside the indi-
vidual contribute to the problems and stresses that clients are experiencing. She
also encourages clinicians to use stories and metaphors from clients’ cultural back-
grounds to illustrate key cognitive and behavioral principles and ways for clients
to incorporate those principles into their lives.
The program of research developed by Ricardo Muñoz exemplifies the adaptation
of traditional CBT intervention strategies in a culturally sensitive manner to the
Latino community. Muñoz studied under Peter Lewinsohn at the University of
Oregon, and as will be seen in Chapter 6, Lewinsohn is a major figure in the devel-
opment of behavioral activation, a central component in the cognitive behavioral
treatment of depression. Muñoz applied his well-established expertise in CBT
to the treatment of mental health problems, especially depression and tobacco
dependence, in the Latino community in San Francisco. He developed treatment
manuals that have been disseminated around the country for working with Latino
clients (Muñoz & Mendelson, 2005). His approach incorporates four major CBT
strategies: (a) cognitive restructuring, (b) behavioral activation, (c) social
problem solving to manage personal relationships, and (d) social problem solving
to manage physical health issues (Aguilera, Garza, & Muñoz, 2010).
Of note, many constructs that resonate with Latino individuals are assimilated
into his CBT approach (see Muñoz & Mendelson, 2005, for an extensive discus-
sion). Muñoz and his colleagues sought feedback from Latino individuals when
he was developing his treatment manuals. Vocabulary was modified to meet the
typical education level of the ethnically diverse clients he served, and culturally
relevant images, stories, and metaphors were included to communicate key points.
For example, “la gota de agua labra la pierda” (translated to “drops of water can
carve a rock”) was used to illustrate the fact that, over time, thoughts can shape the
way in which we view the world and interact with it, thereby reinforcing depres-
sion. In addition, cultural values were acknowledged and modeled by Muñoz
and his colleagues in treatment development and by therapists who executed the
treatment, such as the importance of family (i.e., familism), respect (i.e., respeto),
and an emphasis on spirituality and religion. Importantly, Muñoz demonstrates a
commitment to science, and his approach has been evaluated in clinical research.
For example, a series of studies have evaluated his Mothers and Babies (Mamás
y Bebés) course, a CBT approach to prevent postpartum depression, and studies
show that his approach outperforms usual care in the prevention of this mental
health disorder (Le, Perry, & Stuart, 2011; Muñoz et al., 2007; Tandon, Perry, Men-
delson, Kemp, & Leis, 2011).
The body of work developed by Muñoz and his colleagues demonstrates that
not only does CBT have applicability broadly across ethnicity, culture, and social
class but also that therapists can retain integrity with regard to CBT’s basic model
16 Evolution of Cognitive Behavioral Therapy

and principles even when adaptations are made. This being said, much future
research is needed to establish CBT’s efficacy with a number of cultural and ethnic
groups as well as the efficacy of specific adaptations that would be hypothesized
to enhance outcome.

Expansion to Third-Wave CBTs

The third-wave or contextual cognitive behavioral therapies have received a great
deal of attention over the past 15 to 20 years, focusing on principles of accep-
tance, mindfulness, and nonjudgmental awareness (Hayes, 2004; Hayes, Villatte,
Levin, & Hildebrandt, 2011). Examples of third-wave CBTs include acceptance
and commitment therapy (ACT; Hayes et al., 2012), mindfulness-based cogni-
tive therapy (MBCT; Segal, Williams, & Teasdale, 2002, 2013), dialectical behavior
therapy (DBT; Linehan, 1993a, 1993b, 2015), and metacognitive therapy (Wells,
2009). An important feature that distinguishes third-wave cognitive behavioral
therapies from more traditional CBTs is the shift away from content to function.
In other words, many therapists who practice contextual psychotherapies are less
concerned with the overt modification of unhelpful cognitions and instead are
more concerned with shifting the person’s relationship with the cognition itself.
Contextual cognitive behavioral therapies are generally more centered on the pro-
cess by which a person lives his or her life rather than on what, specifically, is being
thought or done (K. S. Dobson & Dozois, 2010). According to Hayes (2004), “The
third-wave interventions are not a rejection of the first and second waves of behav-
ioral and cognitive therapy so much as a transformation of these earlier phases
into a new, broader, more interconnected form” (p. 660).
Experts in the field disagree about the degree to which these approaches truly
represent a new wave and the degree to which they should be subsumed into
the family of cognitive behavioral therapies versus the degree to which these
approaches are distinct (cf. Hofmann & Asmundson, 2008; Öst, 2008). Never-
theless, these approaches have significantly influenced even the most traditional
cognitive behavioral therapists. Discussions on the listservs of the Academy of
Cognitive Therapy and the Association for Behavioral and Cognitive Therapies
regularly focus on applications of mindfulness and acceptance techniques within
the practice of CBT as well as the optimal delivery of these third-wave treatment
packages. Chapter 9 describes third-wave treatment approaches that focus spe-
cifically on mindfulness and acceptance. In the final chapter, I advance my own
reconciliation of CBT and the contextual approaches.

Overview of the Current Volume

This chapter has provided a concise illustration of what CBT is and how it evolved.
What it has not provided is a description of specific treatment strategies and tech-
niques that are used by cognitive behavioral therapists. That is the purpose of the
remaining chapters in the volume. Each chapter is structured in roughly the same
manner. First, I define the basic parameters of a standard cognitive behavioral
Evolution of Cognitive Behavioral Therapy 17

intervention strategy (e.g., cognitive restructuring). Next, I illustrate the tradi-

tional way in which the intervention strategy was translated to specific treatment
techniques and implemented with clients (e.g., the thought record that can be
used to achieve the aims of cognitive restructuring). Then, I summarize innovative
ways that the intervention strategy has been adapted, either in terms of innova-
tive techniques that can be used with clients, contemporary modalities for deliv-
ery, innovative modifications for particular types of clients, or innovative issues
to consider when using the strategy. At the end of each chapter, I propose future
directions for empirical research as well as clinical practice.
The main intervention strategies described in these chapters are as follows. In
Chapter 2, traditional and innovative approaches to case conceptualization are
described and applied to a single case. Chapter 3 describes an exciting development
in the field—the use of motivational interviewing before and during the adminis-
tration of standard cognitive and behavioral intervention strategies to address cli-
ent ambivalence and increase motivation for change. Chapters 4 and 5 are devoted
to traditional and innovative approaches to cognitive restructuring—Chapter 4 is
focused on the restructuring of thoughts that people experience spontaneously in
particular situations, and Chapter 5 is focused on the restructuring of underlying
beliefs that develop on the basis of key experiences from previous times in a person’s
life. In Chapter 6, traditional and innovative approaches to behavioral activation are
considered, focusing on two contemporary behavioral activation treatment pack-
ages that have been subjected to rigorous empirical scrutiny. Chapter 7 is devoted
to the intervention strategy of exposure and describes the historical trajectory by
which exposure has been incorporated into cognitive behavioral treatment proto-
cols for anxiety-based disorders, the dominant theoretical paradigm that has been
used to guide the implementation of exposure since the late 1980s, and a new theo-
retical paradigm that emerged in the late 2000s. Chapter 8 focuses on traditional
and innovative approaches to affect management (which I define as incorporating
strategies for both emotion regulation and distress tolerance) and introduces ways
to evaluate the degree to which affect management strategies are helpful or harmful
in the short and long term. Chapter 9 shifts to a focus on the popular constructs
of mindfulness and acceptance. Chapter 10 closes this volume with two main foci:
(a) challenges that the field faces in the training and dissemination of CBT and
(b) a reconsideration of the fundamental definition of CBT as well as a new per-
spective on what might be considered integrative CBT.
This book is by no means comprehensive. In fact, innovations will be developed
and published just in the time that it takes for this finished product to go to press
and to be released to the general public. I encourage readers to digest the mate-
rial contained in this book with the “spirit” of innovation in mind. Too often, I
encounter therapists who practice from a different theoretical orientation, or who
are just beginning training in CBT, who have the idea that CBT must be delivered
in a prescribed “cookbook” manner and that there is a “right” and a “wrong” way
to do it. In the past, I have argued strongly against these notions (e.g., Wenzel,
2013). Therapists are, without a doubt, delivering CBT if they are implementing a
strategic intervention that (a) follows logically from the case conceptualization of
18 Evolution of Cognitive Behavioral Therapy

the client’s clinical presentation; (b) is done so collaboratively with the client, tak-
ing into account his or her preferences and wishes; (c) moves treatment forward in
some systematic way instead of proceeding without a clear plan or rationale; and
(d) is seen through in its entirety without getting derailed by extraneous discus-
sion of therapist reluctance.
In other words, just about any intervention strategy can be delivered by cog-
nitive behavioral therapists, and they will still be “doing” CBT. In fact, cognitive
behavioral therapists have license to integrate a tremendous amount of creativity
into their clinical work. It is thoughtful consideration of the principles that under-
lie their intervention strategies that is the key issue. I invite the reader to allow
the ideas presented in this book to stimulate critical and creative thought about
innovations that they can use in their own clinical practice.
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