Members of the Academy of Cognitive Therapy have been participating in an interesting dialogue via their (members only) listserve. A European member wondered why we make a point of labelling what we do as "cognitive therapy" instead of "cognitive behavior therapy." I hypothesize that what is generally taught and practiced in Great Britain and elsewhere is what we would call "cognitive therapy" so many Europeans do not see the need to distinguish between CT and CBT. The United Kingdom, Sweden and Norway, to name just three, are far ahead of North America in setting standards and institutionalizing training in cognitive therapy in graduate schools.
Before the establishment of the Academy of Cognitive Therapy no organization in North America had set standards, devised assessment instruments, and evaluated credentials and work samples to determine if mental health professionals in all fields should be certified specifically in cognitive therapy (although a few organizations did offer certification in cognitive behavior therapy or rational emotive therapy).
What is the difference between cognitive therapy and cognitive behavior therapy? There is a significant degree of overlap between CT (which is one form of CBT) and other forms of CBT, but there are often important differences as well. For example, cognitive therapy treatment is always based on a cognitive formulation of the patient's disorder and the cognitive conceptualization of the specific patient. The ultimate aim is to modify patients' cognitions, behavior, emotions, (and sometimes physiological reactions). In order to produce enduring change in the latter three, there is a strong emphasis on the modification of dysfunctional cognitions, especially beliefs.
Some cognitive behavioral therapies that do not necessarily meet these requirements are self-instructional training, problem-solving therapy, and behavior modification. Cognitive therapy is truly an integrative therapy, utilizing techniques from these therapies, and other therapies as well, to bring about cognitive, behavioral, and emotional change. Cognitive therapy is not defined by the types of techniques the therapist uses-it is defined by the therapists' planning and implementing treatment according to a cognitive formulation and conceptualization.
For example, I have just started treating a chronically severely depressed and suicidal patient with strong Axis II pathology, including borderline, avoidant, narcisstic, and passive aggressive features. Below are some of the techniques I have used or probably will use. I have artificially separated the techniques into different categories; most are actually cognitive and/or behavioral in nature. As much as possible, I will teach the patient to implement relevant techniques himself, practicing and using them daily.
Cognitive: Identify, evaluate, and respond to his negative thoughts and images, especially about himself, his world (including other people) and his future; test and modify his dysfunctional assumptions and core beliefs; set specific goals; assess advantages/disadvantages of some of his beliefs, behaviors, problem solving options.
Behavioral: Schedule mastery and pleasureable activities, social skills training, relaxation, problem solving, behavioral experiments.
Emotional: Reduce high levels of affect through controlled breathing, distraction, exercise, highly diverting tasks or pleasurable activities, phone calls to supportive others, soothing music, review of coping cards. Anxiety management and tolerance techniques, testing and modification of his beliefs about experiencing negative emotion. ("If I start to feel bad, I'll get overwhelmed and won't be able to stand it.")
Biological/Physiological: Focus away from his symptoms of anxiety in social situations and toward conversation; assess advisability of his recontacting his psychiatrist and/or seeking a second opinion on his medications.
Interpersonal: Reduce "mind-reading;" modify dysfunctional cognitions about specific others and about relationships, set interpersonal goals; remediate social skills, roleplay interpersonal situations, include his significant other in therapy (if indicated); initiate more social contact, resolve interpersonal issues that arise in our therapeutic relationship; if relevant, make decisions about approaching (dysfunctional) family of origin.
Environmental: Clean up apartment; decide whether to seek a new roommate or move; consider changing job.
Experiential: Psychodrama, restructuring the meaning of traumatic childhood experiences through guided imagery.
Psychodynamic-like: Elicit and test his automatic thoughts and beliefs about therapy and about me (when they interfere with therapy or the therapeutic relationship); generalize what he has learned to other relevant people outside of therapy; draw connections between dysfunctional beliefs from childhood and his interpretations of and reactions to current situations.
Cognitive therapists create flexible treatment plans based on the patient's disorder(s), an ongoing refinement of the conceptualization, and the patient's personal characteristics, preferences, and goals. Many people who label themselves as cognitive behavior therapists would do so as well, but others would not. Instead, they might base treatment on a behavioral formulation of the patient's disorder, use the same cognitive formulation for different psychiatric disorders, or fail to individualize treatment based on a cognitive conceptualization. They might not utilize a standard cognitive therapy approach: striving to create a strong therapeutic relationship, setting specific goals, structuring sessions (unless it is clearly inappropriate to do so) with agendas, summaries, homework, and feedback (for example).
The Academy of Cognitive Therapy was established, in part, to preserve the integrity of cognitive therapy as developed by Aaron Beck, M.D. Cognitive therapy will continue to be refined for the various psychiatric disorders, psychological problems, and medical problems with psychological contributions, guided by empirical tests of the theory and outcome studies measuring efficacy. Its emphasis on cognitive change for enduring emotional and behavioral change is an important differentiating factor between it and many other cognitive behavioral therapies.
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