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Cognitive behavioral therapy (CBT) is the leading evidence-based psychological treatment for mental disorders and has received significant support and recognition from the UK government and health authorities, although many other effective evidence-based therapies exist. the evidence. Scientific research has shown that CBT is the most researched and authenticated psychological treatment that uses evidence-based practices available for the treatment of various psychological problems, including: depression, anxiety, stress and pain, helping people overcome obstacles and the difficulties they face. at work, at home, or in relationship situations (Hollon & Beck, in press). CBT evolved from two earlier types of psychotherapy; behavioral therapy in the early 20th century and cognitive therapy in the 1960s, but like all psychotherapy, this evidence-based psychological treatment has been widely criticized for different reasons and from different quarters. For example, psychotherapist and Professor Andrew Samuels (2007) from the Center for Psychoanalytic Studies at the University of Essex wrote to the Times: “We have allowed CBT advocates to caricature all other psychotherapies as endless research into the patient's past and beyond any scientific investigation. confirmation of effectiveness. Everyone knows the limits of CBT, except, it seems, the government. The science is inadequate, the methods are naive and manipulative, and the reluctance to engage with the key aspect of psychotherapy, the deep and complex relationship that develops between client and therapist, is very lax indeed. Clients entering TCC are mechanically approached, requiring them to be passive and compliant. So what's being offered is second-class therapy for citizens who consider themselves second-class." Accordingly, this essay critically assesses the current understanding of CBT and examines its efficacy in relation to depression and panic disorder. due to its "research-oriented nature of efficacy” (Parry, 2004) and the fact that CBT was originally developed to treat these disorders. Additionally, there is debate as to whether CBT is capable of inducing profound change ( that is, changes in fundamental schemas and beliefs) and lasting (that is, reducing relapse rates) in people's lives and if it eliminates the pain they experience in the long term.
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Kendall and Hollon (1979), cited by Beidel and Turner (1982), defined cognitive-behavioral therapy as "deliberate attempts to preserve the proven effectiveness of behavior change in a less doctrinal context and incorporate cognitive activities as efforts to bring about change." therapeutic". . . . In other words, CBT pays attention to how people perceive, interpret, reason and reflect on internal and external events. The UK CBT Organization notes that "the term 'cognitive behavioral therapy' (CBT) is used variously to refer to behavioral therapy, cognitive therapy, and therapy based on a pragmatic combination of principles based on behavioral and cognitive theories" (BABCP, 2008). As a result, contemporary CBT is influenced by the behavior therapy which draws on behavioral theories such as learning theory (where operant and classical conditioning functions are considered more important) to describe the acquisition of emotional problems and the modification of undesirable behavior and was developed by Wolpe and colleagues in the 1950s and 1960s (Wolpe, 1958).The richness of this approach and its effectiveness led to behavior therapy being used quickly across the board, particularly for anxiety disorders (Westbrook et al. 2007). However, previous behavioral approaches have discounted the role of cognition and cognitive processes (ie, thoughts and beliefs) in the onset and maintenance of emotional disturbance (Mahoney, 1974). In stark contrast, cognitive therapy is based on how cognitions and the way individuals interpret events lead to the development of emotional disorders. This therapy was developed by A.T. Beck in the early 1960s, but became more widely known with the 'cognitive revolution' of the 1970s, and is the best validated and widely used model of emotional disturbance (Westbrook et al. 2007). Although initially obsessed with depression, Beck's model has since been applied effectively to other disorders, including anxiety (Beck, Emery, & Greenberg, 1985), personality disorders (Beck, Freeman, and Associates, 1990), and anger (Beck, 1999). . From this it can be concluded that mental disorders occur as a result of faulty patterns of thought and behavior. Epictetus, a first-century Greek philosopher, once said, "People are not concerned with things, but with their opinions of them." This clearly shows the importance of CBT.
Before discussing whether CBT is capable of inducing profound and lasting change, it is first necessary to clarify what the term profound and lasting change means for a specific disorder. Scholars have argued that psychosocial interventions have been shown to produce lasting changes in individual problems, significantly reducing stress and anxiety in ways that produce lasting changes over time. But the more important question is whether psychosocial interventions (eg CBT) produce deep and lasting changes and reduce relapse rates, as well as produce changes at a deeper level (eg changes in schemata). and core beliefs), or simply provide symptomatic relief. That is, when the result of CBT leads to a reduction in suffering and an improvement in well-being, quality of life and happiness once the intervention has finished and is stable over time. However, in some cases the problem may recur but still be long lasting as long as it affects the person with a lower frequency or intensity compared to previous conditions if left untreated (Hollon et al. 2006). Profound changes can be defined as changes that lead to a positive and subjectively sustainable effect on the person. The next part of this essay will critically examine and explain depression and panic disorder from a cognitive-behavioral perspective and will argue whether CBT is capable of changing a person's fundamental beliefs and assumptions and whether this is stable over time. .
Research studies have shown that CBT is an effective approach for many emotional disorders and offers more support than other approaches, such as psychodynamic psychotherapy (Roth & Fonagy, 2005). Roth and Fonagy (2005), in their recent update on what works for whom, report that CBT is a highly effective treatment option for most adult mental disorders compared to other forms of treatment. They noted that there is clear evidence of efficacy in the following conditions; Depression, panic/agoraphobia, generalized anxiety disorder, specific phobias, social phobia/OCD, PTSD, bulimia, and some personality disorders. There is also increasing evidence that CBT is effective outside of randomized controlled trials in everyday clinical practice (eg, Westbrook & Kirk, 2005; Merrill, Tolbert, & Wade, 2003). More recently, the government-funded Improving Access to Psychological Therapy (IAPT) movement has also advocated the use of CBT. In addition, the UK government has planned to offer CBT for depression and anxiety in 250 treatment centers (Layard, 2006). However, one must be very critical when examining the connection between the government and its funding for the training of CBT therapists. The government makes mistakes and the fact that CBT is cheap, fast and easy can be very attractive to the government. Therefore, the case for CBT changing people's lives is best made by examining RCTs and meta-analyses, which receive more attention in academia than government funding decisions. In addition, the UK's National Institute for Clinical Excellence (NICE) guidelines provide further support for the efficacy of CBT for depression and anxiety disorders. They give the following recommendations;
- Depression (NICE, 2OO4a): “For patients with mild depression, health professionals should consider recommending a self-help program based on cognitive behavioral therapy (CBT)…” (p. 5); "When considering individual psychological treatments for treatment-resistant moderate depression, the treatment of choice is CBT..." (p.27);
- Generalized Anxiety and Panic (NICE, 2004c): “The interventions that have been shown to have a longer duration of action are, in descending order: (initial) cognitive-behavioral therapy…” (p. 6); (Quoted from Westbrook et al., 2007)
However, most research studies are based on randomized controlled trials demonstrating the success of CBT in treating many mental disorders. Therefore, randomized controlled trials are the gold standard for the effectiveness of CBT. However, this claim may lack positive support for a number of reasons (Moloney & Kelly, 2004). One of the major disadvantages of these clinical trials is that only trials with positive results tend to be published more frequently (Boyle, 2002). Therefore, there is a strong tendency towards some studies that do not produce any positive effect. This can cause significant problems as we only see one side of the result and are not fully aware of the other side. The second problem is that CBT studies have significant methodological problems. Problems include; Studies often use privileged research populations, i.e., college students, and lack adequate sample sizes to allow generalizations to broader clinical populations, making it difficult to interpret results and draw firm conclusions (Holmes, 2002). . In addition, studies tend to use insufficient control groups for comparison purposes (ie waiting list group) and there are insufficient long-term follow-up studies of people treated with CBT. This can cause long-term problems, as the effects of CBT are less promising when follow-up exceeds 12 months (James, 2007). Moloney and Kelly, (2004) state that "An additional and very significant challenge to the evidence base for the effectiveness of CBT is the large body of literature comparing clinical outcomes that has accumulated over the last half century. This showed convincingly that the efficacy of psychotherapy for a wide range of clinical problems depends little on the clinical orientation of the therapist or even on his or her qualifications and presumed experience.As a result, one must be critical in drawing conclusions from randomized controlled trials.
CBT interventions have been shown to have long-lasting effects beyond the end of treatment. Furthermore, this intervention aims to reduce the risk of recurrence in chronic conditions and the risk of recurrence in episodic conditions. Even more remarkable, CBT interventions have the power to prevent early onset in individuals at risk (Hollon, DeRubeis, & Seligman, 1992). "It remains to be seen whether CBT is truly curative, but there is more evidence that CBT has a lasting effect than any other intervention in this area at present" (Hollon, 2003). The Department of Health stated in 2006 that the UK government wanted to give patients more access to 'talk therapy' (ie CBT) to reduce rates of depression. Some scholars argue that CBT is the treatment of choice for depression because it is an evidence-based and inexpensive therapy for depression (Tudor, 2006). Patients treated with the CBT intervention are less likely to experience a depressive relapse after completing the intervention than patients treated with medication (Hollon & Shelton, 2001). The lasting effect of the CBT intervention has also been shown in other studies on mental illness. Studies have consistently shown that CBT outlasts medications used to treat panic disorder (Barlow, Gorman, & Shear & Woods, 2000; Clark et al., 1994) and social phobia (Liebowitz, Heimberg, Schneier et al. ., 1999). Long-lasting effects have also been found in the treatment of bulimia nervosa and CBT has been shown to be more effective than interpersonal psychotherapy (Agras et al. 2000) and more stable than medication or behavioral therapy (Craighead & Agras, 1991). ).
Depression is one of the most common psychiatric disorders and one of the leading causes of illness worldwide. The most widely studied psychosocial treatment for depression is Beck's cognitive behavioral therapy (CBT), also known as cognitive therapy (CT) (Beck et al. 1979). The main strength of CBT in depression is its basis in empirical research. From a cognitive-behavioral standpoint, the defining characteristic of depression is a negative cognitive thought pattern. Essentially, this therapy is a short-term (8-16 sessions) directive therapy based on problematic thoughts and behaviors that hold dysfunctional beliefs about oneself, the world, and the future. Beck's cognitive model of depression is based on the hypothesis that distorted cognitions (thoughts, beliefs, images) and a person's idealistic evaluations of themselves, situations, and events can negatively affect a person's feelings and behavior. Therefore, it is not the events themselves (for example, divorce or dismissal from a job) that can cause suffering, but rather a person's understanding of them. This explains how people can react differently to the same life event or situation. Furthermore, the association between affect and cognition is reciprocal, which means that both influence each other, leading to a growth of the psychological problem in question (Beck, 1971). As a result, the way in which the person responds to environmental stimuli and the negative dysfunctional assumptions associated with that stimulus are believed to be the cause of their depression, and patients are often unaware of or fail to examine their negative automatic thoughts. Thoughts down to the last detail. Therefore, cognitive therapy aims to pay attention to these negative automatic thoughts and how the person interprets the events around them and try to identify different ways of thinking, challenge the individual's negative thoughts and try different ways to change their patterns. thinking. beliefs and intuitions. Unhelpful cycles of thought, feeling, emotion, and physiology must be broken and steps taken to reduce the likelihood that the problem will recur (Bennett-Levy et al. 2004).
Cognitive-behavioral therapy for depression consists of the following steps: 1) Sessions begin with an explanation of the fundamentals of CBT, the goal of which is to help the individual understand how the therapy model works and the progression of therapeutic change. CBT is a very active patient intervention, so 2) the first few sessions are dedicated to increasing active behavioral performance. In this way, it helps the therapist to observe the behaviors and the related thoughts and feelings of the person and thus gain a better picture of the problems the person is facing. Subsequent sessions include 3) advanced self-control techniques to make the connection between thoughts and how your feelings are integrated and consequently produce your apparent behavior. Patients at this stage are also encouraged to examine their thought patterns for logical inaccuracies consisting of arbitrary reasoning, selective abstraction, overgeneralization, magnification and minimization, personalization, and dichotomous thinking (Beck, 1976). In the middle of therapy 4) the schema concept is introduced and the therapy focuses on both negative and positive thoughts and with the help of the patient challenges negative thoughts that lead to depression. This part of therapy is very important and therefore critical to achieving remission and making deep and lasting changes in the patient's life. In the final phase of therapy, 5) Strategies to prevent relapse and prevent future recurrences of depression are discussed (Psychosocial Treatments for Major Depressive Disorder, A Guide to Treatments That Work).
Fava et al. (2004) conducted a 6-year follow-up study comparing 40 patients with recurrent major depression who had been treated with antidepressants. Patients were randomly assigned to the CBT or clinical treatment group. Meanwhile, antidepressant medication was discontinued in both groups. The results were remarkable, with the group receiving the CBT intervention having a significantly lower relapse rate (40%) compared to clinical treatment (90%) over a 6-year follow-up period. The results suggest that CBT may ameliorate the long-lasting effects of recurrent depression. However, this study has been criticized for its small sample size. Furthermore, the therapy sessions were conducted by an experienced psychiatrist and therefore the results may differ between different less qualified therapists. An important point to consider is that CBT is a short-term intervention that focuses on situations in the here and now. When examining whether CBT leads to profound changes, i. Due to changes in core beliefs and schemata, it is difficult to interpret these beliefs since many of the events that form our core assumptions take place in childhood and adolescence. Because CBT focuses on situations in the here and now, perhaps one of the biggest limitations of this intervention is for those who do not recover from CBT and relapse, as their core beliefs and schemas are strongly entrenched and with CBT. it's not possible. to uncover core beliefs that are formed in childhood and early adulthood are addressed in depth with this type of brief therapy. As in the case of Fava al el (2004), long-lasting effects are clearly present and stable, however, in the 40% of patients who still relapse, CBT has not been able to induce profound changes. It can be concluded that CBT can alleviate a current episode of depression, but cannot completely stop future depression because CBT has not altered the core schemata that Beck believes are the root cause of depression.
One of the limitations of CBT is that “there is continuing uncertainty about the efficacy of different psychotherapies (ie their clinical relevance) as opposed to their efficacy (ability to bring about change under 'laboratory' conditions). Cognitive behavioral therapy works well in university clinical trials with subjects recruited from advertisements, but the evidence on how effective it may be in real-world clinical practice is less reliable. For example, in the London Depression Study, couples therapy worked better than antidepressants in treating major depression in cohabiting patients, but cognitive behavioral therapy failed and was discontinued due to poor adherence in a patient population. particularly problematic (but clinically typical)”. (Holmes, 2001). Furthermore, clinical psychologist Oliver James (2009) argues that CBT does not produce profound and lasting changes in people with depression. He said the Department of Health invested £173m in CBT two years ago and claimed the therapy permanently cures half of all people suffering from depression. Furthermore, he argued that there is not a single study to support this claim. Contrary to this statement, he presents the study of the American psychologist Professor Drew Weston and colleagues (2004) and found that 2 years after CBT, two thirds of patients relapsed or wanted additional help. “If left untreated, most people with depression come and go. At 18 months, those receiving CBT have no better mental health than those receiving no treatment," added Dr Jaime. More recently, the Institute of Psychiatry at Kings College London (2005) held a discussion conference on Maudsley Titled: "CBT Is the New Coca-Cola: This House believes Cognitive Behavioral Therapy is superficially appealing but overly commercialized and has few beneficial ingredients." Pidd (2006), quoted by The Guardian newspaper, stated: "Even the strongest supporters of CBT readily acknowledge that the treatment has its limitations and caution against seeing it as a great hope for health." -all. But no treatment is a panacea,” says Philippa Garety, Professor of Clinical Psychology in the Department of Psychiatry and Head of Psychology at the South London and Maudsley Trust, who has done extensive research on CBT and schizophrenia. "However, what is certain is that CBT is useful for a number of problems because so much is related to how we experience the world and make sense of it."
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Now let's take a closer look at some more studies and critique some clinical trials that have used CBT as an intervention to treat people with depression. A study by DeRubeis et al. (2005) illustrate one of the strongest results on sustainable effects in the literature. The study compared the effectiveness of antidepressants for moderate to severe depression with cognitive therapy in a placebo-controlled study of 240 patients. The researchers observed the following results. Patients with moderate to severe depression responded well to 8 weeks of CT or ROM compared with the pill-placebo, and the response rate for both interventions was almost indistinguishable at 16 weeks. At this point, patients who responded to the ROM intervention were randomized to continue ROM or withdraw to the placebo pill the following year. Meanwhile, patients who responded to the CT intervention were terminated and only allowed one refresher session per month during the following year of follow-up. Results showed that patients who continued to take ADM experienced fewer relapses than patients who stopped taking the placebo pill. In addition, patients with a history of CT surgery performed well, while those with ROM continued (Hollon et al. 2005). Most importantly, in patients with prior exposure to the CT procedure, the risk of recurrence was reduced by approximately 70% compared with drug discontinuation. In contrast, patients who continued to take ADM cut their risk in half compared to those who stopped the drug. Thus, the results of this study suggest that "prior CT has a sustained effect at least as great as keeping patients on medication, a purely palliative intervention that is the current standard of care for recurrent depression" (Am, Psychiatric Assoc 2000), cited by Hollon et al (2006)
These results were also reported by Blackburn et al. (1986), Kovacs et al. (1981) and Simons et al. (1981). (1986) and the common finding that they all reported was that patients treated with prior CT were only half as likely to relapse, and the results were the same for patients treated only after drug treatment was treated. Both treatment interventions were not superior to each other and both were effective in reducing relapse rates (Evans et al. 1992). Also, some researchers have suggested that CBT might have long-lasting effects when given after taking medications to prevent stress. For example, Paykel et al (1999), cited in Hollon et al (2006), showed that “the addition of CT to medical treatment in partial responders not only helped to eliminate residual symptoms of depression, but also reduced the risk of subsequent relapse”. end of psychosocial treatment”. In addition, an expanded version of cognitive behavioral therapy called "mindfulness-based cognitive therapy" has been shown to reduce relapse rates and recurrence of depressive symptoms after completion of treatment in patients initially treated with Teasdale et al. . Were treated. (2000).
In contrast to these results, the studies by Perlis et al. (2002) and Shea et al. (1992) could not replicate previous findings that pre-CT has lasting effects. Perlis et al. (2002) reported in their study that the combination of cognitive therapy and fluoxetine 40 mg did not provide significant symptom relief and reduced relapse rates no more than fluoxetine 40 mg alone during the 28-week follow-up period. In addition, the National Institutes of Mental Health (NIMH) study of depression found negligible evidence for the effectiveness of interpersonal psychotherapy and none for cognitive therapy (Elkin et al. 1989). Thus, it could be argued that the long-lasting effects of CBT have yielded mixed results in the literature, however, with few exceptions, studies have generally found CBT to produce long-lasting effects beyond the end of treatment (Hollon et al. 2006). although larger studies are needed. However, it remains less clear whether CBT is capable of producing profound changes in people's lives and altering people's fundamental beliefs and schemata, which are typically formed during childhood and late adolescence, and few studies address this phenomenon. But it can be argued that patients who experience frequent flare-ups of their depressive symptoms have not yet fully experienced the schema changes and therefore cannot prevent future flare-ups.
However, it can be argued that changes in beliefs and dysfunctional schemas can be explored using neuroscience during CBT for depression. This may provide some evidence to support the claim that CBT is capable of inducing profound change in people living with depression. For example Meyer et al. (2004) found that depressed people had high rates of dysfunctional beliefs associated with reduced serotonin transporter function. Similarly, another PET imaging study found that “CBT recovery was associated with functional changes in the limbic and cortical areas of the brain, with unique changes in the frontal cortex, cingulate, and hippocampus selectively associated with CBT in comparison with a group treated with paroxetine. Goldapple et al. (2004), cited by Kuyken et al (2007). Additional support and a more recent finding come from a small study published by Siegle et al. (2006) was carried out. They found that patterns of reactivity to stressful stimuli were evident in the cingulate and amygdala during baseline and were subsequently associated with changes in symptoms over the course of a 16-session CBT intervention. However, work in the neuroscience of CBT is still in its infancy, but it has advanced our understanding of the cognitive theory of depression and the changes that occur in the brain before and after CBT use, and this shows that overwhelmingly profound changes can occur. Adaptations of the mind and brain occur associated with recovery from depression (Kuyken et al. 2007)
The next part of this essay focuses on panic disorder, explaining how cognitive-behavioral theories explain this disorder, and whether CBT can produce profound and lasting changes for this patient population. The reason this study focuses on this specific disorder is because recent studies suggest that CBT can be overwhelmingly effective and have long-lasting effects after CBT treatment. Hollon and Beck (2004) argue that long-lasting effects are evident in relation to anxiety disorders, especially panic disorders; However, it is not recognized as well as in depression. Let us know how to start talking about panic disorder. A well-known cognitive model of panic disorder is that of Clark (1986), and he argues that the factors underlying panic attacks are: "1) catastrophic misinterpretation of bodily sensations as an indication of imminent mental or physical harm , 2) security behaviors displayed around the probability of catastrophe and 3) selective attention, since people are very sensitive and direct their attention to a dangerous sensation or situation” (quoted from Westbrook et al. 2007). , on the other hand, explain panic attacks as a conditioned response to internal or external stimuli that must be extinguished by exposure (Barlow & Lehman 1996).Numerous studies have demonstrated the long-lasting effects of CBT in panic disorder (Margraf , Barlow, Clark & Telch, 1993.) Clinical studies have reported that 12 to 15 CBT sessions 2 years later did not elicit panic in approximately 85% of patients (p . g., Craske, Brown and Barlow, 1991). This suggests that CBT is capable of producing profound and lasting changes for the individual, as most patients do not relapse even after 2 years of CBT intervention.
Roth and Fonagy (2005) suggested that psychosocial interventions, particularly CBT, are more likely to persist after treatment ends than those achieved with medication. For example, Sharp et al. (1996) concluded that patients treated with CBT alone or with drugs were less likely to relapse and retain gains at 6-month follow-up compared with patients treated with fluvoxamine alone. Consistent with these findings, Clark et al. (1994) found that TC was superior to imipramine and the relaxation intervention used in patients with panic disorder, both superior to the waiting list control group. Furthermore, at 6-month follow-up, only 5% of patients treated with CT relapsed compared to 40% of patients who discontinued the drug. This study clearly demonstrates the sustained effects of the CT intervention after discontinuation of treatment. This study also showed that CT produced profound changes in people with panic disorder. In particular, CT helped to reduce the patient's strongly held catastrophic cognitions. However, this was not the case with the other two interventions, and the prevalence of such core beliefs at the end of treatment resulted in high relapse rates after treatment. Barlow and colleagues (2000) provide additional support for the continuing effects of panic disorder with the CBT intervention. In their multicenter study, patients with panic disorder were randomized to three months of weekly acute treatment, followed by six months of monthly maintenance treatment with CBT or imipramine, each alone and in combination, or pill-placebo, again. alone or in combination with CBT. The researchers concluded that the patients responded better to imipramine, but that CBT lasted longer. Relapse rates in those treated with CBT alone were 8% compared to 25% for those treated with imipramine. Interestingly, patients who received CBT medication seemed to blunt the long-lasting effects of CBT. The recurrence rate for this group was 36%. Thus, previous studies indicate that CBT clearly has long-lasting effects in the treatment of panic disorder.
An important question is whether CBT is capable of producing profound changes (ie changes in core beliefs and schemas) for people. Brown & Barlow (1995) cited by Rees et al. (1999) argue that “50% of people with panic disorder who start CBT achieve advanced functioning, defined as absence of panic, relative absence of negative affect, adequate social and occupational functioning, and subsequent absence of the use of other resources. Therapies such as psychoactive drugs and mental health treatments”. This suggests that CBT is capable of inducing profound changes in some patients, but this is limited in number. In another study by Michelson and Marchione (1991), they argued that CBT is the treatment of choice for panic disorder with agoraphobia (PDA). Their results showed that 150 research studies demonstrated that 87% of epidural patients showed significant improvement with a CBT intervention with only a 10% relapse rate, compared to a 60% improvement rate with a 35% relapse in patients treated with antidepressants. Additionally, those treated with anxiolytics had a 90% relapse rate with a 60% rate of improvement. Additionally, patients with panic disorder alone had a 90% improvement rate with a 5% relapse rate. These results clearly demonstrate the profound and long-lasting effects of CBT in panic disorder (http://www.excelatlife.com/Effectiveness_cbt.htm).
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