Thoma 2015

THOMA ET AL.
CONTEMPORARY COGNITIVE BEHAVIOR THERAPY
Contemporary Cognitive Behavior Therapy:

A Review of Theory, History, and Evidence
Nathan Thoma, Brian Pilecki, and Dean McKay
Abstract: Cognitive behavior therapy (CBT) has come to be a widely practiced

psychotherapy throughout the world. The present article reviews theory, his-
tory, and evidence for CBT. It is meant as an effort to summarize the forms and
scope of CBT to date for the uninitiated. Elements of CBT such as cognitive
therapy, behavior therapy, and so-called “third wave” CBT, such as dialecti-
cal behavior therapy (DBT) and acceptance and commitment therapy (ACT)
are covered. The evidence for the efficacy of CBT for various disorders is re-
viewed, including depression, anxiety disorders, personality disorders, eating
disorders, substance abuse, schizophrenia, chronic pain, insomnia, and child/
adolescent disorders. The relative efficacy of medication and CBT, or their com-
bination, is also briefly considered. Future directions for research and treat-
ment development are proposed.
Cognitive behavioral therapy (CBT) is a time-limited, problem-fo-

cused psychotherapy that has been applied to a wide array of disor-
ders. This review is meant as a friendly introduction to CBT concepts
and supporting research to the uninitiated. We are delighted for the
opportunity to present this material in a psychodynamically oriented
journal and are grateful for the editor’s openness in inviting us to do
so.
With over 60 years of research and development, hundreds of books
on the topic, and thousands of peer-reviewed journal publications, the
CBT literature has grown to be a substantial one. We therefore feel that
we will only have the opportunity to scratch the surface of this litera-
ture. Nonetheless, we attempt to render as comprehensive a picture as
we can within the present constraints. We will elaborate on the history
and evolution of CBT, touch on the major treatment approaches that fit
under the CBT umbrella, and discuss the evidence for the efficacy of
Nathan Thoma, Ph.D., Weill Cornell Medical College.

Brian Pilecki, Ph.D., Brown University.
Dean McKay, Ph.D., Fordham University.
Psychodynamic Psychiatry, 43(3) 423–462, 2015

© 2015 The American Academy of Psychoanalysis and Dynamic Psychiatry
424 THOMA ET AL.
CBT as applied to depression, anxiety disorders, personality disorders,

and a variety of other focal problems. In a companion article, we will
compare CBT with elements of psychodynamic therapy (PDT) in or-
der to highlight commonalities and differences with PDT, in an attempt
to bring further dimensionality to the CBT approach for those more
versed in PDT.
History of CBT
As the name cognitive behavioral therapy implies, CBT can be seen

as the integration of two separate strains of psychotherapy—that of
cognitive therapy (CT) and behavior therapy (BT). BT emerged first,
arising in the 1950s and 1960s from an interest in applying the prin-
ciples of behaviorism to promote behavior change in humans (Kazdin
& Wilson, 1978). Behaviorism was a movement in psychology sparked
early in the 20th century by laboratory researchers aiming to use ex-
perimental methods to understand and manipulate behavior, starting
with a focus on animal behavior. This movement sought to distinguish
itself by making psychology into a natural science, operationalizing
its constructs in terms of observable behaviors and testing falsifiable
hypotheses through replicable experiments (Baum, 2003). This was in
contrast to the rising dominance of Freudian psychoanalysis, an ap-
proach characterized by a focus on case studies rather than systematic
experimentation and by theories of unobservable phenomena (e.g.,
the unconscious mind, repression processes, etc.) whose existence and
functioning were seen as difficult to verify at the time.
History of Behavior Therapy
While an interest in learning principles has long existed in human

history, one of the earliest and most influential figures to apply the ex-
perimental method to the study of learning principles was the Russian
physiologist Ivan Pavlov (Baum, 2003). While studying the digestive
system of dogs, Pavlov noticed that the dogs began to salivate not only
when meat was placed in their mouths but that the dogs had also come
to salivate when simply hearing the footsteps of their keeper coming
down the hall in the morning as he carried their food to them (Baum,
2003). Pavlov realized that through their repeated experiences of hear-
ing the footsteps preceding the appearance of food, a hard-wired physi-
ological reflex (that of salivating upon the taste of food) had come to
occur at the onset of an associated stimulus (that of the sound of foot-
CONTEMPORARY COGNITIVE BEHAVIOR THERAPY 425
steps in the morning). Subsequently, he began experimenting with the

pairing of one stimulus, such as a bell, with another, such as food. The
type of learning achieved through pairing what Pavlov called an uncon-
ditional stimulus (the food) with a conditional stimulus (the bell) became
known as classical conditioning, and was seen as a fundamental process
through which organisms come to adaptively respond to changes in
their environment (Baum, 2003).
Carrying forward an interest in applying experimental methods to
understand conditioning process, John Watson is generally seen as the
father of behaviorism, starting with the publication of his manifesto
Psychology as the Behaviorist Views It (Watson, 1913). Watson extended
the experimental approach to humans. In his most famous (and contro-
versial) experiment, he conditioned an 11-month old infant known as
“Little Albert” to fear the site of white fur after repeatedly pairing the
site of a cuddly white rat with a sudden, loud banging noise occurring
right behind the boy. Because the fear response generalized to all white
furry objects, including stuffed rabbits and a Santa Claus beard, and not
just the original object of the rat, Watson hypothesized that all human
behavior could be understood in terms of associational pairing and
generalization. Thus, he espoused a worldview in which humans enter
the world as blank slates to be entirely modified by the environment.
Watson is remembered not only for his contributions to the advance-
ment of scientific psychology, but also for his rather extreme views on
child rearing, which advocated withholding affection and touch from
children, lest they should be conditioned to become dependent upon
such treatment as adults (Glass & Arnkoff, 1992).
Adding specificity to the learning processes studied by Watson, Ed-
ward Thorndike developed the law of effect (Thorndike, 1931), which
observed that behaviors followed by satisfying experiences tend to
increase in frequency and behaviors followed by aversive experienc-
es tend to decrease in frequency. Burrhus Skinner, perhaps the best
known and most influential behaviorist, further elaborated upon this
observation, studying a process he called operant conditioning. Through
operating on the environment, organisms learn to change their behav-
ior based on the effect of their behavior on the environment, labeled
rewards and punishment (Skinner, 1953). Effects that increased the
behavior were called rewards, those that decreased a behavior were
called punishments. However, Skinner rejected Thorndike and oth-
ers’ reliance upon unobservable mental states, such as satisfaction and
aversion, and called his own approach radical behaviorism, restricting his
objects of study to explicitly observable and measurable phenomena.
Skinner proposed that the principles of operant conditioning, as stud-
ied through radical behaviorism, could explain a wide array of human
426 THOMA ET AL.
behavior from the simplest of habits all the way up to the acquisition of
language (Skinner, 1957). Skinner’s operant learning methods are still
directly applied to this day in such paradigms as token economies on
inpatient units as well as behavioral interventions with children, such
as “time outs.”
One of the first researchers to apply behavioristic principles to clini-
cal applications was Mary Cover Jones, Watson’s assistant in the Little
Albert experiment. She reasoned that if conditioning could be used to
induce a phobia, perhaps it could be used to undo a phobia as well
(Jones, 1924). For example, she reduced fear in a three-year-old boy
who was afraid of fuzzy white objects by gradually bringing a rabbit
in a cage closer and closer to the boy while he ate so that he eventually
was able to touch it. Other early clinical applications include Pavlovian
extinguishing of bedwetting (Mowrer & Mowrer, 1938) and the devel-
opment of progressive relaxation techniques (Jacobson, 1929), which
were applied to a wide variety of physical and mental conditions, in-
cluding hypertension, insomnia, and phobias.
While there are many behavior therapies that are heralded as the
forerunners for current practices (such as Wolpe’s systematic desensiti-
zation or Beck’s cognitive therapy, described below), one of the first be-
havior therapies widely administered to clients was assertion training.
Developed by Andrew Salter, assertion training was designed to assist
clients to overcome their inhibitions, which were widely considered the
etiological basis for neurosis (Salter, 1949). Salter’s work was highly in-
fluential, even if little recognized outside behavior therapy circles. His
work in developing a behavior therapy was the basis for more highly
developed assertiveness training programs, including the widely used
client-oriented book Your Perfect Right (Alberti & Emmons, 2008). As-
sertion training remains a critical component of many CBT protocols.
Like many of the early developers of CBT, Joseph Wolpe was a psy-
chiatrist originally trained as a psychoanalyst. Wolpe then became in-
terested in finding ways to apply behavioristic principles to humans
(Glass & Arnkoff, 1992). Working in his native country of South Africa,
he began with de-conditioning experiments on cats and then applied
his findings to humans, developing one of the earliest behavior thera-
pies known as systematic desensitization (Wolpe, 1958). This approach,
using what Wolpe called reciprocal inhibition, centered on exposure to
feared stimuli through use of imaginal imagery, which would then be
alternated with relaxing imagery. The theory held that the relaxation
response would become coupled with the target imagery in place of
the fear response, under the belief that incompatible physiological re-
sponses would allow for the transfer of new associations. Systematic
desensitization was used to treat phobias, social anxiety, generalized
anxiety, stuttering, impotence, and other disorders. This approach be-

came highly influential, setting the stage for manualization of BT as
well as disseminating the use of exposure techniques. More recent
evidence has shown that systematic desensitization did not appear to
require the relaxation component, thus pointing toward the exposure
component as the active ingredient. These findings invalidated Wolpe’s
original theory, but supported the systematic application of exposure
(Marks, 1987).
The experimental psychologist Albert Bandura, with his focus on
social-cognitive processes, came to influence BT in a variety ways, par-
ticularly in that his rigorous scientific approach allowed for the consid-
eration of unobservable mental states and their relationship to social
behaviors. Social skills training grew to incorporate role plays with the
therapist, often making use of modeling as a means of learning—a cen-
tral concept for Bandura (Bandura, 1969).
Armed with the concepts of conditioning, operant-learning, extinc-
tion through exposure, relaxation training, assertion training, and mod-
eling, clinicians increasingly made use of behavioral interventions in
psychotherapy. By the mid-1960s, such clinical practices became wide-
spread, leading to further developments that brought BT into maturity.
Psychiatric hospitals employed token economies for schizophrenic pa-
tients and mentally retarded patients (Kazdin & Bootzin, 1972). These
social learning programs relied heavily on principles of reinforcement
as well as social skills training, which include assertion training. Be-
haviorally focused interventions for children and adolescents with
autism, hyperactivity, conduct disorder, aggressiveness, and other be-
havior problems began to flourish (Bornstein & Kazdin, 1985). Addi-
tionally, training programs for parents were developed, to help parents
modify the contingencies in children’s environments (Ross, 1981). As
technology evolved, forms of relaxation training came to incorporate
the use of physiological measures that provided continuous feedback
to clinicians and patients in a process known as biofeedback (Schwartz
& Beatty, 1977). Increased interest also developed more broadly in the
intersection between physical health and mental health, leading to the
development of behavioral medicine (Pomerleau, 1979), an approach
to both medicine and psychology that rely on a biopsychosocial model,
rather than the medical model of disease (Engel, 1977).
Edna Foa is recognized as a founding developer and investigator of
exposure with response prevention (ERP), an approach which she applied
to the treatment of obsessive-compulsive disorder (OCD; Foa & Gold-
stein, 1978). Foa refined the methods of ERP from earlier experimental
clinical applications by Meyer (1966), who included a role for cogni-
tion by referring to this procedure as a modification of expectations.
428 THOMA ET AL.
The modification of expectations is an explicit acknowledgement that

clients form cognitive biases toward anticipated outcomes, and the
process of exposure facilitates changes in these expectations. Follow-
ing from Meyer’s work, ERP was considered an extinction paradigm,
in which patients who are guided by therapists are gradually exposed
to increasingly feared stimuli so that over time they experience a re-
duction in their learned fear response. Foa went on to apply a related
approach, known as prolonged exposure (PE), to the treatment of post-
traumatic stress disorder (PTSD), initially with victims of sexual assault
(Foa, Rothbaum, Riggs, & Murdock, 1991). In PE, patients expose them-
selves to feared traumatic memories in their imagination, narrating to
the therapist the unfolding of the events as they do so. Foa was later
named by Time Magazine as one of the 100 most influential people in
the world in 2010 for her scientific investigations of the applications of
exposure therapy (Kluger, 2010). Exposure techniques are now a cen-
terpiece in many CBT protocols, particularly those centering on anxi-
ety, such as OCD, PTSD, panic disorder, generalized anxiety disorder
(GAD), phobias, hypochondriasis, and social anxiety. In light of the
manner of everyday application of ERP, whereby clinicians routinely
engage in a wide range of other behaviors designed to facilitate coping
with the exposure exercise, this approach has recently been reconceptu-
alized, and is now referred to as the inhibitory learning model (Craske,
Treanor, Conway, Zbozinek, & Vervliet, 2014). In this model, it is the
learning of new methods of coping with the stimuli that is critical to
change, and not exposure, that is considered central in the efficacy of
the method.
History of Cognitive Therapy
While BT took its original inspiration from experimentalists like Wat-

son and Skinner, both of whom eschewed the consideration of unob-
servable mental states, behaviorally oriented clinicians naturally came
to seek out means of working actively with cognitions and emotions
since it would be difficult to effectively engage with a patient while
neglecting major components of his or her experience. This clinical in-
terest help set the stage for the development of cognitive therapy (CT).
There were additional currents leading in this direction as well, includ-
ing the “cognitive revolution” in experimental psychology (Neisser,
1967), which aimed to tie together the study of perception, memory,
linguistics, neuroscience, and the nascent field of computer science.
The personal construct psychology of George Kelly (1955), a theory of
personality psychology embracing a constructivist view of personality,

likewise set important precedents.
The philosophical beginnings of CT can be found as early as the Stoic
philosophers of ancient Greece. In the first century B.C.E., Epictitus is
known to have stated that “people are disturbed not by things, but the
view which they take of them” (Long, 2002, p. 68). Albert Ellis, consid-
ered an early trailblazer of modern CT, has pointed to the Stoics as an
important influence (Dryden & Ellis, 1988), along with the analytic phi-
losophy of Russell (1930) and the psychoanalytic writings of Horney
(1950) and Adler (1927). Ellis had originally trained as a psychoanalyst,
but sought to build a psychotherapy around helping clients gain a more
rational perspective on their problems and enacting behavioral chang-
es in their lives. He called his approach rational-emotive therapy (RET;
Ellis, 1962). Ellis’s confrontational style focused on freeing patients of
“should statements” that he viewed as the source of much of their suf-
fering as well as correcting their irrational beliefs that kept them from
achieving desired goals (Ellis, 1962). Additional beginnings of CT can
be found in the work of the behavior therapist Meichenbaum (1977),
with his focus on adding cognitive modification to coping skills train-
ing to achieve “stress inoculation.” Mahoney, also originally a behavior
therapist, developed theoretical contributions centering on a construc-
tivist worldview and applied this worldview to behavior change (Ma-
honey, Kazdin, & Lesswing, 1974).
Aaron Beck is generally considered the founder of CT and may be the
single most influential figure in the field of CBT. Shortly after complet-
ing his training as a psychoanalyst in the 1960s, Beck sought to scien-
tifically investigate and validate psychoanalytic theory (Beck, 2006). He
began by trying to test the Freudian theory that depression results from
anger turned inward. Beck predicted that in the unrepressed realm of
dreams depressed patients would be seen acting out angrily and ag-
gressively toward others. However, he found that instead, depressed
patients’ dream lives were filled with less hostility than those of non-
depressed patients, and further, that in their dreams patients were
generally “rejected, deserted, or thwarted,” by others (Beck, 2006).
He thus decided that instead of suffering from anger turned inward,
these patients were suffering due to an exaggeratedly negative view of
themselves, their world, and their future. Strongly influenced by Ellis,
Beck went on to develop CT for depression (1967, 1979), anxiety disor-
ders (Beck & Emery, 1985), and personality disorders (Beck, Freeman,
& Davis, 2004). However, rather than confronting patients about their
irrational beliefs as in RET, Beck’s approach sought to join patients in
a process of collaborative discovery, inviting them to become scientific
observers of their own experience as the therapist guides patients to-
430 THOMA ET AL.
ward more a more functional outlook through Socratic dialogues (Beck

& Weishaar, 2013). In Beckian CT, patients are trained to notice and
respond more rationally to negative automatic thoughts, first by labeling
various cognitive distortions, and then engaging cognitive restructuring
with the therapist and in journaling exercises as homework.
The success of Beckian CT can be attributed to several factors. The
first is Beck’s focus on developing psychotherapy in concert with sci-
entific investigation. This ranged from the development and validation
of new measures, such as the Beck Depression Inventory (BDI; Beck,
Ward, & Mendelson, 1961), to testing treatment packages in randomized
controlled trials (RCTs). The first such RCT of CT for depression was
published in 1977, in which CT compared favorably with antidepres-
sant medication (Rush, Beck, Kovacs, & Hollon, 1977). The number of
RCTs centering on CBT now numbers in the hundreds (Hofmann, As-
naani, Vonk, Sawyer, & Fang, 2012; Thoma et al., 2012). A second factor
is Beck’s focus on developing treatments that addressed specific psy-
chological disorders and symptom profiles rather than targeting uni-
versal, underlying psychic structures. This allowed for a greater focus
on targeted symptom relief. There are now CBT protocols for all major
psychiatric disorders, as well as other problems in living such as anger
and chronic pain (see www.psychologicaltreatments.org). A third fac-
tor is Beck’s willingness to incorporate and integrate elements of other
therapies that show efficacy. As Beck put it, “Cognitive therapy is the
integrative therapy” (1991, p. 191). Much of BT was integrated into CT,
including behavioral activation, exposure exercises, behavioral experi-
ments, relaxation training, and social skills training. Today, all of these
techniques are blended together into the body of interventions known
as CBT. The number of psychotherapists that identify either as cognitive
or cognitive-behavioral in orientation has climbed steadily since Beck’s
early work, with 36% of psychologists in a national sample endorsing a
CBT orientation (Thoma & Cecero, 2009). This was the largest group in
this survey, with 26% endorsing psychodynamic or interpersonal orien-
tations and an additional 26% endorsing integrative/eclectic.
More recent theoretical and clinical developments in CBT have
grown out of a focus on mindfulness, an attitude of accepting and non-
judgmental awareness of the present moment, an influence that has
seen explosive growth in the past decade. This is often called the “third
wave” in CBT, with the first two waves being BT and CT, respectively.
Third Wave CBT
The “third-wave” of CBT emerged as an influential movement in the

1990s and refers to the integration of principles of acceptance, mindful-
ness, and non-judgmental awareness with traditional CBT approaches
(Hayes, 2004). Mindfulness practices and theory can be traced back
thousands of years ago toward Buddhism and other spiritual traditions
that conceptualize suffering as the result of desiring what one doesn’t
have and the corruption of perceptual processes by language (see Her-
bert & Forman, 2010). There is lack of consensus on a single definition
of mindfulness that is due to its inherently ineffable nature (Germer &
Chan, 2014), though Kabat-Zinn’s (1994, p. 4) definition is one of the
most highly quoted: “paying attention in a particular way: on purpose,
in the present moment, and non-judgmentally.” Similar to mindfulness,
the principle of acceptance is one that has had deep roots in the history
of psychotherapy such as with Freud and in the humanistic tradition
(Williams & Lyon, 2010). Though some CBT theorists have criticized
the idea of a third-wave within CBT and suggested that third-wave ele-
ments are not radically different than those of traditional CBT (Hof-
mann & Asmundson, 2008), there nonetheless seems to be a growing
proliferation of mindfulness- and acceptance-based psychotherapies
including mindfulness-based stress reduction (MBSR), mindfulness-
based cognitive therapy (MBCT), acceptance and commitment therapy
(ACT), and dialectical behavior therapy (DBT).
Perhaps one of the most well known and most extensively investigat-
ed third-wave forms of CBT is ACT. This therapy is based on contextual
behavioral science (CBS) and relational frame theory (RFT), a modern
learning theory that is built upon an extensive foundation of basic sci-
ence and experimental research (Hayes, Barnes-Holmes, & Roche, 2001;
Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). From an
ACT perspective, all forms of mental illness arise from some form of
experiential avoidance, or the attempt to escape from or change private
experience (Hayes, Strosahl, & Wilson, 2011). Based upon a concept of
suffering similar to that in Buddhism mentioned above, ACT relies on
strategies to cultivate acceptance and contact with the present moment,
or mindfulness, which is less common in traditional CBT approaches
that have been generally more focused on symptom reduction and
change. Also similar to traditional meditative traditions, ACT attempts
to focus on the decoupling of experience (thoughts and emotions) with
overt behavior (Herbert & Foreman, 2010). This is another distinction
from traditional CBT; instead of attempting to change the contents of
cognitions, ACT focuses more on changing one’s relationship to the
432 THOMA ET AL.
process of thinking altogether. To accomplish this, ACT relies heavily

on experiential exercises, role-plays, and metaphors to help clients not
just understand the benefits of acceptance, but to actually experience it
firsthand (Plumb Vilardaga, Villatte, & Hayes, 2014).
Finally, and perhaps most importantly, the use of acceptance and
mindfulness strategies is not the end goal of ACT, but rather a method
for helping individuals become more engaged in living a meaning-
ful life and achieving values-based goals. For example, an ACT-based
course of treatment for generalized anxiety disorder will not directly
attempt to reduce anxious thoughts or symptoms, but rather ask the
client to imagine what kind of life they would be living if they didn’t
have anxiety and then help them work toward those goals. Though at
times distress related to symptoms may decrease the more that one is
able to accept them (e.g., accepting a symptom such as chronic pain
can reduce distress over the pain), “feeling better” is not a goal of ACT
and is rather viewed as being more problematic than helpful; rather,
the goal of “feeling better” is thought to actually increase experiential
avoidance and consequently increase suffering and distress. As a trans-
diagnostic treatment, ACT has been found to be helpful in treating a
variety of disorders including depression, anxiety, and chronic pain
(A-Tjak et al., 2015).
In addition to ACT, DBT is another example of a well-known third-
wave therapy within the CBT tradition. DBT is a therapy that was origi-
nally developed for the treatment of borderline personality disorder
(Linehan, 1993). In contrast to most CBT formats, DBT involves a more
long-term treatment lasting up to several years that includes individ-
ual therapy, groups for learning skills such as emotion regulation and
mindfulness, and typically some type of phone coaching that patients
may request when attempting to implement skills. DBT is considered
a third-wave CBT because of its emphasis on mindfulness principles
and the incorporation of acceptance principles that are conceptualized
to be vital before instituting change strategies. Here also one can find
more traditionally Eastern philosophical influences in the term dialec-
tic which refers to the synthesis of opposites, namely acceptance of the
patient as a good person and helping the patient change problematic
behavioral tendencies. Linehan (1993) emphasizes the importance of
clinicians’ need to manage their own emotional experiences, as well as
maintaining clear clinical boundaries in light of the extreme demands
of delivering treatment to the populations for whom DBT was designed
(i.e., borderline personality). Accordingly, DBT is most effectively de-
livered when clinicians are part of a group who can engage in between-
session debriefing sessions.
Evidence in Support of CBT
In evaluating the evidence in support of CBT, we will briefly review

the evidence from RCTs, meta-analysis, and process-outcome research
for CBT for each of a variety of disorders. Each of these kinds of evi-
dence has strengths and limitations (Barber, 2009). RCTs are important
due to the inference of causality that can be drawn from controlled ex-
periments. Meta-analysis allows for the aggregation of RCTs into aver-
age effects and in some cases allows for the detection and correction of
possible publication bias. Process-outcome findings are important in
that a shortcoming of RCTs is that they do not tell you what it is about
the treatment that causes the change—such as theoretically relevant
techniques or general effects of psychotherapy. Taken together, these
differing methodologies will allow for a convergent view of the efficacy
of CBT.
Evidence for CBT for Depression
There are more RCTs of CBT for depression than there are for any oth-
er psychotherapy for any other disorder, making it the most replicated
test of psychotherapy in the literature. Thoma and colleagues (2012)
found 120 trials of CBT for depression as of 2010, a number which has
since grown. This included comparisons of CBT to a variety of control
conditions, including a wait list, treatment-as-usual (TAU), other psy-
chotherapies, medication, and the combination of CBT and medication.
Most of these trials focused on major depressive disorder (MDD) and
over half used the Beckian model. In comparison to a wait list control,
CBT has shown large effects, with Cohen’s d = 0.90 (Thoma et al., 2012).1
This demonstrates that CBT does better than doing nothing. In compar-
ison to TAU, medium effects were found, with d = 0.40. However, this
finding is ambiguous, as Wampold et al. (2011) demonstrated that TAU
can consist of a wide array of control conditions that range from very
inactive to bona fide treatment. In comparison to medication, no differ-
ence was found, with an effect size close to zero at d = 0.10. This sug-
gests that on average, the effects of CBT for depression are comparable
to that of antidepressant medication. In comparison to other forms of
psychotherapy, likewise the effect was nonsignificant and close to zero,
with d = 0.05. In sub-analyses, in which comparisons between CBT and
BT were removed, the results were the same. Alternatively, a compari-
1. By convention, effect sizes of d = 0.20, 0.50, and 0.80 are considered to be small,
medium, and large, respectively (Cohen, 1988).
434 THOMA ET AL.
son between CBT and CBT with medication, the combined treatment
had larger effects, showing additive effects of the two treatments.
Taken together, these findings indicate that CBT is decidedly better
than nothing but perhaps no better and no worse than medication or
other psychotherapies for treating a major depressive episode. Com-
bining CBT with medication appears to have beneficial additive effects.
Interestingly, Thoma et al. (2012) found that the quality of the method-
ology of the RCTs was inversely related to outcome. This is to say, the
better the trial, the worse the outcome for CBT. Additionally, there was
evidence of publication bias. This means that the aggregated results
may be somewhat inflated due to trials with small sample sizes and
poor results going unpublished.
Trials of group versus individually based CBT have yielded similar
results, with some evidence favoring the efficacy of individual treat-
ment (Cuijpers, van Straten, & Warmerdam, 2008). Findings for CBT
for chronic depression and dysthymia have been somewhat less strong
than for MDD. Cuijpers et al. (2010) found only a medium effect for CBT
versus a control condition (which could have been either a wait list or
TAU), with d = 0.43. And unlike CBT for MDD, medication was found
to be superior, by a medium effect of d = 0.50. Combined treatment
showed a small to medium advantage over either treatment alone.
In examining the mechanisms of change in CBT for depression,
some authors have pointed toward evidence supporting the effects of
theoretically relevant change processes (e.g., Garrett, Ingram, Rand, &
Sawalani, 2007) while others have questioned this evidence (e.g., Ahn
& Wampold, 2001). Much of this dispute rests on the debate between
the relative importance of common factors versus specific techniques.
The theory proposed by Beck indicates that it is changes in cogni-
tions, such as negative beliefs about the self, the world, and the future,
which produce changes in emotional symptoms and lead to the alle-
viation of depression (Beck, 1979). This would imply that changes in
cognitions should precede changes in symptoms. A variety of studies
have found change in dysfunctional attitudes and beliefs to be correlat-
ed with reduced depressive symptoms at post-treatment (Garrett et al.,
2007), but this does not speak to the problem of temporal sequencing.
Findings centering on observations of within-session changes in cogni-
tions leading to within-session changes in mood have been mixed. Per-
sons and Burns (1985, 1986) and Teasdale and Fennell (1982) found that
modification of negative thoughts was correlated with improvements
in mood. However, Safran, Vallis, Segal, and Shaw (1987) did not find
this relationship.
Yet it remains possible that there is a necessary incubation period
after changes in cognitions before symptom relief occurs. To investigate
this possibility, Tang and DeRubeis (1999) evaluated instances of sud-

den, notable drops in measures of depression administered before each
session of CBT for depression in an RCT. They found that a measure
of in-session change in cognitions predicted subsequent reduction in
symptoms whereas measures of the therapeutic alliance did not. Tang,
DeRubeis, Beberman, and Pham (2005) replicated these results. Sudden
gains were also predictors of change at outcome and follow-up. Fur-
ther, it appeared that the changes in cognition, which led to decreases
in symptoms, also led to increases in the therapeutic alliance (Tang &
DeRubeis, 1999). This causal arrow points in the opposite direction
than would be predicted by so-called common factors models, which
propose that it is something about the relationship with the therapist,
as measured by the therapeutic alliance, that causes symptom reduc-
tion (Wampold, 2001).
Cognitive-behavioral therapy has been found to be more robust
against relapse than medication (Evans et al., 1992). Patients’ use
of CBT-based coping skills (e.g., questioning their own automatic
thoughts) has been shown to mediate this resilience, indicating that
CBT patients appear to learn CBT-specific skills, make use of them, and
remain less prone to future episodes of MDD (Strunk, DeRubeis, Chiu,
& Alvarez, 2007).
While it is encouraging that changes in cognition have been found to
produce both symptom reduction and increases in the alliance, research
on the use of specific CBT techniques in treating depression has been
more mixed. For example, one dismantling study sought to compare
the full CBT package to its separate components, such as behavioral ac-
tivation and cognitive restructuring (Jacobson et al., 1996). Behavioral
activation centers on promoting patients’ engaging in more activity,
and specifically, activity they might find rewarding or mood enhanc-
ing. Cognitive restructuring is the Beckian approach to helping patients
remediate distorted, negative thinking. CBT that included behavioral
activation plus cognitive restructuring was compared to cognitive re-
structuring alone and behavioral activation alone. There was no differ-
ence in post-treatment outcome, indicating that cognitive restructur-
ing appears to be a sufficient but not necessary strategy for producing
change in CBT for depression (likewise with behavioral techniques).
Interestingly, patients with more severe symptomatology did signifi-
cantly better in the behavioral activation condition, indicating that this
appears to be a particularly important strategy in severe depression,
perhaps due to combating amotivation through more direct activation
and rekindling of the reward-seeking system. In a replication and ex-
tension of this finding, CT was compared with behavioral activation
and also to antidepressant medication (Dimidjian et al., 2006). In severe
436 THOMA ET AL.
patients, there was no difference between medication and behavioral

activation, each of which outperformed CT.
Strunk, Brotman, and DeRubeis (2010) found that cognitive tech-
niques and structuring/agenda setting techniques predicted symptom
change and behavioral techniques/homework did not. The changes
in the alliance did not predict subsequent symptom change, whereas
symptom reduction predicted improvements in the alliance. This study
was contradicted by findings by Strunk, Cooper, Ryan, DeRubeis, and
Hollon (2012), which found that in combined CBT and medication, be-
havioral techniques/homework predicted symptom change and cogni-
tive techniques or structuring/agenda setting did not. The divergence in
these findings is difficult to reconcile, but it may relate to differences in
implementation of CBT in the trials under study. Despite efforts to cre-
ate uniformity of treatment implantation using the same manual across
trials, measurable differences have been found across trials, with some
sites emphasizing more behavioral techniques and others more cogni-
tive techniques (Webb et al., 2013). It is possible that differences in imple-
mentation are in response to differing patient needs in differing samples.
One study actually found a negative relationship between use of cog-
nitive techniques and outcome (Castonguay, Goldfried, Wiser, Raue, &
Hayes, 1996). In contrast, this study also found that early therapeutic
alliance as well as a variable called experiencing were positively related
to outcome. Experiencing is a transtheoretical construct that taps a cli-
ent’s engagement in examining his or her internal experiences, explor-
ing his or her own thoughts and emotions, and making new meaning
from this process (Klein, Mathieu, Gendlen, & Keisler, 1969). The nega-
tive relationship between use of cognitive techniques and outcome was
explained by therapists labeling client resistance as distorted think-
ing, essentially doubling down on cognitive techniques in the face of a
therapeutic rupture. Thus it appears important to administer CBT (and
likely any psychotherapy) flexibly.
A common finding in psychotherapy research has been the inability
to detect differences when active, bona fide psychotherapies are com-
pared head to head (Wampold, 2001). Wampold (2001), calling upon
the ideas of Frank (1961), has proposed that psychotherapy works in
large part through general mechanisms of what they call remoralization,
or patients’ gaining a sense that they have value and can be effective in
their lives through engaging in a healing relationship with a respected
and caring authority figure. It is likely that these factors are particularly
relevant in the phenomenon of MDD, in which hallmark symptoms are
a negative sense of self-worth and a sense of hopelessness about the fu-
ture. It would make sense that well-conducted psychotherapies might
have equivalent outcomes for this disorder in particular. However, it
remains possible that the specific techniques of a given psychotherapy,

such as CBT, form a codified means of achieving the process of remor-
alization and do so through theory-relevant mechanisms in interaction
with common factors (see Barber, 2009, for a discussion of the interplay
between techniques and common factors).
Anxiety Disorders
The anxiety disorders represent a broad class of diagnoses. At the

heart of all the conditions in this category is the experience of patholog-
ical levels of anxious arousal that impedes functioning through specific
behavioral and cognitive expressions. Cognitive-behavioral approach-
es have dominated the treatment outcome literature in the anxiety dis-
orders, with exposure and its variants as one of the most frequently
investigated clinical methods. While the findings from clinical trials for
anxiety disorders employing CBT have been generally favorable (see
McKay, in press), there has also been marked heterogeneity in how
investigators have tried to improve efficacy beyond that found with
standard CBT protocols. To illustrate, CBT has demonstrated efficacy in
reducing symptoms of worry associated with generalized anxiety dis-
order (GAD; Hanrahan, Field, Jones, & Davey, 2013). Included in pro-
tocols for GAD are progressive relaxation (which paradoxically serves
as a form of exposure) and cognitive therapy for dysfunctional cogni-
tions. However, researchers have also acknowledged that CBT gener-
ally reduces worry, and does not necessarily improve other disabling
symptoms of GAD (such as irritability or relationship problems result-
ing from chronic worry). In order to address disabling symptoms other
than worry, investigators have included treatment modules addressing
interpersonal functioning that have resulted in an increase in treatment
efficacy (Newman et al., 2011). Recent work has addressed interperson-
al functioning in social anxiety disorder (Stangier, Schramm, Heiden-
reich, Berger, & Clark, 2011), although this line of research is not as well
developed, and procedures have not yet examined the additive effect of
interpersonal interventions to CBT.
The process of conducting CBT for anxiety disorders has been less
well investigated. As noted, the majority of the CBT protocols for anxi-
ety disorders emphasize exposure therapy. Exposure therapy is widely
considered the standard treatment for anxiety disorders (Abramowitz,
Deacon, & Whiteside, 2010). It is also a challenge to disseminate given
that many clinicians express concerns with client risk (due to anxiety
provocation during sessions), limitations in who can be treated with
the approach (i.e., children, older adults, individuals with medical con-
438 THOMA ET AL.
ditions). However, the concerns raised about the procedure have not
been associated with any poor outcome, and so dissemination is pri-
marily a matter of good supervision and training for uninitiated thera-
pists (Richard & Gloster, 2006). To remind readers, exposure involves
a direct confrontation with the feared objects of the client, through in
vivo practice with the therapist, in guided imagery, and in between ses-
sion homework assignments (see Abramowitz, Deacon, & Whiteside,
2010, for detailed coverage). The therapeutic mechanism of exposure
is habituation to the feared stimuli. While many clinicians express con-
cern over exposure, it may be more accurate to say that exposure re-
quires considerable care and training for proper implementation, and
that when done properly it is a highly effective method for alleviating
anxiety. Indeed, recent investigations have shown that as fear of caus-
ing client harm increases, efficacy of exposure interventions decreases
(Farrell, Deacon, Kemp, Dixon, & Sy, 2013). Accordingly, a potential
harmful side effect of exposure is not conducting it at all, but conduct-
ing it at a level below the necessary threshold of intensity. This means
that hesitant clinicians may require additional supervision to overcome
their concerns over potential harm, as well as their personal discomfort
whereby they may view exposure as incompatible with compassion
(McKay & Ojserkis, 2014).
While exposure may give pause to PDT practitioners, there is a new
conceptualization of the approach that may put clinicians at greater
ease. Specifically, it has been acknowledged that most clinicians do not
merely present feared stimuli and wait for habituation. Instead, clini-
cians engage in a wide range of other therapeutic interventions de-
signed expressly for encouraging clients to practice exposure and to
facilitate a beneficial response. This is the inhibitory learning model
mentioned earlier (i.e., Craske et al., 2014). This approach emphasizes
new learning, such as distress tolerance or altered expectations for out-
come following exposure rather than habituation per se. It also perhaps
better represents the everyday practice of exposure, whereby interper-
sonal processes play a significant role in how clinicians engage clients
in exposure. For example, one principle of the inhibitory learning mod-
el emphasizes expectancy violation. Clinicians may introduce humor,
which is contrary to fear experience, when conducting exposure. An-
other aspect is occasional reinforcement during the course of exposure.
This again is not consistent with the original conceptualization of expo-
sure, but it does serve an important framework for understanding the
interpersonal relationship between client and therapist in completing
exposure exercises.
CBT for Personality Disorders
Various forms of CBT have been applied and investigated for the
treatment of personality disorders (PDs). The first set of models of CBT
consist of various combinations of traditional CT and BT. The other two
models that have been investigated were specifically developed to ad-
dress PDs, and borderline personality disorder (BPD) in particular. The
first of these is dialectical behavior therapy (DBT; Linehan, 1993) and
the second is schema therapy (ST; Young, Klosko, & Weishaar, 2003).
Relatively few RCTs have been conducted of traditional CBT for PDs.
This may be because many clinicians and researchers would not as-
sume that short-term CT or BT would be expected to show efficacy in
patients defined by the chronicity and pervasiveness of their symp-
toms. Several trials have applied CBT to avoidant personality disorder
(AvPD), which can be seen as a more generalized form of social phobia,
and therefore a reasonable target for CBT. Alden (1989) found CBT to be
more effective in treating AvPD than a wait list control. Emmelkamp et
al. (2006) found CBT to be more effective than WL as well as psychody-
namic therapy (PDT). The latter was not significantly better than WL.
In testing CBT and PDT on cluster C PDs, Svartberg, Stiles, and Seltzer
(2004) found patients in both treatments improved, with no significant
difference between the two groups. Differences between trials may be
due to sampling differences and/or differences in treatment implemen-
tation.
Linehan’s DBT has been tested on PDs more than any other man-
ualized psychotherapy. Linehan moved the field of CBT forward by
targeting one of the most difficult and intractable disorders, BPD, and
manualizing a year-long treatment for it, and thus moving CBT beyond
the typical 12–20 session format. Further, rigorous training programs
have been developed, helping DBT to become one the most widely dis-
seminated manualized therapies. Kliem, Kröger, and Kosfelder (2010)
used a contemporary statistical method for including multiple outcome
measures and found a medium effect size favoring DBT over TAU, cli-
ent-centered therapy, and treatment by community experts. However,
when compared with active treatments that were designed for BPD,
namely Kernberg’s transference-focused psychotherapy (TFP; Clarkin,
Levy, Lenzenweger, & Kernberg, 2007) and a BPD-specific, manualized
PDT (McMain et al., 2009), DBT showed a disadvantage by a small ef-
fect. Across the trials studied, gains in DBT decreased, on average, by a
small effect upon measurement at long-term follow-up.
Given the widespread dissemination and clinical notoriety of DBT,
it may be somewhat surprising that the approach has only a medium
effect over TAU and potentially even a small disadvantage against oth-
440 THOMA ET AL.
er BPD-focused treatments. However, in an RCT specifically aimed at

comparing DBT to working clinicians who were considered experts in
BPD, DBT showed significant advantages across a variety of outcome
measures (Linehan et al., 2006). None of the experts were CBT-orient-
ed, and all identified either as psychodynamic or eclectic. Thus, while
other treatments (e.g., TFP and the approach employed by McMain et
al., 2009) are promising and deserve further attention, one advantage
DBT currently has is that of offering a BDP-specific treatment that has
been codified in terms of both implementation and in training of thera-
pists. As a result, it now has widespread availability in the community.
However, it should be noted that the quality of implementation of DBT
in the community has not been systematically assessed.
Jeffrey Young, once a protégé of Aaron Beck, developed ST after no-
ticing clinically that patients with chronic depression and personality
disorders only benefitted to a limited extent from Beckian CBT (Young
et al., 2003). ST differs from traditional CBT in that it is a longer-term
therapy and it incorporates a focus on the developmental origins of
current problems. It differs from PDT in that it is a directive therapy
incorporating CBT techniques. It differs from both CBT and PDT in that
it also incorporates experiential, emotion-focused techniques original-
ly developed within Gestalt therapy, such as “chair work” and use of
imagery exercises (Young et al., 2003). In the mode model, a primary
component of ST, patients are seen as struggling with conflicts between
parts of the self, known as modes. With therapist guidance, patients
engage in dialogues between these modes by sitting in different chairs
in the room, or by encountering the various modes in imagery.
Schema therapy has been tested in several RCTs to date. Geisen-Bloo
et al. (2006) compared three years of ST with TFP for BPD and found
ST to be significantly more effective than TFP across all outcome mea-
sures at post-treatment. Additionally, the alliance was higher in ST
(Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007) and the
dropout rate was much lower, at 25% dropouts over three years in ST
versus 50% dropouts in TFP. Additionally, a randomized effectiveness
trial has been conducted, demonstrating that ST could be implemented
effectively in the community (Nadort et al., 2009). A form of group ST
has shown promising results, performing significantly better than TAU
for borderline personality disorder in one trial (Farrell, Shaw, & Web-
ber, 2009). ST has also been tested with additional PDs. In a recent trial,
two years of ST was compared with TAU and clarification-oriented
psychotherapy (COP), a humanistic therapy tailored to personality dis-
orders. Included were cluster C PDs, along with histrionic, narcissistic,
and paranoid PDs. At post-treatment, ST outperformed TAU and COP,
with PD recovery rates of 81.4%, 51.8%, and 60.0%, respectively (Bame-

lis, Evers, Spinhoven, & Arntz, 2014).
Treatment of PDs has long been considered an area of strength for
PDT (Gabbard, 2014). Yet there may be no definitive answers as yet
as to whether PDT or CBT is better for PDs. In a meta-analysis, Leich-
senring and Leibing (2003) found large effects on PDs for PDT as well
as CBT. While the effect sizes appeared larger for PDT, the effect sizes
in this study were not directly comparable as they were not restricted
to between-groups comparisons within head-to-head trials. Further, a
variety of models of CBT and PDT were included. Lastly, a variety of
studies have shown that differences in the effectiveness of individual
therapists within a given treatment arm account for a larger propor-
tion of the variance in outcome than differences between treatments
(Wampold, 2001). What may be of greater interest is not whether a given
treatment is better than another but rather, what therapeutic processes
seem important in psychotherapy (Borkovec & Castonguay, 1998).
To date, the research into mechanisms of change in CBT for PDs has
been more limited than for other disorders, such as MDD and anxi-
ety disorders. In a process study of the trial of DBT versus commu-
nity experts, DBT skills use mediated the decrease in suicide attempts,
self-injury, depression, and the increase in control of anger over time
(Neacsiu, Rizvi, & Linehan, 2010). Patients in the DBT condition used
three times as many DBT skills as those in the control condition. Thus,
there is some evidence that DBT achieves its effects through the be-
havioral and cognitive skills that it purports to teach. Further, in an-
other process study of DBT, patients experienced positive change in
ways that went beyond symptom reduction, and experienced changes
in the relationship with their therapist over the course of treatment in
theoretically relevant ways (Bedics, Atkins, Comtois, & Linehan, 2012).
Patients reported the development of a more positive introject, includ-
ing increased self-affirmation, self-love, self-protection, and decreased
self-attack. These changes were significantly greater than those in the
comparison condition, which was treatment by community experts.
Further, patients who perceived their therapists as both affirming and
protecting engaged in less self-injury.
While efficacy studies of ST have been showing a good deal of prom-
ise, there are as yet few studies of process within ST. However, there
can be said to be a good deal of overlap in the experiential, emotion-
focused techniques employed within ST and those of Greenberg’s emo-
tion-focused therapy (EFT; Greenberg, 2002). The experiential compo-
nents of ST are considered by its practitioners to be its most central and
change-promoting elements (Young et al., 2003). There is a wealth of
process-outcome literature produced by Greenberg and his group, in-
442 THOMA ET AL.
dicating the importance of activating and working with emotion along

with the success of Gestalt-style techniques such as “chair work” in
doing so (for a review, see Elliott, Greenberg, Watson, Timuluk, & Fri-
ere, 2013). However, there has yet to be any research examining these
processes specifically with ST and with PD patients.
Substance Abuse
Treatment of substance abuse with CBT has been shown to be highly

efficacious. The conceptualization of substance use problems in this
framework emphasizes expectations regarding consequences that re-
sult from substance use and dysfunctional ideas regarding abstinence
(Marlatt & Gordon, 1985). Additional modern conceptualizations of
substance abuse emphasize harm reduction, where individuals with
addictions are taught methods for refraining from use, while also train-
ing in how to use in ways that minimize adverse impact (Marlatt, Lar-
imer, & Witkiewitz, 2011). As with exposure therapy, harm reduction
has controversial roots, beginning with controlled drinking, an early
behavior therapy approach for alcohol abuse (Sobell & Sobell, 1973).
Controlled drinking has been extensively studied (Rosenberg, 1993)
and generally found efficacious for problem drinkers.
As noted, the relapse prevention model and harm reduction ap-
proach to substance abuse emphasize changes in outcome and efficacy
expectations. This approach is at least partially compatible with PDT in
its focus on targets that are much broader than simply the reduction of
substance use. Experimental research has persuasively shown, for ex-
ample, that desire for alcohol increases under conditions of social stress
(Greeley & Oei, 1999). Improving one’s personal expectation of tolerat-
ing interpersonal distress would in turn alleviate the urge to drink as a
coping mechanism.
Eating Disorders
For the purposes of this discussion, we will focus primarily on an-

orexia nervosa (AN) and bulimia nervosa (BN). It is in this domain
that psychodynamically oriented investigators have emphasized vari-
ous roles for food as a source of intrapsychic conflict for sufferers (i.e.,
Lowenkopf & Wallach, 1985; Pyle, Mitchell, & Eckert, 1981). More re-
cent conceptualizations have emphasized interpersonal processes as
a critical maintaining factor in eating disorders, and treatments have
now been structured to address these domains of functioning (Tanof-
sky-Kraft & Wilfley, 2010). This model is structured in a manner similar

to other structured interpersonal psychotherapy protocols, which em-
phasize treatment for specific domains of interpersonal deficits such as
conflict, role transitions, loss, or general deficits. As will be discussed
here, treatment trials for bulimia, more so than other conditions, have
involved careful comparisons between CBT and other active treat-
ments. As will be discussed, these treatment trials evaluating different
active treatments have been revealing about the relative contributions
of disparate theoretical models of intervention.
Intervention employing CBT for AN or BN emphasizes improvement
in general functioning through managing food intake, reducing purges,
and addressing distorted cognitions regarding weight and shape (Fair-
burn, Marcus, & Wilson, 1993). This approach has indeed been valuable
in reducing acute symptoms of AN and BN in sufferers. However, early
in the development of structured protocols it was noted that without
attending to interpersonal processes, treatment outcome was not sat-
isfactory, with longer term follow-up showing problems with relapse
(Fairburn, Jones et al., 1993). More recent trials have put a sharper point
on the central importance on interpersonal processes in CBT, including
the relationship between therapist and client, where alliance was an im-
portant factor in outcome of treatment, whereas adherence to between
session procedures was not (Loeb et al., 2005).
A recent treatment trial examined CBT compared to psychoanalytic
therapy for the treatment of bulimia (Poulsen et al., 2014). The treat-
ment conditions involved either two years of weekly psychoanalytic
therapy or 20 sessions (spread over five months) of CBT. Outcome
generally favored CBT when comparisons were conducted during
the course of treatment, suggesting that CBT produced faster benefits.
However, when both groups were compared at the end points for the
respective treatments, there were no significant differences in eating
disorder pathology as well as general psychopathology. Accordingly,
although treatment was longer in duration, clear benefits were derived
from psychoanalytic therapy.
Schizophrenia
Much of the emphasis in the treatment of schizophrenia presently

involves a broad category of interventions referred to as psychiatric re-
habilitation. This approach draws on decades of research from diverse
areas such as social skills deficits, neuropsychological deficits, func-
tional impairments, and cognitive interventions for distorted beliefs.
Early work in behavior therapy focused on social skills training as a
444 THOMA ET AL.
model of rehabilitation, with reinforcement of prosocial behaviors, as

well as incremental gains in functional behavior, through token econo-
mies (i.e., O’Brien & Azrin, 1972). The work in cognitive remediation,
which is aimed to address neuropsychological deficits such as memory
and executive functioning impairments, show small but significant ef-
fect sizes in improving the target functional domains as well as small
effect sizes for symptom reduction (McGurk, Twamley, Sitzer, McHu-
go, & Mueser, 2007).
In addition to addressing functional, social, and neuropsychological
deficits, investigators have also developed protocols to address cogni-
tive errors and dysfunctional beliefs that contribute to positive symp-
toms associated with schizophrenia such as delusions. Employing a set
of behavioral experiments in collaboration with the client, Chadwick
and Lowe (1990a, 1990b) found that individuals with schizophrenia
were able to alter their delusional beliefs. More recently, comprehen-
sive behavioral interventions have been developed to address symp-
toms associated with schizophrenia, including acceptance and commit-
ment therapy (ACT) as well as CBT employing behavioral experiments
and specific behavioral exercises (i.e., behavioral activation). These
approaches to treatment are associated with symptom improvement.
A recent comprehensive trial compared ACT to CBT in a sample of
individuals with schizophrenia, and found both groups significantly
improved, but that there was no significant difference between the
treatments (Sawyer et al., 2012). Overall, the existing research suggests
strongly that treatment for schizophrenia requires comprehensive in-
tervention that targets multiple domains.
Chronic Pain
Conceptualizations of chronic pain have recently emphasized exces-

sive internal focus as a significant contributor to impairment. A specific
construct that has been the focus of investigation in this regard is anxi-
ety sensitivity (Asmundson, 1999). Anxiety sensitivity is a construct
originally developed to predict panic symptomatology, but has been
shown to have far wider applicability. In the context of chronic pain,
heightened interoceptive awareness promotes greater pain perception,
which in turn worsens symptoms of chronic pain and increases impair-
ment. As part of this model, individuals with chronic pain experience
increases in anxiety as the anticipation of experiencing any worsening
of their pain. Individuals with elevated anxiety sensitivity in turn are
particularly prone to suffering from this cycle and have greater disabil-
ity from pain.
As with other psychological problems reviewed here, chronic pain

has been treated employing CBT. In this case, treatment focuses more
on alleviating dysfunctional cognitions associated with pain experi-
ences (i.e., assumptions about functioning with pain). More recent ap-
proaches have emphasized the role of mindfulness training and ACT in
reducing disability due to chronic pain (McCracken & Vowles, 2014). In
the case of ACT and mindfulness, the goal is not necessarily to reduce
pain perception, but to instead evaluate the degree that one can still en-
gage in activities while simultaneously experience pain. At its founda-
tion, it is a shift from thinking that interferes with functioning (e.g., “I
want to do this, but I have pain”) to thinking that facilitates functioning
(e.g., “I want to do this and I have pain”). At this point, mindfulness
interventions show promise in improving functioning in chronic pain
sufferers, although the research is still in the early stages of develop-
ment (Chiesa & Serretti, 2011). Studies evaluating the efficacy of ACT
for chronic pain show small but significant effect sizes (Veehof, Oskam,
Schreurs, & Bohlmeijer, 2011), which is not superior to CBT, but may be
more desirable for some clients.
Insomnia
Insomnia treatment, which currently is referred to as sleep medicine,

has grown to be a highly specialized approach (Penzel et al., 2014). At
perhaps the most basic level, insomnia has been conceptualized as a
breakdown of the stimulus control of the bed as a prompt for sleep
(Bootzin, 1979). Protocols for sleep management have evolved to em-
phasize managing time spent in bed in order to re-establish the bed as
a place associated primarily with sleep (as opposed to other activities
such as watching television, eating, or sleeplessness). This is to establish
the bed as a discriminant stimulus for sleep. Another major component
involves sleep restriction whereby patients are asked to adjust the time
that they go to sleep or wake up so that over time, healthy sleep habits
are formed. Broadly, this approach involves restricting a client to sleep
only in bed, in order to ensure that the bed is primarily associated with
sleep rather than with frustrated efforts at sleep, and to correct the cli-
ent’s circadian cycle. These core components of insomnia management
(along with restriction on efforts on sleep extension, or daytime naps)
represent comprehensive sleep management. When applied, compre-
hensive sleep management programs can rapidly improve sleep dura-
tion and quality (i.e., Harris, Lack, Kemp, Wright, & Bootzin, 2012).
446 THOMA ET AL.
Child and Adolescent Psychopathology
As with adult disorders, child and adolescent treatment protocols

employing CBT have been well tested and validated with strong treat-
ment outcomes. In the adult disorders, the level of detail for how to
implement procedures and the knowledge of factors that complicate
intervention with CBT is now highly evolved to encompass modifi-
cations for so-called refractory cases (McKay, Abramowitz, & Taylor,
2010; McKay, Arocho, & Brand, 2014). This is likewise the case with
treatment for children and adolescents, where specific prescriptions
for modifications to existing protocols are recommended when com-
plicating features have been identified (McKay & Storch, 2009). Clinical
guidelines have emphasized CBT for many childhood diagnoses (i.e.,
the National Institutes for Clinical Excellence, in the United Kingdom).
Depression
There has been extensive research into the efficacy of CBT for depres-
sion in children. Interestingly, unlike other conditions, CBT has shown
mixed results in alleviating depression in younger populations. There
are several models of intervention that have been developed for chil-
dren with depression, with some emphasizing increasing behaviors in
a manner akin to behavioral activation for adults along with specifi-
cally targeting dysfunctional cognitions that promote depressed mood
(i.e., Lewinsohn, Clarke, Hops, & Andrews, 1990). Another emphasizes
primarily cognitions in a manner similar to the approach described by
Beck, Rush, Shaw, and Emery (1979) tailored for children. In one large
multi-site trial using a protocol that was a flexible adaptation of the
Lewinsohn et al. model, children treated with a combination of CBT
with fluoxetine were the only ones to significantly improve (compared
to those treated with either intervention alone; The Treatment on Ado-
lescent Depression Study; TADS, 2007). In a more recent review of the
available evidence, it was concluded that CBT did not yet have ade-
quate empirical support for it to be declared an evidence-based treat-
ment for childhood depression (Nel, 2014). This disappointing outcome
suggests that far more work needs to be done in order to alleviate child-
hood depression. One area not fully developed is determining methods
for best involving parents and caregivers in the childhood depression
treatment, as well as other systematic methods for integrating treat-
ment with medication-based therapies (Curry & Becker, 2009).
Anxiety
Given the heterogeneity of anxiety disorders, which includes spe-

cific phobia, separation anxiety, selective mutism, generalized anxiety,
social anxiety, and panic disorder, there are a wide range of interven-
tions available for treating this class of conditions in children. How-
ever, there are some protocols available that can be flexibly applied to
any of the aforementioned diagnoses. One prominent example is the
Coping Cat protocol (Kendall, 1994). This procedure engages children
in a sequence of scenarios designed to challenge cognitions regarding
potential harm, uncertainty, and other major cognitive errors that per-
petuate fear. Recent individual patient data analysis shows that CBT is
generally effective in alleviating child and adolescent anxiety (Bennett
et al., 2013).
There is a good deal of controversy in this domain of research regard-
ing the role of parents or caregivers in treatment. Models of etiology of
child anxiety have emphasized attachment and rearing as significant
contributors, as well as the degree to which a child feels a sense of con-
trol over her/his environment (Chorpita & Barlow, 1998). This would
suggest that involvement of parents in child treatment would be cru-
cial for efficacious intervention. On the other hand, clinical trial data
have not shown an incremental benefit to including parents or care-
givers in treatment (Breinholst, Esbjørn, Reinholdt-Dunne, & Stallard,
2012). Further, while early environment appears to contribute to the
development of anxiety, actual parenting style accounts for a very small
amount of variance in explaining anxiety, but parental control accounts
for a large amount of variance (McLeod, Wood, & Weisz, 2007). This
would suggest that, rather than protocols emphasizing parental control
over the rate of behavioral homework compliance in child treatment,
interventions should be tailored to address parental control concurrent
to addressing childhood anxiety problems (Taboas, McKay, Whiteside,
& Storch, 2015).
Tic and Habit Disorders
Tics are repetitive motor or verbal behaviors that usually start in

childhood. These responses are often experienced as under “pseudo-
control” in that the sufferer can resist the urge to perform the tic, but
as it is resisted the urge increases in intensity. The early conceptualiza-
tion of tics by Azrin and Nunn (1973) remains the dominant model for
tics, and the associated treatment of habit reversal training (HRT) has
448 THOMA ET AL.
since garnered substantial empirical support. Most striking about the

success of HRT is that it is used in the alleviation of a problem that was
considered primarily a medical problem. Treatment with HRT includes
the following five components: awareness training, relaxation training,
competing response training, motivation procedures, and generaliza-
tion training. A recent meta-analysis of outcome studies for tics showed
that individually administered HRT is associated with large effect sizes
(d = 0.85; Bate, Malouff, Thorsteinsson, & Bhullar, 2011).
Tourette’s syndrome is also broadly considered a tic disorder. How-
ever, a great deal of research has also shown a unidirectional link be-
tween Tourette’s syndrome and OCD (Ferrão, Miguel, & Stein, 2009).
That is, Tourette’s syndrome confers a specific risk for comorbid OCD
presentation, but OCD does not confer a risk of comorbid Tourette’s
syndrome (or other tic disorders). Treatment for Tourette’s syndrome
also involves HRT. As with other tic disorders, HRT has resulted in gen-
erally large effect sizes as revealed in a recent meta-analysis of treat-
ment trials, although these effect sizes were attenuated when attention
deficit co-occurred in participants (McGuire, Piacentini et al., 2014).
Finally, trichotillomania, or compulsive hair pulling, is a condition
for which HRT has been extensively studied. As with the other con-
ditions discussed, HRT is associated with generally large effect sizes
(d = 1.41) from a recent meta-analysis (McGuire, Ung et al., 2014). Of
particular note, however, is that studies that attained the best outcome
included specific interventions to improve mood regulation as well as
develop strategies to control hair pulling. Further, in this meta-analysis,
outcome studies of serotonin reuptake inhibitor medications were also
evaluated, which by contrast had significantly smaller effect sizes for
trichotillomania (d = 0.41).
Cognitive Behavior Therapy with or without

Medication for Depression
Early in the development of CBT, and cognitive therapy in particular,

investigators sought to demonstrate the comparable efficacy to medica-
tion. Among the earliest trials to evaluate this difference was by Rush,
Beck, Kovacs, Weissenburger, and Hollon (1981), where individuals
with major depression were treated with either cognitive therapy or
imipramine. The results showed that individuals who were treated
with cognitive therapy had better outcome at the end of treatment, and
also remained well at follow-up. Since that time, numerous trials have
compared CBT to medication, with varied results. The results of these
disparate trials are complex, and accordingly readers are referred to

Hollon and Beck (2004) for a comprehensive review.
One particularly significant issue overlooked in past analyses of the
CBT versus medication discussion has been a specific evaluation of the
combined benefit of CBT and medication, which is how treatment is
often delivered in clinical settings. For example, in one meta-analytic
evaluation, CBT was found to be superior to medication in the treat-
ment of depression, but the effect was carried largely by an outlier
study, whereas the other studies in the review did not show unequivo-
cal superiority (Parker, Crawford, & Hadzi-Pavlovic, 2008). This would
suggest a complex picture for treatment efficacy. Investigating further,
in a meta-analysis of treatment outcome for depression where inpa-
tients received both CBT and antidepressant medication, revealed that
while initial treatment outcome was often comparable, remission rates
were worse for those who received combined treatment compared to
those who received only one modality (Köhler et al., 2013).
Treatment trials for medication with or without CBT, or its com-
bination, have been conducted for the majority of other psychiatric
conditions. There is a wide breadth of medications and treatment ap-
proaches. Given the aforementioned differences observed in the case of
depression, there are no definitive practice guidelines for determining
best course of treatment plan based on presenting clinical condition.
Long-Term Effects of Cognitive Behavior Therapy
Examination of the currently accepted standards for declaring treat-

ment protocols empirically supported do not emphasize outcome at
follow-up (Chambless & Ollendick, 2001). However, most investiga-
tors view long-term follow-up as an essential criteria for declaring a
treatment efficacious. Indeed, in some areas of therapeutic expertise,
good outcome at follow-up is an essential. For example, most journals
require at least one-year follow-up for studies evaluating treatments for
addictive behaviors. Despite this, many investigations of CBT outcome
also evaluate follow-up outcome. In this domain, CBT consistently per-
forms well across most conditions, and with most populations. Rather
than consider this for all the myriad conditions investigated, consider
a generalized treatment approach, transdiagnostic cognitive behavior
therapy, for anxiety disorders. This approach is intended for the full
range of anxiety disorders, and treatment is associated with large effect
sizes for maintenance of gains at follow-up (Reinholt & Krogh, 2014).
As a further example, CBT tailored specifically for treating adult survi-
450 THOMA ET AL.
vors of childhood sexual abuse shows maintenance of gains at follow-

up (Ehring et al., 2014). Finally, parental involvement in CBT for child-
hood anxiety has shown not only maintenance of gains, but further
improvement at follow-up (Manassis et al., 2014).
Future Directions
While much development and research has been done on CBT, there
clearly remains more work to be done. Some of this rests on a shift in
emphasis in the kind of research to be completed. Randomized con-
trolled trials are the gold standard in intervention research, however
RCTs have some limitations, particularly when applied to psychother-
apy research (see Wachtel, 2010, for a critique). While RCTs can tell us
that a given psychotherapy works better than a control condition, RCTs
do not tell us what about the therapy caused the change (Borkovec &
Castonguay, 1998). Thus, process-outcome research is needed to deter-
mine the active ingredients. While some progress has been made, this
remains a priority for CBT researchers, as it is also for psychotherapy
researchers of all stripes (Barber, 2009).
Better understanding the mechanisms at play in CBT will help bet-
ter understand how to further enhance CBT treatments in several re-
gards. For one, it will clarify the relationship between techniques and
so-called common factors, such as the benefits of a therapeutic relation-
ship. In our view, all therapist behaviors can ultimately be regarded
as specific effects that a therapist can deliver more or less of, or de-
liver more or less skillfully. We strongly agree with those who argue
for the importance of the therapeutic relationship, and further, we view
it as a manipulable variable. Thus, better understanding mechanisms
will help us understand therapist effects better—that is, what makes
more effective CBT therapists thusly more effective. Is it that they are
better at forming and maintaining the relationship? More nuanced in
their administration of techniques? Or a complex combination? This is
also a priority that will feed into how we train the next generation of
therapists and disseminate the findings of CBT. Lastly, better under-
standing mechanisms may help us fundamentally modify treatments
to further improve outcomes. No CBT protocols we are aware of have
consistently shown a 100% remission rate. Our survey of the literature
has shown us that remission rates vary widely, such as less than 30%
for the short-term treatment of complex PTSD in persons who have
experienced childhood sexual abuse (Cloitre et al., 2010) and up to 80%
recovery rate in a two-year course of schema therapy for personality
disorders (Bamelis et al., 2014). One question would be as to whether
non-responders need more of the same (i.e., a longer version of the

same treatment) or something different (i.e., a modified or even entirely
different approach).
We also believe that it is a priority to bring more emphasis to examin-
ing long-term outcomes for CBT. Too much of the research literature has
examined outcomes primarily at post-treatment or at near-term follow-
up periods of three or six months (Tolin, McKay, Forman, Klonsky, &
Thombs, in press). While longer-term outcome measurement is difficult
to achieve, it is essential to determine how much a given treatment is
able to fundamentally help the population under study achieve mean-
ingful changes. Along these lines, we also believe that greater emphasis
on functional outcomes, such as interpersonal functioning, rather than
just target symptom reduction (e.g., panic attacks), is also a valuable
endeavor (Tolin et al., in press).
Ultimately we would like to see the quality and reach of CBT to con-
tinue to grow. This includes further integration of important aspects of
other therapies, including both PDT and humanistic therapies. Integra-
tive efforts thus far have been seen in functional analytic psychotherapy
(FAP) which uses a behavioristic framework to understand and work
with such phenomena as transference and countertransference (Tsai,
Fleming, Cruz, Hitch, & Kohlenberg, 2014); the addition of interper-
sonal and experiential elements to CBT for generalized anxiety disor-
der (Erikson, Newman, & McGuire, 2014); the integration of a develop-
mental perspective and Gestalt techniques in schema therapy (Rafaeli,
Maurer, & Thoma, 2014); and use of relational work to repair ruptures
in the alliance (Safran & Kraus, 2014), to name a few (see Thoma &
McKay, 2014, for compilation of such integrative efforts within CBT).
Continued research, further communication between clinicians and re-
searchers, and further dialogues between therapists of differing orien-
tation will all serve to further the evolution of psychotherapy, helping
psychotherapy fulfill its greatest potential.
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Nathan Thoma
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nthoma@gmail.com

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THOMA ET AL.

CONTEMPORARY COGNITIVE BEHAVIOR THERAPY

Contemporary Cognitive Behavior Therapy:

Nathan Thoma, Brian Pilecki, and Dean McKay

Abstract: Cognitive behavior therapy (CBT) has come to be a widely practiced

Cognitive behavioral therapy (CBT) is a time-limited, problem-fo-

Nathan Thoma, Ph.D., Weill Cornell Medical College.

Psychodynamic Psychiatry, 43(3) 423–462, 2015

CBT as applied to depression, anxiety disorders, personality disorders,

As the name cognitive behavioral therapy implies, CBT can be seen

History of Behavior Therapy

While an interest in learning principles has long existed in human

steps in the morning). Subsequently, he began experimenting with the

anxiety, stuttering, impotence, and other disorders. This approach be-

The modification of expectations is an explicit acknowledgement that

History of Cognitive Therapy

While BT took its original inspiration from experimentalists like Wat-

personality psychology embracing a constructivist view of personality,

ward more a more functional outlook through Socratic dialogues (Beck

Third Wave CBT

The “third-wave” of CBT emerged as an influential movement in the

process of thinking altogether. To accomplish this, ACT relies heavily

Evidence in Support of CBT

In evaluating the evidence in support of CBT, we will briefly review

Evidence for CBT for Depression

this possibility, Tang and DeRubeis (1999) evaluated instances of sud-

patients, there was no difference between medication and behavioral

remains possible that the specific techniques of a given psychotherapy,

The anxiety disorders represent a broad class of diagnoses. At the

CBT for Personality Disorders

er BPD-focused treatments. However, in an RCT specifically aimed at

with PD recovery rates of 81.4%, 51.8%, and 60.0%, respectively (Bame-

dicating the importance of activating and working with emotion along

Treatment of substance abuse with CBT has been shown to be highly

For the purposes of this discussion, we will focus primarily on an-

sky-Kraft & Wilfley, 2010). This model is structured in a manner similar

Much of the emphasis in the treatment of schizophrenia presently

model of rehabilitation, with reinforcement of prosocial behaviors, as

Conceptualizations of chronic pain have recently emphasized exces-

As with other psychological problems reviewed here, chronic pain

Insomnia treatment, which currently is referred to as sleep medicine,

Child and Adolescent Psychopathology

As with adult disorders, child and adolescent treatment protocols

Given the heterogeneity of anxiety disorders, which includes spe-

Tic and Habit Disorders

Tics are repetitive motor or verbal behaviors that usually start in

since garnered substantial empirical support. Most striking about the

Cognitive Behavior Therapy with or without

Early in the development of CBT, and cognitive therapy in particular,

disparate trials are complex, and accordingly readers are referred to

Long-Term Effects of Cognitive Behavior Therapy

Examination of the currently accepted standards for declaring treat-

vors of childhood sexual abuse shows maintenance of gains at follow-

non-responders need more of the same (i.e., a longer version of the

M. Forman (Eds.), Acceptance and mindfulness in cognitive behavior therapy: Un-

Thoma, N. C., & Cecero, J. J. (2009). Is integrative use of techniques in psychother-

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