Cognitive Behaviour Therapy - why does it work?

Those of you who regularly ready my column will be very familiar with my frequent recommendation of cognitive behaviour therapy. This type of psychotherapy has become increasingly common over the last 25 years and is strongly evidence-based.

It was preceded by behaviour therapy. Even among early behaviourists such as Joseph Wolpe, considered by some to be the father of behaviour therapy, cognition was important. Systematic Desensitization was developed by Wolpe and involved exposing anxious patients to phobic stimuli in imagination in order to reduce their physiological and behavioural responses to the anxiety producing stimuli. There was a lot of cognition involved. Later therapists began emphasizing the cognitive aspects of therapy more and the behavioural aspects less.

Modern day cognitive behaviour therapy is an amalgam of many different techniques. It includes such things as: psychoeducation about the nature of the problem being treated, self-monitoring of symptoms, relaxation exercises, cognitive restructuring, and imaginal and real life exposure to feared stimuli. While there is overwhelming evidence that cognitive behaviour therapy works, there is less agreement on why it works or what the most effective ingredients are. Over at least 25 years there have been attempts to deconstruct the therapy to establish which of the ingredients are most effective.

Most analyses of this research have concluded that whatever the therapy is called, it is the behavioural components that are most effective. In some ways it is academic. It is pretty hard to do behaviour therapy without doing some education about the nature of the problem being treated. Self-monitoring is the way we measure progress and is therefore pretty much indispensible too. Therapists can differ, however, in how much emphasis they place on such things as relaxation therapy, imaginal exposure and deliberate cognitive restructuring.

In most cases if you have a choice between exposing a fearful patient to a phobic stimulus in imagination or in real life, the real life or in vivo exposure is more effective and leads to more rapid improvement. When someone who is fearful of elevators gets in an elevator and rides it, in spite of their fear, they undergo cognitive change whether or not this is talked about or emphasized.

Behavioural change and cognitive change are inextricably connected. However, a pure cognitive therapist might try to change the fear of elevators by pure discussion without any actual exposure to the real thing. Research has shown repeatedly that this is less effective than therapy that deliberately encourages direct exposure to the elevator.

Because of the popularity of the term “cognitive behaviour therapy” many therapists have co-opted the term and say they are doing it when in fact they are not. They may simply be talking to the patient about their problems and offering support without making any direct recommendations for behavioural change, monitoring the behavioural change or understanding the importance of the behavioural aspects of the therapy.

On the other side of the coin, some people are getting cognitive behaviour therapy and don’t realize it because the cognitive aspects may not be formalized or emphasized.

In most cases, if discussion in the office is not followed by behavioural change in real life, therapy will be ineffective.


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