The cognitive behavioral approach to therapy stresses

Effectiveness of the cognitive-behavioural approach

C-B approaches have been evaluated in a number of clinical pain studies. The results tend to support the effectiveness of C-B therapy in reducing pain and improving funcitonal activities (Morley et al 1999)

The C-B approach offers promise for use with a variety of chronic pain syndromes across all developmental levels. The American Psychological Association Task Force on Treatment Efficacy designated cognitive-behavioural therapy for chronic pain as one of 20 applications of psychological treatments for which there was significant empirical support.

Taken as an aggregate, the available evidence suggests that the C-B approach has a good deal of potential as a treatment modality by itself and in conjunction with other treatment approaches. The cognitive-behavioural perspective is a reasonable way for health care providers to think about and deal with their patients regardless of the therapeutic modalities utilized.

Central pain modification

Cognitive behavioural approaches, designed to improve self-efficacy and coping strategies, are also beneficial. These interventions emphasize the control of pain by understanding the interaction of emotions and cognition with the physical and behavioural aspects of pain. In one study (Keefe et al 1996), patients with knee OA who participated in a programme that involved their spouse had greater improvement in pain, psychological disability, self-efficacy, and pain behaviours, as well as better marital adjustment and coping skills, compared to patients who participated in a traditional programme without their spouse.

Education is also an effective treatment. The Arthritis Self-Help Course has been shown to be effective. This course consists of six weekly education sessions focusing on exercise, relaxation techniques, joint protection techniques, and a description of the various medications used in treating patients with arthritis. Studies by Lorig and colleagues (Lorig and Holman 1993) have shown that patients with OA who participate in this programme have significant improvement in knowledge, pain, and quality of life, and a decreased frequency of physician visits and lower health care costs.

Finally, provision of social support through simple telephone contact can improve functional status and pain in patients with OA (Weinberger et al 1993). The content of the telephone calls seems to be important: symptom monitoring is not as effective as specific advice and counselling (Maisiak et al 1996).

5.21.4.1.2 Cognitive-behavioral models

Behavioral and cognitive-behavioral approaches have been the focus of many preventive intervention programs (Gilchrist & Schinke, 1985; Pentz, 1985) and are increasingly being used to treat adolescent substance abuse (Turner, Liddle, & Dakof 1996; Waldron & Slesnick, 1997). These approaches, based on principles of learning, often incorporate a stress-coping model of substance abuse and focus on teaching adolescents appropriate skills to avoid substance use. Treatment components may include self-monitoring, social skills training (e.g., problem solving or assertiveness), mood regulation (e.g., relaxation training, anger management, or modifying cognitive distortions), and relapse prevention (e.g., drug and alcohol refusal skills). Modeling, behavior rehearsal, feedback, and homework assignments are characteristic of treatment techniques.

Anxiety interventions and outcomes for sleep

Cognitive behavioral approaches e.g., cognitive behavioral therapy (CBT) are typically recommended as the first line intervention for child anxiety (e.g., UK National Institute for Health and Care Excellence guidelines), and can be delivered by a clinician to the young person, or to the parent. CBT can be conducted face to face, online, or in a group. Although clinical guidelines for anxiety rarely provide guidance on how to manage sleep difficulties, some evidence has examined the effect of CBT for anxiety on sleep in young people. For example, Kendall and Pimentel (2003) found that CBT for Generalized Anxiety Disorder (GAD) was effective in reducing associated sleep problems in young people (aged 9–13 years), however, sleep was measured using the anxiety diagnostic interview rather than with a specific sleep measure. In studies that have used sleep-specific measures, results have indicated smaller effects. Peterman et al. (2016) investigated the effectiveness of CBT on sleep problems, with a validated sleep questionnaire, among children and adolescents with anxiety disorders (7–17 years). They found that parent-reported sleep problems, but not child-reported sleep problems, improved following CBT for anxiety disorders. Specifically, sleep issues around bedtime, such as bedtime resistance, showed improvement, rather than sleep behaviors, such as sleep latency and sleep duration. Mcmakin et al. (2019) examined data from an RCT comparing cognitive behavioral therapy and client-centered treatment for treatment of anxiety with young people aged 9–14 with a range of anxiety disorders, including generalized, social and separation anxiety. They found small reductions in sleep problems and improvements in subjective sleep patterns using a sleep diary, but outcomes were not deemed clinically significant.

In the studies discussed so far it has not been clear whether sleep problems that improved would have improved on their own, so whether the effects were due to the anxiety treatment. A couple of studies have been able to address this question. Haugland et al. (2021) randomized adolescents with anxiety to brief or standard-length group cognitive behavioral therapy (GCBT) or a waitlist control. Sleep was measured using DSM-5 insomnia criteria as well as self-reported time in bed, sleep onset latency and sleep duration. The study found that insomnia and sleep onset latency improved across all groups, with no difference between group CBT or waitlist control. The authors also compared adolescents who improved on anxiety to those who did not, and again found no difference in sleep change. In a comparison of medication and psychological therapies, Caporino et al. (2017) compared CBT, sertraline, combined treatment and pill placebo, using a sample of children and adolescents, aged 7–17 years, with diagnoses of Social Phobia (SP), GAD, and Separation Anxiety Disorder (SAD). Both parents and young people reported on sleep using items combined from a range of measures (although not sleep specific). Similar to Peterman et al. (2016), they found variations in results depending on the respondent. Parent report showed greater reductions in separation-related sleep difficulties in active treatment compared to placebo, with greatest reductions when treatment included sertraline. Youth reported significantly greater decreases in dysregulated sleep (e.g., sleeplessness) when treatment involved CBT.

While the literature is still in its infancy, the findings are mixed and cannot provide clear support for anxiety treatment reducing sleep disturbances. While pre-to post-treatment studies indicate some changes, RCT evidence with control groups might suggest that this change could be through natural improvement rather than via psychological therapy. In a study by Bai et al. (2020) youth who took part in an anxiety treatment trial were followed over time, and longitudinal, bidirectional associations between sleep and anxiety were examined. The authors found that irrespective of receiving treatment for anxiety, bidirectional relationships between sleep and anxiety persisted. The authors concluded that interventions should continue to assess and treat persistent sleep problems alongside anxiety and depression.

Substance Dependence

A range of cognitive-behavioral approaches have been repeatedly found to be effective for treating substance use disorders. These interventions prominently include contingency management techniques (where social, monetary, or other voucher rewards are provided contingent on negative toxicology screens for substance use), skill acquisition and relapse prevention approaches (where responses for avoiding or coping with high-risk situations for drug use are identified and rehearsed, as are alternative nondrug behaviors), and behavioral family therapy (where contingency management, interpersonal support, and skill-building interventions might be combined) (for a review, see Carroll and Onken13). Despite the success of these approaches, treatment of drug dependence is an area in great need of additional strategies for boosting treatment response and the maintenance of treatment gains.

Pain Management

A “top-down” cognitive-behavioral approach to pain management may prove helpful for adaptation to traumatic events.21 Moreover, hypnotherapy can promote the use of imagery to modify perception of the painful experience. For example, pain may be coupled with a specific color (e.g., red) and comfort with a second color (e.g., blue or green). One can next encourage the subject to imagine a change in the color coupled with pain reduction.

Direct suggestion under hypnosis can allow for induction of “glove-hand anesthesia.” The patient can be instructed to place the hand that is “asleep” over the area of perceived pain, and to experience that area becoming “anaesthetized.”22 This type of approach requires a high level of hypnotic susceptibility.

Hypnotherapy is especially applicable to children because of their relatively strong capacity for imagination and for suspension of belief. It is therefore a useful intervention in painful conditions and medical interventions.

Characteristics of cognitive therapy

Cognitive therapy, like other behavioural and cognitive-behavioural approaches is a time-limited, structured therapy aimed at helping individuals cope with emotional problems and achieve symptom relief as well as reducing the chances of relapse. Like behaviour therapy it is structured, problem-focused and outcome oriented, placing great importance on the empirical testing of its theoretical and practical applications. In contrast to some forms of behaviour therapy, it always embeds its therapeutic techniques within a case conceptualization based on cognitive theory. The therapy takes place with weekly 50 min sessions (12–20 sessions in total), over 3–6 months. Because cognitive therapy seeks to change patients' longstanding beliefs about themselves and the world, it is necessary to establish a sound therapeutic alliance. Rather than tell patients their beliefs are unfounded, the therapist uses questioning and guided discovery to demonstrate that the beliefs are illogical or unhelpful. Beck coined the term ‘collaborative empiricism’ to describe the special nature of the relationship in cognitive therapy where patient and therapist test out the hypotheses of the cognitive model as applied to the patient's problems (Fig. 38.2). The therapy teaches a sceptical approach to cognitive events, encourages achieving distance from thoughts as a prelude to learning to modify them and thereby gain control over powerful negative feelings. While still requiring patients to engage actively in therapy, it has a set of techniques to work with patients who are sceptical, and so may be applicable to a wider range of less ‘motivated’ patients.

Cognitive behavioural therapy in adults with LD

There has been a surge of interest in cognitive–behavioural approaches, which can be successful, provided the problems of comprehension, self-reporting of cognitions and self-regulation can be overcome. This is often the case for people with mild or moderate LD, and the treatment can form a useful adjunct to pharmacotherapy, especially in the management of depression and dysthymic disorder. Cognitive distortions in general are common, in particular those of placing things into extreme categories – all good or all bad, completely acceptable or totally unwanted, and so on. The lack of subtlety in categorisation is also felt to underlie some of the behaviours shown by people with LD who commit sex offences, and cognitive–behavioural therapy has an important place in their management.

6.3.2.5 Cognitive behavioral psychotherapy (CBT)

As for other substance use disorders cognitive or cognitive-behavioral approaches play a significant role in the treatment of BZD dependent patients. CBT has especially been studied in the context of pharmacotherapies for substance use disorders (Ray et al., 2020). Adapted to the needs of patients with BZD dependence this means the patient shall understand the function the sedative or hypnotic had in his life and learn better ways to come along with stress, distress, negative mood or psychosomatic symptoms. Lader (2014) and others stressed the importance of cognitive-behavioral psychotherapy (CBT) which can be applied in single or group therapies for relapse prevention in BZD use disorders. The patient should learn to “say no” and use self-control strategies. CBT-based self-control training aims at giving the patient a better control over his medication use. Identifying, avoiding or managing risk situations is one of the mean goals. This method has extensively been studied in alcohol and other substance use disorders (Soyka, 2015; Soyka and Batra, 2019; Vicens et al., 2016) but can also be used in BZD dependence. Morgan et al. (2004) performed a randomized controlled trial with a CBT-based package against sleep disorders versus a control group for patients with insomnia (N = 209) and found clinical improvements for the CBT group. Higher baseline depression scores were associated with poorer outcomes. In addition, beside improved sleep quality hypnotic drug use was also reduced. For inpatient treatment of BZD dependence psychoeducation, CBT and some form of motivational enhancement are usually recommended (Parr et al., 2009). There are also some internet-based CBT treatments (Parr et al., 2009).

Various relaxation techniques such as progressive muscle relaxation or autogenic training usually are part of comprehensive drug treatment. Further psychotherapeutic strategies depend on the underlying disorder or apparent symptoms. For anxiety patients, gradual exposition training, systemic desensibilization, social skills training or others can be useful.

BEHAVIOURAL JOINT PROTECTION EDUCATION

In contrast, structured group programmes, of 8–16 hours duration, emphasising active learning, problem solving, behavioural approaches, frequent practice and home programmes have been proven effective.

An RCT with people with early RA (n = 127) compared an 8 hour cognitive-behavioural approach joint protection programme with a standard arthritis education programme (including 2.5 hours of usual joint protection, not using behavioural approaches). At 1 year the behavioural group, compared to the standard group, significantly improved the use of joint protection, improved functional ability and reduced hand pain, general pain and early morning stiffness (Hammond & Freeman 2001). Benefits continued at 4 years and the behavioral group had fewer hand deformities (Hammond & Freeman 2004). Timing of education needs careful consideration as there is evidence it can be provided both too early and too late (Hammond 2004). Other studies in patients with established RA have also shown benefits:

balance of rest and activity (Furst et al 1987);

use of assistive devices (Nordenskiold 1994);

functional ability (Nordenskiold et al 1998).