cognitive behavioral therapy problem solving

Problem-Solving Therapy

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In Problem-Solving Therapy , Drs. Arthur Nezu and Christine Maguth Nezu demonstrate their positive, goal-oriented approach to treatment. Problem-solving therapy is a cognitive–behavioral intervention geared to improve an individual's ability to cope with stressful life experiences. The underlying assumption of this approach is that symptoms of psychopathology can often be understood as the negative consequences of ineffective or maladaptive coping.

Problem-solving therapy aims to help individuals adopt a realistically optimistic view of coping, understand the role of emotions more effectively, and creatively develop an action plan geared to reduce psychological distress and enhance well-being. Interventions include psychoeducation, interactive problem-solving exercises, and motivational homework assignments.

In this session, Christine Maguth Nezu works with a woman in her 50s who is depressed and deeply concerned about her son's drug addiction. Dr. Nezu first assesses her strengths and weaknesses and then helps her to clarify the problem she is facing so she can begin to move toward a solution.

The overarching goal of problem-solving therapy (PST) is to enhance the individual's ability to cope with stressful life experiences and to foster general behavioral competence. The major assumption underlying this approach, which emanates from a cognitive–behavioral tradition, is that much of what is viewed as "psychopathology" can be understood as consequences of ineffective or maladaptive coping behaviors. In other words, failure to adequately resolve stressful problems in living can engender significant emotional and behavioral problems.

Such problems in living include major negative events (e.g., undergoing a divorce, dealing with the death of a spouse, getting fired from a job, experiencing a major medical illness), as well as recurrent daily problems (e.g., continued arguments with a coworker, limited financial resources, diminished social support). How people resolve or cope with such situations can, in part, determine the degree to which they will likely experience long-lasting psychopathology and behavioral problems (e.g., clinical depression, generalized anxiety, pain, anger, relationship difficulties).

For example, successfully dealing with stressful problems will likely lead to a reduction of immediate emotional distress and prevent long-term psychological problems from occurring. Alternatively, maladaptive or unsuccessful problem resolution, either due to the overwhelming nature of events (e.g., severe trauma) or as a function of ineffective coping attempts, will likely increase the probability that long-term negative affective states and behavioral difficulties will emerge.

Social Problem Solving and Psychopathology

According to this therapy approach, social problem solving (SPS) is considered a key set of coping abilities and skills. SPS is defined as the cognitive–behavioral process by which individuals attempt to identify or discover effective solutions for stressful problems in living. In doing so, they direct their problem-solving efforts at altering the stressful nature of a given situation, their reactions to such situations, or both. SPS refers more to the metaprocess of understanding, appraising, and adapting to stressful life events, rather than representing a single coping strategy or activity.

Problem-solving outcomes in the real world have been found to be determined by two general but partially independent processes—problem orientation and problem-solving style.

Problem orientation refers to the set of generalized thoughts and feelings a person has concerning problems in living, as well as his or her ability to successfully resolve them. It can either be positive (e.g., viewing problems as opportunities to benefit in some way, perceiving oneself as able to solve problems effectively), which serves to enhance subsequent problem-solving efforts, or negative (e.g.,viewing problems as a major threat to one's well-being, overreacting emotionally when problems occur), which functions to inhibit attempts to solve problems.

Problem-solving style refers to specific cognitive–behavioral activities aimed at coping with stressful problems. Such styles are either adaptive, leading to successful problem resolution, or dysfunctional, leading to ineffective coping, which then can generate myriad negative consequences, including emotional distress and behavioral problems. Rational problem solving is the constructive style geared to identify an effective solution to the problem and involves the systematic and planful application of specific problem-solving tasks. Dysfunctional problem-solving styles include (a) impulsivity/carelessness (i.e., impulsive, hurried, and incomplete attempts to solve a problem), and (b) avoidance (i.e.,avoiding problems, procrastinating, and depending on others to solve one's problems).

Important differences have been identified between individuals characterized as "effective" versus "ineffective" problem solvers. In general, when compared to effective problem solvers, persons characterized by ineffective problem solving report a greater number of life problems, more health and physical symptoms, more anxiety, more depression, and more psychological maladjustment. In addition, a negative problem orientation has been found to be associated with negative moods under both routine and stressful conditions, as well as pessimism, negative emotional experiences, and clinical depression. Further, persons with negative orientations tend to worry and complain more about their health.

Problem-Solving Therapy Goals

PST teaches individuals to apply adaptive coping skills to both prevent and cope with stressful life difficulties. Specific PST therapy objectives include

enhancing a person's positive orientation
fostering his or her application of specific rational problem-solving tasks (i.e., accurately identifying why a situation is a problem, generating solution alternatives, conducting a cost-benefit analysis in order to decide which ideas to choose to include as part of an overall solution plan, implementing the solution, monitoring its effects, and evaluating the outcome)
reducing his or her negative orientation
minimizing one's tendency to engage in dysfunctional problem-solving style activities (i.e., impulsively attempting to solve the problem or avoiding the problem)

PST interventions involve psychoeducation, interactive problem-solving training exercises, practice opportunities, and homework assignments intended to motivate patients to apply the problem-solving principles outside of the therapy sessions.

PST has been shown to be effective regarding a wide range of clinical populations, psychological problems, and the distress associated with chronic medical disorders. Scientific evaluations have focused on unipolar depression, geriatric depression, distressed primary-care patients, social phobia, agoraphobia, obesity, coronary heart disease, adult cancer patients, adults with schizophrenia, mentally retarded adults with concomitant psychiatric problems, HIV-risk behaviors, drug abuse, suicide, childhood aggression, and conduct disorder.

Moreover, PST is flexible with regard to treatment goals and methods of implementation. For example, it can be conducted in a group format, on an individual and couples basis, as part of a larger cognitive–behavioral treatment package, over the phone, as well as on the Internet. It can also be applied as a means of helping patients to overcome barriers associated with successful adherence to other medical or psychosocial treatment protocols (e.g., adhering to weight-loss programs, diabetes regulation).

Arthur M. Nezu, PhD, ABPP, is currently professor of psychology, medicine, and community health and prevention at Drexel University in Philadelphia. He is one of the codevelopers of a cognitive–behavioral approach to teaching social problem-solving skills and has conducted multiple RCTs testing its efficacy across a variety of populations. These populations include clinically depressed adults, depressed geriatric patients, adults with mental retardation and concomitant psychopathology, distressed cancer patients and their spousal caregivers, individuals in weight-loss programs, breast cancer patients, and adult sexual offenders.

Dr. Nezu has contributed to more than 175 professional and scientific publications, including the books Solving Life's Problems: A 5-Step Guide to Enhanced Well-Being , Helping Cancer Patients Cope: A Problem-Solving Approach , and Problem-Solving Therapy: A Positive Approach to Clinical Intervention . He also codeveloped the self-report measure Social Problem-Solving Inventory—Revised . Dr. Nezu is on numerous editorial boards of scientific and professional journals and a member of the Interventions Research Review Committee of the National Institute of Mental Health.

An award-winning psychologist, he was previously president of the Association for Advancement of Behavior Therapy, the Behavioral Psychology Specialty Council, the World Congress of Behavioral and Cognitive Therapies, and the American Board of Cognitive and Behavioral Psychology. He is a fellow of the American Psychological Association, the Association for Psychological Science, the Society for Behavior Medicine, the Academy of Cognitive Therapy, and the Academy of Cognitive and Behavioral Psychology. Dr. Nezu was awarded the diplomate in Cognitive and Behavioral Psychology from the American Board of Professional Psychology and currently serves as a trustee of that board.

He has been in private practice for over 25 years, and is currently conducting outcome studies to evaluate the efficacy of problem-solving therapy to treat depression among adults with heart disease.

Christine Maguth Nezu, PhD, ABPP, is currently professor of psychology, associate professor of medicine, and director of the masters programs in psychology at Drexel University in Philadelphia. She previously served as director of the APA-accredited Internship/Residency in Clinical Psychology, as well as the Cognitive–Behavioral Postdoctoral Fellowship Program, at the Medical College of Pennsylvania/Hahnemann University.

She is the coauthor or editor of more than 100 scholarly publications, including 15 books. Her publications cover a wide range of topics in mental health and behavioral medicine, many of which have been translated into a variety of foreign languages.

Dr. Maguth Nezu is currently the president-elect of the American Board of Professional Psychology, on the board of directors for the American Board of Cognitive and Behavioral Psychology, and on the board of directors for the American Academy of Cognitive and Behavioral Psychology. She is the recipient of numerous grant awards supporting her research and program development, particularly in the area of clinical interventions. She serves as an accreditation site visitor for APA for clinical training programs and is on the editorial boards of several leading psychology and health journals.

Dr. Maguth Nezu has conducted workshops on clinical interventions and case formulation both nationally and internationally. She is currently the North American representative to the World Congress of Cognitive and Behavioral Therapies. She holds a diplomate in Cognitive and Behavioral Psychology from the American Board of Professional Psychology and has been active in private practice for more than 20 years.

Her current areas of interest include the treatment of depression in medical patients, the integration of cognitive and behavioral therapies with patients' spiritual beliefs and practices, interventions directed toward stress, coping, and health, and cognitive behavior therapy and problem-solving therapy for individuals with personality disorders.

D'Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer Publishing Co.
D'Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Social Problem-Solving Inventory—Revised (SPSI-R): Technical manual . North Tonawanda, NY: Multi-Health Systems.
Nezu, A. M. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35 , 1–33.
Nezu, A. M., & Nezu, C. M. (in press). Problem-solving therapy. In S. Richards & M. G. Perri (Eds.), Relapse prevention for depression . Washington, DC: American Psychological Association.
Nezu, A. M., Nezu, C. M., & Clark, M. (in press). Problem solving as a risk factor for depression. In K. S. Dobson & D. Dozois (Eds.), Risk factors for depression . New York: Elsevier Science.
Nezu, A. M., Nezu, C. M., & Perri, M. G. (2006). Problem solving to promote treatment adherence. In W. T. O'Donohue & E. Livens (Eds.), Promoting treatment adherence: A practical handbook for health care providers (pp. 135–148). New York: Sage Publications.
Nezu, A. M., Nezu, C. M., & D'Zurilla, T. J. (2007). Solving life's problems: A 5-step guide to enhanced well-being . New York: Springer Publishing Co.
Nezu, A. M., Nezu, C. M., Friedman, S. H., Faddis, S., & Houts, P. S. (1998). Helping cancer patients cope: A problem-solving approach . Washington, DC: American Psychological Association.
Nezu, C. M., D'Zurilla, T. J., & Nezu, A. M. (2005). Problem-solving therapy: Theory, practice, and application to sex offenders. In M. McMurran & J. McGuire (Eds.), Social problem solving and offenders: Evidence, evaluation and evolution (pp. 103–123). Chichester, UK: Wiley.
Nezu, C. M., Palmatier, A., & Nezu, A. M. (2004). Social problem-solving training for caregivers. In E. C. Chang, T. J. D'Zurilla, & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 223–238). Washington, DC: American Psychological Association.
Cognitive–Behavioral Relapse Prevention for Addictions G. Alan Marlatt
Cognitive–Behavioral Therapy With Donald Meichenbaum Donald Meichenbaum
Depression With Older Adults Peter A. Lichtenberg
Depression Michael D. Yapko
Emotion-Focused Therapy for Depression Leslie S. Greenberg
Relapse Prevention Over Time G. Alan Marlatt
Behavioral Interventions in Cognitive Behavior Therapy: Practical Guidance for Putting Theory Into Action, Second Edition Richard F. Farmer and Alexander L. Chapman
Experiences of Depression: Theoretical, Clinical, and Research Perspectives Sidney J. Blatt
Preventing Youth Substance Abuse: Science-Based Programs for Children and Adolescents Edited by Patrick Tolan, José Szapocznik, and Soledad Sambrano

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Cognitive Behavioral Therapy (CBT)

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Cognitive conceptualisation (excerpt from Basics and Beyond) | J. Beck Download Archived Link
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Developing a cognitive formulation | Michael Free Download Primary Link Archived Link
Case formulation in CBT | Caleb Lack Download Primary Link Archived Link
A case formulation approach to cognitive-behavior therapy | Jacqueline Persons | 2015 Download Primary Link Archived Link
The case formulation approach to cognitive behavior therapy | Jacqueline Persons | 2014 Download Primary Link Archived Link

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Cognitive- behavioural therapy An information guide | Neil Rector | 2010 Download Primary Link Archived Link
A therapist’s guide to brief cognitive behavioral therapy | Cully, Teten | 2008 Download Primary Link Archived Link
Problem solving (OCT Practical Guides | Helen Kennerley | 2016 Download Primary Link Archived Link
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Making CBT Work (Working with your CBT therapist / Making your CBT therapist work with you) | Paul Salkovskis Download Archived Link

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A manual of cognitive behavior therapy for people with learning disabilities and common mental disorders | Hassiotis, Serfaty, Azam, Martin, Strydom, King | 2012 Download Primary Link Archived Link
CBT case formulation | Jacqueline Persons Download Primary Link
Cognitive Interpersonal Cycle Worksheet | Stirling Moorey | 2007 Download Primary Link Archived Link

What Is Cognitive Behavioral Therapy?

Assumptions of cbt.

people actively process information;
our appraisals (the way that we think and interpret events) determine how we feel;
dysfunctional thinking and biases in information processing (cognition/thinking) are responsible for the problems that people experience;
different problems are associated with different cognitive themes (cognitive specificity theory): depression is associated with loss and defeat; anxiety is associated with danger and threat; obsessive-compulsive disorder is associated with inflated responsibility; substance abuse is associated with permissive beliefs; eating disorders are associated with self-criticism; social anxiety is associated with fear of evaluation; and PTSD is associated with appraisals of immediate threat;
the thoughts that we have can be ‘distorted’ or biased . Common biases include over-generalization, arbitrary inference, selective abstraction, and catastrophizing;
changing how we think and act will impact how we feel: cognition, emotion, and behavior interact in a reciprocal manner;
psychopathology is a result of an interaction between stress and vulnerability;
cognition happens at multiple levels (Alford & Beck, 1997) and all can influence the way that we feel and behave: preconscious, unintentional, automatic (e.g., negative automatic thoughts); the conscious level (e.g., if a patient is asked to explain the meaning of an automatic thought); and the metacognitive level (beliefs about beliefs);
experiences, memories, thoughts, attitudes, and beliefs are encapsulated as ‘schemas’ and which may become activated and influence our perceptions and behaviors.

Principles of CBT

Judith Beck (1995) identified 11 principles of the practice of cognitive behavioral therapy, and these were expanded by Wills (2009):

cognitive behavioral therapists use formulation to focus their therapeutic work
cognitive behavioral therapists use formulation to tackle interpersonal and alliance issues
cognitive behavioral therapy requires a sound therapeutic relationship
cognitive behavioral therapists stress the importance of collaboration in the therapeutic relationship
cognitive behavioral therapy is brief and time-limited
cognitive behavioral therapy is structured and directional
cognitive behavioral therapy is problem- and goal-oriented
cognitive behavioral therapy initially emphasizes a focus on the present
cognitive behavioral therapy uses an educational model
homework and self-practice is a central feature of cognitive behavioral therapy (incorporating the use of CBT worksheets)
cognitive behavioral therapists teach clients to evaluate and modify their thoughts
cognitive behavioral therapy uses various methods to change cognitive content including thought records, behavioral experiments, surveys
cognitive behavior therapy uses a variety of methods to promote behavioral change including exposure, behavioral experiments, role-play.

Procedures and Techniques of CBT

Data gathering and symptom monitoring are used to understand problems and to measure change. CBT is an evidence-based approach that relies upon accurate data gathering regarding symptoms and experiences.
Behavioral activation is a set of techniques for encouraging engagement in meaningful activity and is an effective treatment for depression.
Case formulation is a method for understanding the origin and maintenance of a problem in cognitive and behavioral terms. CBT therapists may use a mixture of cross-sectional formulation to understand difficulties in the here-and-now, longitudinal formulation to understand the origins and precipitants of a problem, and cognitive behavioral models to understand the mechanisms underlying a problem.
Cognitive restructuring describes techniques for changing what we think. It often involves the use of thought records, behavioral experiments, data gathering, or psychoeducation.
Exposure is a technique from behavior therapy that is extensively used by CBT therapists, particularly for the treatment of anxiety. ‘Facing your fears’ is an essential behavioral component of CBT.
Problem solving describes a series of techniques that are often taught as part of a CBT intervention. Effective problem solving helps people to make adaptive choices.
Socratic methods are used by CBT therapists to help their clients explore what they know, and to form their own opinions on a topic. Aaron Beck encouraged the use of Socratic-like technique in his original treatment manual “use questioning rather than disputation and indoctrination … it is important to try to elicit from the patient what he is thinking rather than telling the patient what the therapist believes he is thinking” (Beck et al, 1979).
Alford, B. A., & Beck, A. T. (1997). The relation of psychotherapy integration to the established systems of psychotherapy. Journal of psychotherapy integration , 7 (4), 275-289.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression . New York: Guilford.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond . New York: Guilford.
Wills, F. (2009). Beck’s cognitive therapy . CBT Distinctive Features Series. New York: Routledge.
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CBT Coping Skills and Strategies

Positive ways to deal with negative feelings

How CBT Works

Self-monitoring, diaphragmatic breathing, progressive muscle relaxation, behavioral activation, listing pros and cons, cognitive restructuring, setting and managing goals.

What do you do when you're feeling anxious? Angry? Scared? Negative feelings are an inevitable part of life, but how you *deal* with them can make or break your mental well-being. CBT coping skills are tools that can help you handle negative emotions in a healthy way. They provide strategies for getting through difficult situations with less tension, anxiety, depression , and stress.

CBT coping skills help you deal with uncomfortable emotions (anxiety, depression, etc.) so you can feel better physically, make better decisions, and more. These cognitive strategies are especially important if you are dealing with certain mental health conditions, such as post-traumatic stress disorder (PTSD).

At a Glance

CBT (aka 'cognitive behavioral therapy') focuses on changing negative thoughts and behaviors. It's a highly effective treatment for many mental health conditions, but you can also use CBT techniques anytime, anywhere. When you implement these tactics in your everyday life, handling stressful situations and negative thinking will be a breeze. So, let's learn how to ditch those unhealthy coping techniques—goodbye avoidance, social withdrawal, and substance use; hello diaphragmatic breathing, progressive muscle relaxation, and behavioral activation! By learning how to use these CBT skills, you'll be better able to manage your negative feelings in positive ways.

Tom M Johnson / Blend Images / Getty Images

Cognitive behavioral therapy (CBT) is based on the idea that psychological problems arise from the way we interpret or evaluate situations, thoughts, and feelings . Negative interpretations and evaluations can lead to unhealthy behaviors.

CBT works by changing how you think. By replacing maladaptive ways of thinking and negative interpretations of events, you can reduce unhealthy behavioral patterns. It also teaches you the skills and cognitive strategies needed to better cope with whatever life throws your way.

How to Get Started

If you are looking to replace some of your unhealthy ways of handling problems with more helpful ones, consider trying some of the following CBT skills, including diaphragmatic breathing, progressive muscle relaxation, self-monitoring, behavioral activation, listing pros and cons, cognitive restructuring, and goal setting.

Self-monitoring is a basic CBT coping skill. To a large extent, is at the core of all the cognitive-behavioral coping strategies described here, so this is a great place to start.

It works like this: in order to address a problem or a symptom, we need to first become aware of it. Self-monitoring can help with this. With this awareness, we can then take action to regulate our behaviors so we have more positive outcomes.

You can develop this skill by paying attention to your own thoughts, behaviors, and reactions. To do this, you might try writing in a journal or using a mood tracker .

As you do this, you may start to notice certain patterns and triggers. It also allows you to track your progress as you work toward implementing healthier CBT skills.

Diaphragmatic breathing, also called breathing retraining or deep breathing , is a basic cognitive coping strategy for managing anxiety. It is a simple technique but can be very powerful.

Diaphragmatic breathing involves pulling your diaphragm down while taking a deep breath in. You should see your abdominal area rise with each breath, which is why it is sometimes referred to as "belly breathing."

Relaxation exercises with a CBT app can be an effective way to reduce your stress and anxiety. One such exercise is called progressive muscle relaxation (PMR) and involves alternating between tensing and relaxing different muscle groups throughout the body.

With PMR, complete muscle relaxation is obtained by first going to the other extreme (that is, by tensing your muscles). You'll hold your muscles tight and then slowly release the tension so it feels like a wave of relaxation pouring over your body.

By tensing your muscles—a common anxiety symptom —and immediately relaxing them, over time, the symptom of muscle tension may become a signal to relax.

When people feel depressed or anxious, they may be less likely to do the things they enjoy. That's exactly why it is important to learn how to be more active. Behavioral activation is a CBT coping skill that helps you get more active, even when you might not be feeling it.

The goal of behavioral activation is simple: Get more active in areas of your life that you find pleasurable and enjoyable. Being more involved with and engaged in these experiences improves your mood.

As your mood improves, so will your thoughts and coping behaviors. Plus, being engaged in things you enjoy is a great way to distract yourself from feelings of rumination and anxiety.

Making decisions can be hard, especially if you're having a hard time with negative thinking, anxiety, or depression. It might leave you feeling paralyzed or trapped. When this happens, you may not know the best choice. Or you might make decisions that aren't good for you in the long-term.

One way to move forward in situations like this is to weigh the short—and long-term pros and cons. This cognitive coping strategy can help us identify the best path to take—that is, a path associated with less risk and consistent with our goals and priorities.

Cognitive restructuring is a common CBT coping skill. How we evaluate and think about ourselves, other people, and events can have a major impact on our mood. This cognitive strategy focuses on identifying negative thoughts or evaluations and modifying them.

Cognitive restructuring involves gathering evidence about certain thoughts and recognizing how they may be misinterpreted or distorted.

Then, you work on systematically replacing them with more positive affirmations . By modifying our thoughts, we can improve our mood and make better choices regarding our behaviors.

Goals (or things that you want to accomplish in the future) can give your life purpose and direction, as well as motivate healthy behaviors focused on improving your life. However, they can also be very overwhelming and a source of stress. Because of this, you want to be careful when setting goals .

So, how can you put this CBT coping skill to use? Start by approaching your goals in a way that improves your mood and quality of life without increasing distress.

This could be by setting smaller goals versus bigger ones, for instance, or breaking larger goals down into more manageable chunks.

Sometimes, you just need a little extra help to manage the problems that life throws your way. That's when CBT coping skills come in handy. They can help you better handle and manage difficult emotions and situations. By changing how you interpret feelings and events, you'll feel better able to manage your emotions.

If you are struggling with anxiety, stress , depression, or other challenges, CBT coping skills can be a great tool to help you start feeling better. However, if you aren't getting adequate relief from these approaches, talk to a mental health professional.

Frequently Asked Questions

CBT coping skills teach you how to better deal with difficult situations, such as how to relax your body (so your mind can also relax), also changing how you look at circumstances and events so you have more positivity. These processes use the same types of strategies like those used in cognitive behavioral therapy (CBT).

Regularly practicing cognitive coping strategies such as these can help improve your skills. It can also be beneficial to work with a mental health professional as they can focus directly on improving your CBT coping skills in the therapy session. Taking care of your physical health, such as through a healthy diet and exercise, can also help improve your cognitive health.

CBT coping skills such as cognitive restructuring can help change thought patterns that lead to anxiety. Other skills, like diaphragmatic breathing and progressive muscle relaxation, help relax your body when in an anxious state, thereby reducing your feelings of anxiousness.

American Psychological Association. Cognitive behavioral therapy (CBT) .

Nakao M, Shirotsuki K, Sugaya N. Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies . Biopsychosoc Med . 2021;15(1):16. doi:10.1186/s13030-021-00219-w

Hirano M, Ogura K, Kitahara M, Sakamoto D, Shimoyama H. Designing behavioral self-regulation application for preventive personal mental healthcare . Health Psychol Open . 2017;4(1):2055102917707185. doi:10.1177/2055102917707185

Ma X, Yue ZQ, Gong ZQ, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults . Front Psychol . 2017;8:874. doi:10.3389/fpsyg.2017.00874

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Hirayama T, Ogawa Y, Yanai Y, Suzuki SI, Shimizu K. Behavioral activation therapy for depression and anxiety in cancer patients: a case series study . Biopsychosoc Med . 2019;13:9.doi:10.1186/s13030-019-0151-6

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National Institute on Aging. Cognitive health and older adults .

By Matthew Tull, PhD Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.

Cognitive Behavioral Therapy (CBT): Types, Techniques, Uses

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

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Cognitive behavioral therapy (CBT) is a form of talking therapy that can be used to treat people with a wide range of mental health problems, including anxiety disorders (e.g., generalized anxiety, social anxiety ) or depression.

CBT is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior.

Therefore, negative and unrealistic thoughts can cause us distress and result in problems. When a person suffers from psychological distress, how they interpret situations becomes skewed, which, in turn, has a negative impact on the actions they take.

CBT aims to help people become aware of when they make negative interpretations and of behavioral patterns that reinforce distorted thinking.

Cognitive therapy helps people develop alternative ways of thinking and behaving to reduce their psychological distress.

CBT Triangle

The cognitive behavioral therapy (CBT) triangle, commonly called the ‘cognitive triangle,’ provides a structured framework to understand the interplay between thoughts, feelings, and behaviors.

It is a foundational element in the study and practice of cognitive behavioral therapy.

Chart explaining how thoughts, emotions, and behavior interrelate in CBT (Cognitive Behavioral Therapy)

The cognitive triangle is a tool used in CBT to demonstrate the interplay between thoughts, feelings, and behaviors.

Individuals can identify and avoid harmful patterns by recording and categorizing negative thoughts. While surface emotions might be apparent, deeper underlying emotions can influence reactions.

Addressing these root emotions and modifying thought patterns can lead to positive behavioral changes, aiding in treating mental health issues like anxiety or depression.

Thoughts: Cognitive Processes

Situated at the top of the triangle, thoughts serve as the cognitive foundation. Research indicates that individuals produce thousands of thoughts daily .

Among these, cognitive distortions , or erroneous thinking patterns, can significantly influence one’s perceptions and interpretations. Common distortions include:

All-or-nothing thinking : Viewing situations in binary terms, without considering nuance.
Catastrophizing : Anticipating the most adverse outcomes without empirical justification.
Mind Reading : Presuming to understand others’ thoughts without direct evidence.
Emotional reasoning : Basing conclusions on emotions rather than objective data.
Labeling : Characterizing oneself or others based on a singular trait or event.
Personalization : Attributing external events to oneself without a clear causal link.

Intrusive thoughts , which can hinder daily functioning, are common, as evidenced by their mention by therapists. Many people experience them, suggesting these thoughts might arise from inherent brain patterns rather than facts.

In CBT, challenging these thoughts is essential, and with practice, the brain can reprogram its default thinking patterns.

The cognitive therapist teaches clients how to identify distorted cognitions through a process of evaluation. The clients learn to discriminate between their own thoughts and reality. They learn the influence that cognition has on their feelings, and they are taught to recognize, observe, and monitor their own thoughts.

The behavior part of the therapy involves setting homework for the client to do (e.g., keeping a diary of thoughts). The therapist gives the client tasks to help them challenge their irrational beliefs.

The idea is that the client identifies their unhelpful beliefs and then proves them wrong. As a result, their beliefs begin to change.

Feelings: Emotional Responses

Feelings are emotional responses that influence our communication, reactions, and decisions.

While they can motivate positive actions, such as waking up energized and preparing breakfast, they can also lead to negative behaviors if not addressed appropriately, like suppressing anger or resorting to substance abuse.

Recognizing and healthily expressing these feelings is crucial for emotional well-being. Dismissing or ridiculing them is counterproductive.

Emotions are best managed through acceptance; understanding and validation can alleviate emotional intensity. Though originating in the brain, feelings manifest in the body, alerting us to potential issues or affirming positive situations.

To establish a healthy relationship with emotions, it’s vital to accept and validate them. This process can reduce their overpowering nature.

When managing challenging feelings, it’s essential to acknowledge them, seek balance, and, if persistent, examine underlying thoughts that might reinforce them.

Behaviors: Observable Actions

Behaviors are responses to stimuli and are influenced by thoughts and feelings. They can indicate an individual’s emotions, especially when not verbally expressed.

For instance, becoming an overly protective parent can be a behavior stemming from certain thoughts and feelings.

Cognitive Behavioral Therapy (CBT) can modify behaviors using techniques like behavioral activation , which aims to increase engagement in positive activities, and gradual exposure , which systematically introduces individuals to feared or avoided situations in a controlled manner.

For example, someone anxious in social situations may set a homework assignment to meet a friend at the pub for a drink.

Over time, these methods help individuals confront and alter negative patterns, promoting healthier behaviors and responses.

General Assumptions

The cognitive approach believes that mental illness stems from faulty cognitions about others, our world, and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately).
These cognitions cause distortions in how we see things; Ellis suggested it is through irrational thinking, while Beck proposed the cognitive triad.
We interact with the world through our mental representation of it. If our mental representations are inaccurate or our ways of reasoning are inadequate, our emotions and behavior may become disordered.

Cognitive behavioral therapy is, in fact, an umbrella term for many different therapies that share some common elements.

Two of the earliest forms of Cognitive Behavioral Therapy were Rational Emotive Behavior Therapy ( REBT ), developed by Albert Ellis in the 1950s, and Cognitive Therapy, developed by Aaron T. Beck in the 1960s.

Rational Emotive Behavior Therapy (REBT) is a type of cognitive therapy first used by Albert Ellis, focusing on resolving emotional and behavioral problems.

The goal of this therapy is to change irrational beliefs to more rational ones.

REBT encourages people to identify their general and irrational beliefs (e.g., ‘I must be perfect’) and subsequently persuades them to challenge these false beliefs through reality testing.

Albert Ellis (1957, 1962) proposes that each of us holds a unique set of assumptions about ourselves and our world that guide us through life and determine our reactions to the various situations we encounter.

Unfortunately, some people’s assumptions are largely irrational, guiding them to act and react in inappropriate ways that prejudice their chances of happiness and success. Albert Ellis calls these basic irrational assumptions .

Some people irrationally assume they are failures if they are not loved by everyone they know – they constantly seek approval and repeatedly feel rejected. All their interactions are affected by this assumption so that a great party can leave them dissatisfied because they don’t get enough compliments.

According to Ellis, these are other common irrational assumptions :

The idea that one should be thoroughly competent at everything.
The idea that it is catastrophic when things are not the way you want them to be.
The idea that people have no control over their happiness.
The idea that you need someone stronger than yourself to depend on.
The idea that your history greatly influences your present life.
The idea that there is a perfect solution to human problems, and it’s a disaster if you don’t find it.

Ellis believes that people often forcefully hold on to this illogical way of thinking and therefore employ highly emotive techniques to help them vigorously and forcefully change this irrational thinking.

The ABC Model

A major aid in cognitive therapy is what Albert Ellis (1957) called the ABC Technique of Irrational Beliefs .

The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

Albert Ellis’ ABC Model in the Cognitive Behavioral Therapy

A – Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
B – Beliefs. In the second column, the client writes down the negative thoughts that occurred to them.
C – Consequence. The third column is for the negative feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column, C, is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc.

Ellis believes that it is not the activating event ( A ) that causes negative emotional and behavioral consequences ( C ) but rather that a person interprets these events unrealistically and therefore has an irrational belief system ( B ) that helps cause the consequences ( C ).

REBT Example

Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.

After identifying irrational beliefs, the therapist will often work with the client in challenging the negative thoughts based on evidence from the client’s experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.

A therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless.

If she realizes that getting bad grades is disappointing but not awful and that it means she is currently bad at math or studying but not as a person, she will feel sad or frustrated but not depressed.

The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.

Critical Evaluation

Rational emotive behavior therapists have cited many studies in support of this approach. Most early studies were conducted on people with experimentally induced anxieties or non-clinical problems such as mild fear of snakes (Kendall & Kriss, 1983).

However, several recent studies have been done on actual clinical subjects and have also found that rational emotive behavior therapy ( REBT ) is often helpful (Lyons & Woods 1991).

Cognitive Therapy

Aaron Beck’s (1967) therapy system is similar to Ellis’s but has been most widely used in cases of depression . Cognitive therapists help clients to recognize the negative thoughts and errors in logic that cause them to be depressed.

The therapist also guides clients to question and challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply alternative ways of thinking in their daily lives.

Aaron Beck believes that a person’s reaction to specific upsetting thoughts may contribute to abnormality. As we confront the many situations that arise in life, both comforting and upsetting thoughts come into our heads. Beck calls these unbidden cognitions automatic thoughts.

When a person’s stream of automatic thoughts is very negative, you would expect a person to become depressed (e.g., ‘I’m never going to get this essay finished, my girlfriend fancies my best friend, I’m getting fat, I have no money, my parents hate me – have you ever felt like this?’).

Quite often, these negative thoughts will persist despite contrary evidence.

Beck (1967) identified three mechanisms that he thought were responsible for depression:

The cognitive triad (of automatic negative thinking)
Negative self-schemas
Errors in Logic (i.e., faulty information processing)

The Cognitive Triad

The cognitive triad is three forms of negative (i.e., helpless and critical) thinking that are typical of individuals with depression: namely, negative thoughts about the self, the world, and the future.

These thoughts tended to be automatic in depressed people as they occurred spontaneously.

As these three components interact, they interfere with normal cognitive processing, leading to impairments in perception, memory, and problem-solving, with the person becoming obsessed with negative thoughts.

Negative Self-Schemas

Beck believed that depression-prone individuals develop a negative self-schema.

They possess a set of beliefs and expectations about themselves that are essentially negative and pessimistic.

Beck claimed that negative schemas might be acquired in childhood due to a traumatic event. Experiences that might contribute to negative schemas include:

Death of a parent or sibling.
Parental rejection, criticism, overprotection, neglect, or abuse.
Bullying at school or exclusion from a peer group.

People with negative self-schemas become prone to making logical errors in their thinking, and they tend to focus selectively on certain aspects of a situation while ignoring equally relevant information.

Cognitive Distortions

Beck (1967) identifies several illogical thinking processes (i.e., distortions of thought processes ). These illogical thought patterns are self-defeating and can cause great anxiety or depression for the individual.

Arbitrary interference : Drawing conclusions on the basis of sufficient or irrelevant evidence: for example, thinking you are worthless because an open-air concert you were going to see has been rained off.
Selective abstraction : Focusing on a single aspect of a situation and ignoring others: E.g., you feel responsible for your team losing a football match even though you are just one of the players on the field.
Magnification : exaggerating the importance of undesirable events. E.g., if you scrape a bit of paintwork on your car and, therefore, see yourself as a totally awful driver.
Minimization : underplaying the significance of an event. E.g., you get praised by your teachers for an excellent term’s work, but you see this as trivial.
Overgeneralization : drawing broad negative conclusions on the basis of a single insignificant event. E.g., you get a D for an exam when you normally get straight As and you, therefore, think you are stupid.
Personalization : Attributing the negative feelings of others to yourself. E.g., your teacher looks really cross when he comes into the room, so he must be cross with you.

Butler and Beck (2000) reviewed 14 meta-analyses investigating the effectiveness of Beck’s cognitive therapy and concluded that about 80% of adults benefited from the therapy.

It was also found that the therapy was more successful than drug therapy and had a lower relapse rate, supporting the proposition that depression has a cognitive basis.

This suggests that knowledge of the cognitive explanation can improve the quality of people’s lives.

REBT Vs. Cognitive Therapy

Albert Ellis views the therapist as a teacher and does not think that a warm personal relationship with a client is essential. In contrast, Beck stresses the quality of the therapeutic relationship.
REBT is often highly directive, persuasive, and confronting. Beck places more emphasis on the client discovering misconceptions for themselves.
REBT uses different methods depending on the client’s personality; in Beck’s cognitive therapy, the method is based on the particular disorder.

Strengths of CBT

Model has great appeal because it focuses on human thought. Human cognitive abilities have been responsible for our many accomplishments, so they may also be responsible for our problems.
Cognitive theories lend themselves to testing. When experimental subjects are manipulated into adopting unpleasant assumptions or thoughts, they become more anxious and depressed (Rimm & Litvak, 1969).
Many people with psychological disorders, particularly depressive, anxiety, and sexual disorders, have been found to display maladaptive assumptions and thoughts (Beck et al., 1983).
Cognitive therapy has been very effective in treating depression (Hollon & Beck, 1994) and moderately effective for anxiety problems (Beck, 1993).

Limitations of CBT

Lewinsohn (1981) studied a group of participants before they became depressed and found that those who later became depressed were no more likely to have negative thoughts than those who did not develop depression.

This suggests that hopeless and negative thinking may result from depression rather than the cause of it.

The cognitive model is narrow in scope: Thinking is just one part of human functioning, and broader issues need to be addressed.
Ethical issues : RET is a directive therapy aimed at changing cognitions, sometimes quite forcefully. For some, this may be considered an unethical approach.

Beck, A. T. (1967). Depression: Causes and treatment . Philadelphia: University of Pennsylvania Press.

Beck, A. T., Epstein, N., & Harrison, R. (1983). Cognitions, attitudes and personality dimensions in depression. British Journal of Cognitive Psychotherapy.

Beck, A. T, & Steer, R. A. (1993). Beck Anxiety Inventory Manual . San Antonio: Harcourt Brace and Company.

Butler, A. C., & Beck, J. S. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of the Norwegian Psychological Association , 37, 1-9.

Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta‐analysis including 409 trials with 52,702 patients. World Psychiatry , 22 (1), 105-115.

Dobson, K. S., & Block, L. (1988). Historical and philosophical bases of cognitive behavioral theories. Handbook of Cognitive behavioral Therapies. Guilford Press, London.

Ellis, A. (1957). Rational Psychotherapy and Individual Psychology. Journal of Individual Psychology , 13: 38-44.

Ellis, A. (1962). Reason and Emotion in Psychotherapy . New York: Stuart.

Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitive-behavioral therapies. In A. E. Bergin & S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 428—466). New York: Wiley.

Kendall, P. C., & Kriss, M. R. (1983). Cognitive-behavioral interventions. In: C. E. Walker, ed. The handbook of clinical psychology: theory, research and practice, pp. 770–819. Homewood, IL: Dow Jones-Irwin.

Lewinsohn, P. M., Steinmetz, J. L., Larson, D. W., & Franklin, J. (1981). Depression-related cognitions: antecedent or consequence?. Journal of abnormal psychology , 90(3), 213.

Lyons, L. C., & Woods, P. J. (1991). The efficacy of rational-emotive therapy: A quantitative review of the outcome research. Clinical Psychology Review , 11(4), 357-369.

Rimm, D. C., & Litvak, S. B. (1969). Self-verbalization and emotional arousal. Journal of Abnormal Psychology, 74(2) , 181.

Further Information

BounceBack® – a free skill-building program managed by the Canadian Mental Health Association (CMHA)
Cognitive behavioral therapy
Cognitive and behavioral therapies
An Overview of Psychopathology
An appraisal of rational-emotive therapy Making sense of cognitive behavior therapy (CBT)

What is the main difference between CBT and DBT?

The main difference between CBT and DBT is CBT focuses on challenging negative thought patterns, while DBT emphasizes acceptance and change, offering skills for emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness.

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A new study led by Stanford Medicine scientists found that certain changes in neural activity predicted which patients would benefit from a type of cognitive behavioral therapy. | Emily Moskal

Cognitive behavioral therapy, one of the most common treatments for depression, can teach skills for coping with everyday troubles, reinforce healthy behaviors and counter negative thoughts. But can altering thoughts and behaviors lead to lasting changes in the brain?

New research led by Stanford Medicine has found that it can — if a therapy is matched with the right patients. In a study of adults with both depression and obesity — a difficult-to-treat combination — cognitive behavioral therapy that focused on problem solving reduced depression in a third of patients. These patients also showed adaptative changes in their brain circuitry.

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient’s depression — which vary among people — increases the odds of success.

The same concept is already standard practice in other medical specialties.

“If you had chest pain, your physician would suggest some tests — an electrocardiogram, a heart scan, maybe a blood test — to work out the cause and which treatments to consider,” said Leanne Williams , PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine’s Center for Precision Mental Health and Wellness .

Leanne Williams

“Yet in depression, we have no tests being used. You have this broad sense of emotional pain, but it’s a trial-and-error process to choose a treatment, because we have no tests for what is going on in the brain.”

Williams and Jun Ma, MD, PhD, professor of academic medicine and geriatrics at the University of Illinois at Chicago, are co-senior authors of the study published Sept. 4 in Science Translational Medicine. The work is part of a larger clinical trial called RAINBOW (Research Aimed at Improving Both Mood and Weight).

Problem solving

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems — a conflict with a roommate, say — brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

Previous work from Williams’ lab, which identified six biotypes of depression based on patterns of brain activity, estimated that a quarter of people with depression have dysfunction with their cognitive control circuits — either too much or too little activity.

The participants in the new study were adults diagnosed with both major depression and obesity, a confluence of symptoms that often indicates problems with the cognitive control circuit. Patients with this profile generally do poorly on antidepressants: They have a dismal response rate of 17%.

Of the 108 participants, 59 underwent a year-long program of problem-solving therapy in addition to their usual care, such as medications and visits to a primary care physician. The other 49 received only usual care.

They were given fMRI brain scans at the beginning of the study, then after two months, six months, 12 months and 24 months. During the brain scans, the participants completed a test that involves pressing or not pressing a button according to text on a screen — a task known to engage the cognitive control circuit. The test allowed the researchers to gauge changes in the activity of that circuit throughout the study.

“We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit,” said Xue Zhang , PhD, a postdoctoral scholar in psychiatry who is the lead author of the study.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working smarter

As with any other depression treatment, problem-solving therapy didn’t work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

“That’s a huge improvement over the 17% response rate for antidepressants,” Zhang said.

When researchers examined the brain scans, they found that in the group receiving only usual care, a cognitive control circuit that became less active over the course of the study correlated with worsening problem-solving ability.

But in the group receiving therapy, the pattern was reversed: Decreased activity correlated with enhanced problem-solving ability. The researchers think this may be due to their brains learning, through the therapy, to process information more efficiently.

“We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior,” Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Both groups, on average, improved in their overall depression severity. But when Zhang dug deeper into the 20-item depression assessment, she found that the depression symptom most relevant to cognitive control — “feeling everything is an effort” — benefited from the more efficient cognitive processing gained from the therapy.

“We’re seeing that we can pinpoint the improvement specific to the cognitive aspect of depression, which is what drives disability because it has the biggest impact on real-world functioning,” Williams said.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

“That’s important, because it tells us that there is an actual brain change going on early, and it’s in the time frame that you’d expect brain plasticity,” Williams said. “Real-world problem solving is literally changing the brain in a couple of months.”

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise — a behavior — strengthens muscles, she added.

The researchers found that these early changes signaled which patients were responding to the therapy and would likely improve on problem-solving skills and depression symptoms at six months, 12 months and even one year after the therapy ended, at 24 months. That means a brain scan could be used to predict which patients are the best candidates for problem-solving therapy.

It’s a step toward Williams’ vision of precision psychiatry — using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

“It’s definitely advancing the science,” Zhang said. “But it’s also going to transform a lot of people’s lives.”

Researchers from University of Washington, University of Pittsburgh School of Medicine and The Ohio State University also contributed to the work.

The study received funding from the National Institutes of Health (grants UH2 HL132368, UH3 HL132368 and R01 HL119453).

Listen to a podcast of Leanne Williams discussing depression biotypes.

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Cognitive behavioral therapy enhances brain circuits to relieve depression

by Stanford University Medical Center

New research led by Stanford Medicine has found that it can—if a therapy is matched with the right patients. In a study of adults with both depression and obesity—a difficult-to-treat combination—cognitive behavioral therapy that focused on problem solving reduced depression in a third of patients. These patients also showed adaptative changes in their brain circuitry .

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient's depression—which vary among people—increases the odds of success.

The same concept is already standard practice in other medical specialties.

"If you had chest pain, your physician would suggest some tests—an electrocardiogram, a heart scan, maybe a blood test—to work out the cause and which treatments to consider," said Leanne Williams, Ph.D., the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine's Center for Precision Mental Health and Wellness.

"Yet in depression, we have no tests being used. You have this broad sense of emotional pain, but it's a trial-and-error process to choose a treatment, because we have no tests for what is going on in the brain."

Williams and Jun Ma, MD, Ph.D., professor of academic medicine and geriatrics at the University of Illinois at Chicago, are co-senior authors of the study published Sept. 4 in Science Translational Medicine . The work is part of a larger clinical trial called RAINBOW (Research Aimed at Improving Both Mood and Weight).

Problem solving

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems—a conflict with a roommate, say—brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

Previous work from Williams' lab, which identified six biotypes of depression based on patterns of brain activity, estimated that a quarter of people with depression have dysfunction with their cognitive control circuits—either too much or too little activity.

They were given fMRI brain scans at the beginning of the study, then after two months, six months, 12 months and 24 months. During the brain scans, the participants completed a test that involves pressing or not pressing a button according to text on a screen—a task known to engage the cognitive control circuit. The test allowed the researchers to gauge changes in the activity of that circuit throughout the study.

"We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit," said Xue Zhang, Ph.D., a postdoctoral scholar in psychiatry who is the lead author of the study.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working smarter

As with any other depression treatment, problem-solving therapy didn't work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

"That's a huge improvement over the 17% response rate for antidepressants," Zhang said.

"We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior," Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Both groups, on average, improved in their overall depression severity. But when Zhang dug deeper into the 20-item depression assessment, she found that the depression symptom most relevant to cognitive control—"feeling everything is an effort"—benefited from the more efficient cognitive processing gained from the therapy.

"We're seeing that we can pinpoint the improvement specific to the cognitive aspect of depression, which is what drives disability because it has the biggest impact on real-world functioning," Williams said.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

"That's important, because it tells us that there is an actual brain change going on early, and it's in the time frame that you'd expect brain plasticity," Williams said. "Real-world problem solving is literally changing the brain in a couple of months."

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise—a behavior—strengthens muscles, she added.

It's a step toward Williams' vision of precision psychiatry—using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

"It's definitely advancing the science," Zhang said. "But it's also going to transform a lot of people's lives."

Researchers from University of Washington, University of Pittsburgh School of Medicine and The Ohio State University also contributed to the work.

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Cognitive Behavioral Therapy Relieves Depression Via Changes in Neural Circuits

Cognitive behavioral therapy leads to adaptive changes in brain circuitry, relieving depression..

A person clasps their hands while speaking to a therapist.

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Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient’s depression — which vary among people — increases the odds of success.

The same concept is already standard practice in other medical specialties.

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Problem solving

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working smarter

As with any other depression treatment, problem-solving therapy didn’t work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

“That’s a huge improvement over the 17% response rate for antidepressants,” Zhang said.

“We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior,” Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise — a behavior — strengthens muscles, she added.

It’s a step toward Williams’ vision of precision psychiatry — using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

“It’s definitely advancing the science,” Zhang said. “But it’s also going to transform a lot of people’s lives.”

Reference: Zhang X, Pines A, Stetz P, et al. Adaptive cognitive control circuit changes associated with problem-solving ability and depression symptom outcomes over 24 months. Sci Transl Med . 2024;16(763):eadh3172. doi: 10.1126/scitranslmed.adh3172

This article has been republished from the following materials . Note: material may have been edited for length and content. For further information, please contact the cited source. Our press release publishing policy can be accessed here .

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Comparing cognitive behavior therapy, problem solving therapy, and treatment as usual in a high risk population

Affiliation.

1 University of Southern Queensland, Mental Health Service, Acute Care Team, Adult Mental Health, 100 Sixth Avenue, Maroochydore, QLD 4558, Australia. [email protected]
PMID: 19929153
DOI: 10.1521/suli.2009.39.5.538

Cognitive behavior therapy (CBT), problem-solving therapy (PST), or treatment as usual (TAU) were compared in the management of suicide attempters. Participants completed the Beck Hopelessness Scale, Beck Scale for Suicidal Ideation, Social Problem-Solving Inventory, and Client Satisfaction Questionnaire at pre- and posttreatment. Both CBT and PST indicated significant improvements over time within the majority of measured variables; when compared to TAU, both groups showed significant differences on satisfaction. When PST was compared to TAU, results indicated significant differences on suicidal ideation, indicating overall efficacy of brief therapies with suicide attempters.

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Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

What Is Cognitive Behavioral Therapy?
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Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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Cognitive behavioral therapy enhances brain circuits to relieve depression

Stanford Medicine

Stanford Medicine researchers and their colleagues have found that choosing treatments based on the type of a patient’s depression increases the odds of success.

Credit: Emily Moskal/Stanford Medicine

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient’s depression — which vary among people — increases the odds of success.

The same concept is already standard practice in other medical specialties.

Problem solving

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working smarter

As with any other depression treatment, problem-solving therapy didn’t work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

“That’s a huge improvement over the 17% response rate for antidepressants,” Zhang said.

“We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior,” Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise — a behavior — strengthens muscles, she added.

It’s a step toward Williams’ vision of precision psychiatry — using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

“It’s definitely advancing the science,” Zhang said. “But it’s also going to transform a lot of people’s lives.”

Researchers from University of Washington, University of Pittsburgh School of Medicine and The Ohio State University also contributed to the work.

The study received funding from the National Institutes of Health (grants UH2 HL132368, UH3 HL132368 and R01 HL119453).

Listen to a podcast of Leanne Williams discussing depression biotypes.

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Article title.

Adaptive cognitive control circuit changes associated with problem-solving ability and depression symptom outcomes over 24 months

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Cognitive-Behavioral Therapies: Achievements and Challenges

Brandon a. gaudiano.

1 Department of Psychiatry & Human Behavior, The Warren Alpert Medical School of Brown University

2 Psychosocial Research Program, Butler Hospital

In 1976, psychiatrist Aaron Beck posed this question about a new form of therapy that emphasized changing patients’ dysfunctional cognitions: “Can a fledgling psychotherapy challenge the giants in the field—psychoanalysis and behavior therapy?” (p. 333) [ 1 ]. Since that time, cognitive-behavioral therapy (CBT)—the more general term that subsumes Beck’s particular variant called cognitive therapy—has emerged as one of the most dominant psychotherapy modalities. What is responsible for the meteoric rise of this approach over the past three decades? In this article, I briefly discuss the factors responsible for the current popularity of CBT, review some of the criticisms that have emerged about the treatment, and describe recent innovative work that may end up changing the very nature of CBT in the decades to come.

CBT as an Increasingly Popular and Evidence-Based Practice

CBT has become increasingly popular with clinicians and the general public alike over recent years. Surveys of therapists indicate the CBT is fast becoming the majority orientation of practicing psychologists [ 2 ]. Partly because of its commonsense and clear principles, self-help books based on CBT approaches also have come to dominate the market [ 3 ]. Even media articles frequently extol the virtues of this form of psychotherapy. A recent Washington Post article proclaimed: “For better or worse, cognitive therapy is fast becoming what people mean when they say they are ‘getting therapy’” (p. HE01) [ 4 ].

What accounts for CBT’s sustained and growing popularity? The short-term, structured nature of the treatment made it particularly amenable to empirical investigation, and it has accumulated an impressive research base. Butler et al. [ 5 ] report that there are now over 325 clinical trials of CBT for various clinical populations, including mood disorders, anxiety disorders, marital distress, anger, childhood disorders, and chronic pain. In their examination of 16 separate meta-analyses of CBT studies for a variety of conditions, Butler et al. reported that the treatment produced large effect size improvements compared to control conditions for emotional disorders in adults and adolescents. Furthermore, results indicated that CBT was somewhat superior to antidepressants, and equal in efficacy to behavior therapy in treating adult depression. In recent years, CBT even has been shown to be an effective treatment when added to medications for patients with schizophrenia.

Because of this impressive amount of empirical support, it is not surprising that CBT has found its way onto most treatment guidelines for a variety of psychiatric conditions, including those produced by the U.K.’s National Institute for Health and Clinical Excellence ( http://www.nice.org.uk/ ) and the American Psychiatric Association ( http://www.psych.org/psych_pract/ ). Furthermore, CBT is now one of the psychotherapies taught as a required part of the curriculum in residency training programs in psychiatry [ 6 ]. By its vary nature, CBT can be more easily disseminated and implemented than other approaches because of the development of highly specified, manualized treatment protocols designed to be delivered over shorter-term durations (e.g., 12–20 sessions). Given these factors, it is predictable that CBT has become a favorite choice by managed care companies in the U.S. looking for cost-effective alternatives to traditional psychotherapy. Also not surprisingly, many traditional psychotherapists trained in longer-term approaches have complained about the increasing pressure they feel to truncate treatment (in their view) prematurely given the current healthcare climate.

What is CBT?

With the current popularity of the approach, one might assume that CBT would be relatively straightforward to define. Although the basic techniques and tenets of the approach are fairly straightforward, there are a diversity of specific treatments that can be categorized more or less as falling under the CBT umbrella, including cognitive therapy, problem-solving therapy, dialectical behavior therapy, meta-cognitive therapy, rational-emotive behavior therapy, cognitive processing therapy, mindfulness-based cognitive therapy, cognitive-behavioral analysis system of psychotherapy, and schema-focused therapy [ 7 ]. Thus, it is more accurate to speak of cognitive-behavioral therapies in the plural sense, as they actually constitute a family of related interventions following certain underlying principles and assumptions. Although it is possible to describe the main elements of CBT, one should recognize that the actual application can vary somewhat in practice. Thus, what follows is a more generic description of the prototypical and most distinctive features of classic CBT (also see Table 1 ).

The General Cognitive-Behavioral Therapy Model

Etiological Theory	Techniques & Strategies	Mechanism of Action	Desired Outcomes

Adapted from Forman and Herbert [ 9 ].

Beck states that the cognitive approach to psychotherapy “is best-viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify dysfunctional beliefs and faulty information processing characteristic of each disorder” (p. 194) [ 8 ]. More specifically, Forman and Herbert [ 9 ] describe the fundamental aspects of the model based on its: a) theory of etiology (i.e., the psychopathological processes thought to produce disorder), b) therapeutic strategies/techniques, c) proposed mechanisms of action (i.e. the processes through which the treatment produces its effects), d) and desired outcomes. First, the CBT model proposes that psychopathology is the product of faulty information processing that manifests itself in distorted and dysfunctional thinking, which directly leads to negative emotions and maladaptive behaviors. Thus, the CBT therapist helps the patient to identify, evaluate, and then modify distorted cognitions to produce more realistic and adaptive evaluations. This is typically first accomplished through rational disputation techniques introduced by the therapist during session, followed by behavioral experiments designed to test out the validity of the patient’s assumptions and predictions. For example, the therapist may first help a patient with social phobia review the evidence for and against the notion that her boss thinks that she is a “failure.” Then, between sessions, the therapist may ask the patient to request direct feedback from her boss about her job performance, and compare this information to her prediction about what her boss would say. It is assumed that correcting patients’ distorted cognitions in this manner will produce a direct improvement in both mood (e.g., the patient will feel less anxious) and behavior (e.g., the patient will perform better at work and be more social around coworkers). Although the cognitive techniques tend to be emphasized, CBT also incorporates a variety of other behavioral strategies, including activity scheduling for depression and exposure to feared stimuli for anxiety. Nevertheless, the primary theoretical mechanism of action in CBT is proposed to be cognitive change, which is expected to lead to improvements in other symptoms via cascading and reciprocal effects. The most immediate focus of CBT, then, is on symptom reduction; although improved functioning is also a longer-term goal of treatment.

Criticisms of Traditional CBT

Given the dominance of CBT in certain settings, it is not surprising that the approach has garnered its fair share of critics. Opponents have frequently argued that the approach is too mechanistic and fails to address the concerns of the “whole” patient. However, in recent years some of the most pointed criticisms have emerged from within the CBT community itself [ 10 – 12 ]. First, the specific cognitive components of CBT often fail to outperform “stripped-down” versions of the treatment that contain only the more basic behavioral strategies. This insight comes from a special type of treatment research called component analyses or dismantling studies in which the specific components of CBT are experimentally manipulated. For example, Jacobson et al. [ 13 ] showed that patients with major depression improved just as much following a treatment that contained only the behavioral strategies and explicitly excluded techniques designed to directly modify distorted cognitions, when compared to the full CBT package containing both the cognitive and behavioral elements.

Second, CBT has lacked a strong link to cognitive psychology and neuroscience, or at least until very recently. Even though CBT was being formally codified in the 1970s when experimental cognitive psychology was also emerging as an important new science, CBT developed primarily from clinical observations obtained in the therapy office, instead of the laboratory. Thus, the theoretical basis of CBT was not well connected to the emerging science of human cognition. This has resulted in the need to modify central aspects of CBT theory over the years to better conform to the experimental knowledge being accumulated by cognitive scientists.

Finally, CBT proponents have been slow to experimentally investigate the putative mechanisms of action of CBT, which when tested have often failed to conform to the predictions set forth by the model. For example, Burns and Spangler [ 14 ] failed to confirm any of the predicted causal relationships among dysfunctional attitudes and treatment outcomes in a sample of 521 patients being treated with CBT. These observations have led some to pose a curious question after 325 studies of CBT have already been conducted: “Do we need to challenge thoughts in cognitive behavior therapy?” (p. 187) [ 11 ].

A “Third Wave” of CBT?

Based on these and related complaints concerning traditional CBT, many prominent researchers and clinicians have begun to propose modified approaches that are based on the latest research on psychotherapy and psychopathology. Dialectical behavior therapy (DBT) for borderline personality disorder is an example of one of the first empirically-supported, next-generation CBT approaches, which attempts to balance acceptance- and change-based strategies [ 15 ]. Hayes [ 16 ] coined the term “third wave” to describe the emergence of novel approaches that minimize or wholly exclude direct cognitive disputation, relying instead on more indirect methods of addressing putatively distorted cognitions (e.g., acceptance-based strategies), if doing so at all. The reason for the term “third wave” is because these treatments can be seen as linked to the classic behavior therapy movement of the 1950s (e.g., systematic desensitization), or the so-called first wave, and also to the second wave or “cognitive revolution” of the 1960s and 70s from which traditional CBT emerged.

Techniques designed to directly modify cognitions may be neither necessary nor sufficient for improvement, and in some cases can produce paradoxical effects. For example, research has shown that under certain laboratory conditions, subjects attempting to control or suppress thoughts were more likely to experience them later, in a process called the “postsuppression rebound effect” [ 17 ]. Instead, Hayes [ 16 ] advocates a novel approach called acceptance and commitment therapy (ACT), which emphasizes the acceptance (in contrast to control) of distressing thoughts and feelings, and focuses on the use of innovative strategies for directly changing behavior in accordance with the personal values and goals of patients. Although research on ACT remains in its initial stages, preliminary investigations from 21 clinical trials have demonstrated that the treatment is effective for a variety of clinical conditions, including mood and psychotic disorders, and compares quite favorably when tested against traditional CBT [ 10 ]. Furthermore, initial studies of the mechanisms of action of the treatment have suggested that ACT works more through the modification of behavioral avoidance patterns (as predicted) than changes in distorted cognitions (which are not directly targeted).

What the Future May Hold for CBT

There are several emerging themes in CBT that offer exciting new possibilities for the future of evidence-based psychotherapy. First, component analyses of CBT will continue to be conducted, and this will likely lead to a refined understanding of the most essential and effective strategies contained in the approach. For example, behavioral activation therapy, which emerged from the seminal study by Jacobson et al. [ 13 ], is similarly effective but easier to train clinicians how to implement. Furthermore, a recent clinical trial indicated that behavioral activation was more effective than CBT, but only for more severely depressed patients [ 18 ]. Thus, in addition to identifying the effective components of CBT, a refined study of the approach may also be helpful for identifying possible contraindications, similar to how clinical trials of psychotropic drugs systematically report data on side-effects and safety in addition to efficacy.

Second, more attention is being paid to basic research on psychopathology, and this is leading to modifications in traditional CBT approaches. For example, Clark and colleagues [ 19 ] tested a modified form of CBT that targeted self-focused attention in patients with social phobia based on emerging research on the key cognitive processes related to the disorder. They found the modified CBT protocol to be superior to fluoxetine plus patient-directed exposure instructions.

Third, researchers such as Barlow and colleagues [ 20 ] are developing new CBT interventions that focus on the core principles found to be effective across different psychiatric conditions, making them useful for patients with various emotional disorders. These more streamlined approaches may help to decrease the problem posed by training clinicians in separate CBT manuals for each condition, which up to this point has been costly and produced logistical challenges for treatment dissemination efforts. Nevertheless, the research on such “unified” approaches is still in its infancy, and ultimate success in this area remains very much an open empirical question.

Finally, approaches such as ACT and DBT are becoming empirically supported alternatives to traditional CBT, and this is changing the landscape of psychotherapy. One may now pose a new question: “Can these fledgling ‘third wave’ therapies challenge the giants in the field—behavior therapy and cognitive therapy?” In fact, these treatments already are being researched and disseminated at a surprisingly fast pace. As their popularity increases, similar questions will be asked about their specific efficacy and mechanisms of action; hopefully at a much earlier stage compared to their predecessors. Only further research will confirm their ultimate impact on the field and bona fide “third wave” status. But for traditional CBT to survive all these new challenges, proponents must strive to produce better research, and this may require the modification of some of the approach’s central tenets. Ultimately, CBT will need to conform to this emerging science in order to retain its strong foothold, or the approach may be destined to fade the way of former giants such as psychoanalysis over the upcoming decades.

Acknowledgments

I would like to thank the following colleagues for their helpful feedback on an earlier version of the manuscript: Kristy Dalrymple, Gary Epstein-Lubow, Kathleen Palm, and Lisa Uebelacker.

This work was supported in part by grants from the U.S. National Institute of Mental Health (MH076937) and NARSAD: The Mental Health Research Association.

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Cognitive behavioral therapy improves brain circuits to relieve depression: Study

The study shows that cognitive behavioral therapy can reduce depression with emphasised problem solving..

One of the most popular therapies for depression is cognitive behavioural therapy, which can help people learn coping mechanisms for common problems, reinforce positive actions, and challenge negative thinking. But can thinking and acting differently result in long-lasting brain changes?

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient's depression -- which vary among people -- increases the odds of success.(Unsplash)

According to recent research from Stanford Medicine, researchers found that it can. If the appropriate patients are matched with a therapy. A third of patients in a study with people who had both depression and obesity--a combination that is challenging to treat--saw a reduction in depression thanks to cognitive behavioral therapy that emphasized problem solving. Additionally, adaptive modifications in brain circuitry were observed in these patients.

ALSO READ: Cognitive behavioural therapy can alter brain activity in kids with anxiety issue: Study

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient's depression -- which vary among people -- increases the odds of success.

The same concept is already standard practice in other medical specialties.

"If you had chest pain, your physician would suggest some tests -- an electrocardiogram, a heart scan, maybe a blood test -- to work out the cause and which treatments to consider," said Leanne Williams, PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine's Center for Precision Mental Health and Wellness.

ALSO READ: Breaking the cycle of negative thinking: 10 cognitive behavioural techniques for improved mental health

Problem-solving therapy

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems -- a conflict with a roommate, say -- brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

They were given fMRI brain scans at the beginning of the study, then after two months, six months, 12 months and 24 months. During the brain scans, the participants completed a test that involves pressing or not pressing a button according to text on a screen -- a task known to engage the cognitive control circuit. The test allowed the researchers to gauge changes in the activity of that circuit throughout the study.

"We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit," said Xue Zhang, PhD, a postdoctoral scholar in psychiatry who is the lead author of the study.

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Cognitive behavioral therapy may enhance brain circuits to relieve depression, reveals research

New research led by Stanford Medicine has found that it can-if a therapy is matched with the right patients. In a study of adults with both depression and obesity-a difficult-to-treat combination-cognitive behavioral therapy that focused on problem solving reduced depression in a third of patients. These patients also showed adaptative changes in their brain circuitry.

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient’s depression-which vary among people-increases the odds of success.

The same concept is already standard practice in other medical specialties.

“If you had chest pain, your physician would suggest some tests-an electrocardiogram, a heart scan, maybe a blood test-to work out the cause and which treatments to consider,” said Leanne Williams, PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine’s Center for Precision Mental Health and Wellness.

Problem solving

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems-conflict with a roommate, say-brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

“We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit,” said Xue Zhang, PhD, a postdoctoral scholar in psychiatry who is the lead author of the study.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working smarter

As with any other depression treatment, problem-solving therapy didn’t work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

“That’s a huge improvement over the 17% response rate for antidepressants,” Zhang said.

“We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior,” Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Both groups, on average, improved in their overall depression severity. But when Zhang dug deeper into the 20-item depression assessment, she found that the depression symptom most relevant to cognitive control-“feeling everything is an effort”-benefited from the more efficient cognitive processing gained from the therapy.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise-a behavior-strengthens muscles, she added.

It’s a step toward Williams’ vision of precision psychiatry-using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

“It’s definitely advancing the science,” Zhang said. “But it’s also going to transform a lot of people’s lives.”

Xue Zhang et al. ,Adaptive cognitive control circuit changes associated with problem-solving ability and depression symptom outcomes over 24 months.Sci. Transl. Med.16,eadh3172(2024).DOI:10.1126/scitranslmed.adh3172.

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: [email protected]. Contact no. 011-43720751

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Cognitive Behavioral Therapy (CBT)

Resource type

Cognitive Distortions – Unhelpful Thinking Styles (Extended)

Cognitive Distortions – Unhelpful Thinking Styles (Common)

Window Of Tolerance

Valued Domains

Assertive Communication

Therapy Blueprint (Universal)

Embracing Uncertainty

Thought Record (Evidence For And Against)

Choosing Your Values

Intolerance Of Uncertainty

Theory A / Theory B

Prompts For Challenging Your Negative Thinking

Before I Blame Myself And Feel Guilty

Assertive Responses

Unhelpful Thinking Styles (Archived)

Exploring Valued Domains

Worry Flowchart

Activity Menu

Cross Sectional Formulation

Examining Your Negative Thoughts

Thought Distortion Monitoring Record

Post-Traumatic Stress Disorder (PTSD) Formulation

Low Self-Esteem Formulation

How Trauma Can Affect You (CYP)

Using Behavioral Activation To Overcome Depression

Social Anxiety Formulation

What Is Cognitive Behavioral Therapy (CBT)?

Behavioral Experiment (Portrait Format)

Behavioral Activation Activity Diary

Values: Connecting To What Matters

Mastery Of Your Anxiety And Worry (Second Edition): Workbook

What Keeps Generalized Anxiety And Worry Going?

Worry Postponement

Health Anxiety Formulation

How Your Past Affects Your Present (CBT)

Anxiety - Self-Monitoring Record

Understanding Generalized Anxiety And Worry

Exposure And Response Prevention

Fear Ladder

Panic Formulation

Mastery Of Your Anxiety And Panic (Fifth Edition): Workbook

Decatastrophizing

Simple Thought Record

Longitudinal Formulation 2

Evaluating Unhelpful Automatic Thoughts

What Keeps Depression Going?

Compassionate Thought Challenging Record

Intrusive Thoughts Images And Impulses

Habituation

Behavioral Experiment

Audio Collection: Psychology Tools For Mindfulness

Uncovering Your Deeper Beliefs

Friendly Formulation

What Keeps Obsessive Compulsive Disorder (OCD) Going?

Understanding Obsessive Compulsive Disorder (OCD)

Treating Your OCD With Exposure And Response (Ritual) Prevention (Second Edition): Workbook

CBT Appraisal Model

Understanding Low Self-Esteem

Pie Chart - Responsibility

Changing Avoidance (Behavioral Activation)

Safety Plan

What Is A Panic Attack?

Overview Of CBT

Nightmare Exposure And Rescripting

Exposure Session Record

Cognitive Behavioral Model Of Low Self-Esteem (Fennell, 1997)

Understanding Post-Traumatic Stress Disorder (PTSD)

OCD Hierarchy

What Keeps Low Self-Esteem Going?

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Client Workbook

CBT Thought Record Portrait

Understanding Depression

Core Belief Magnet Metaphor