Cognitive Behavioral Therapy

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The term cognitive behavioral therapy, or CBT, is an overarching term used to classify a number of psychological therapies with various similarities. Among these include rational emotive behavior therapy, rational behavior therapy, rational living therapy, cognitive therapy, and dialectic behavior therapy.

All methods of CBT are based on the idea that our thoughts directly affect our feelings and behaviors, more so than external influences such as other people, specific situation, or events. This is beneficial in that we have the ability to change the way we think in order to gain improvements in the way we feel and act, even if the situation remains static. In CBT, the therapist takes into consideration the patient’s goals in life and then helps them learn the tools to achieve these goals by teaching logical self-counseling skills to the client. Due to the collaborative nature of CBT, it is important to have a good therapeutic relationship between therapist and patient, however this is not a deciding factor in determining a successful outcome of CBT. Cognitive behavioral therapy is effective because it allows patients to view challenging situations with a clear perspective and as a result, respond to them more effectively.

Cognitive behavioral therapies are based on a variety of principles. Some approaches emphasize stoicism and teach the benefits of feeling calm when confronted with an undesirable situation or conflict. Furthermore, they stress the importance of understanding that undesirable situations abound regardless of our reaction to them. Other therapies use a Socratic method of questioning to gain an understanding of each patient’s concerns. This method then encourages patients to themselves ask questions when placed in different surroundings in order to better understand the context, and to help them think through any undesirable feelings or conflicts. It is important to understand that while CBT is designed to help patients achieve their goals, therapists do not tell patients how to achieve them by directing them as to what they should do. Rather, therapists show their patients how to think and behave in ways that will facilitate achieving those goals. Rational thinking methods of CBT emphasize the importance of using induction to introspectively look at thoughts as hypotheses that can be tested or questioned. If patients discover that their thoughts (or hypotheses pertaining to a specific situation) are incorrect, they can change their way of thinking to be more streamlined with the situation at hand. Finally, weekly reading assignments and practice of techniques is required of patients who receive CBT, in order to reinforce what they have learned in their CBT sessions and enable them to practice utilizing their new ways of thinking about their thoughts and behaviors.

Unlike other types of psychotherapy that can go on for years, CBT is time-limited rather than open-ended, with a formal ending point. On average, approximately 16 sessions are required per patient. To get started, it is important to first locate a licensed therapist with experience in CBT. This can be done via a simple phone book search or over the Internet, or by seeking a referral from a doctor, health insurance provider, or a trusted friend. The Mayo Clinic provides a comprehensive overview of what patients can expect when participating in CBT.

Cognitive Behavioral Therapy and Fibromyalgia

Cognitive behavioral therapy can be used to help address the emotional challenges that often occur in relation to mental illness, coping with stressful life situations, anger management, relationship conflicts, grief, emotional trauma, medical illness, and chronic physical symptoms such as pain or insomnia. Many of these situations and symptoms are frequently experienced by fibromyalgia sufferers, and research demonstrates that CBT can be of great therapeutic value to fibromyalgia patients. Among various psychological therapies that have been employed to help manage the symptoms of fibromyalgia, CBT often demonstrates the greatest degree of effect (Glombiewski et al., 2010; Thieme & Gracely, 2009) and many prominent fibromyalgia researchers have cited the importance of CBT as part of the standard therapeutic regimen for fibromyalgia patients (Arnold & Clauw, 2010; Hauser et al., 2009; Goldenberg, 2009; Arnold et al., 2008) .

A 2012 study by Castel and colleagues compared the effectiveness of two psychological treatments for fibromyalgia with each other, as well as with standard care. In this randomized-controlled trial (considered the “gold-standard” for research study design), participants were randomly assigned to receive either 1) CBT (34 patients, including 32 females); 2) CBT with hypnosis (29 patients, including 28 females); or 3) standard care control group that received treatment only medication (30 patients, all female). Both groups that received CBT did so in a small group setting consisting of four to six participants per group. Those in the control group received usual standard care medications, including pain relievers, antidepressants, anticonvulsants, and muscle relaxants as needed. Those in the CBT only group also received standard care medications, as well as 14 weekly two-hour CBT treatment sessions. Those in the CBT plus hypnosis group participated in the same weekly CBT session schedule, received standard care medications, however during the second session, they also received self-hypnosis training. Self-hypnosis was then incorporated into the end of each standard CBT session and were encouraged to continue the self-hypnosis practice at home. The researchers measured the effects of the two interventions and the control group therapy on pain intensity, catastrophizing (characterizing pain as awful, horrible, or unbearable), psychological distress, functioning, and sleep disturbances at the following time points: prior to the start of each session, immediately following each session, and at three- and six-month follow-up visits after the conclusion of the study. The researchers found that fibromyalgia patients who received CBT or CBT with hypnosis experienced much greater improvements than those in the control group, and that those in the hypnosis group fared better than those who received only CBT. Particular improvements were found for those in both CBT groups with regard to catastrophizing, psychological distress, functioning, sleep quantity, and sleep disturbances. Furthermore, improvements in functioning and pain intensity were maintained for both groups at the three- and six-month follow-up (Castel et al. 2012).

A similar randomized-controlled trial by Woolfolk et al. (2012) was conducted to determine the efficacy of individually-administered CBT in ten weekly sessions administered with normal treatment, to a control group consisting of patients receiving only normal treatment measures. Pain intensity, functioning, depression, anxiety, and quality of life were measured prior to the start of the study, three months after completing therapy, and six months after completion. Following analysis, the researchers found that those who received CBT showed greater improvements in pain severity than those who received standard treatment, and these differences remained significant at both follow-up assessments (three and six months). Those in the CBT group also received greater, though less significant improvements, in all other measures of the study when compared to the control group, including functioning, depression, anxiety, and quality of life (Woolfolk et al., 2012).

In addition to studies that have shown improvements in fibromyalgia-related pain, CBT has also been demonstrated to improve fibromyalgia-related insomnia as well. A 2011 study by Miro et al. compared sleep improvement-focused CBT versus a sleep hygiene program on insomnia among 40 fibromyalgia patients. Sleep hygiene is an educational approach designed to provide participants with information related to fibromyalgia and sleep, basic understanding of sleep stages, needs, rhythms, and disruptions, environmental stimuli and factors that influence sleep, and lifestyle factors that influence sleep. Following analysis of the data, the researchers found that those who received the CBT gained significant improvements in their alertness, executive functioning (brain functioning that organizes and manages other functions), sleep quality, and daily functioning. The authors concluded that CBT was useful at improving various insomnia-related measures among fibromyalgia patients (Miro et al., 2011). These findings build on those from previous studies that have also demonstrated the utility of CBT in treating fibromyalgia-associated insomnia (Edinger et al., 2005) as well as improving insomnia in individuals with various psychiatric and other chronic medical conditions (Morin & Espie, 2003; Edinger et al., 2001; Morin, 2005).

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References

1.        What is Cognitive Behavioral Therapy? National Association of Cognitive Behavioral Therapists. Accessed April 13, 2012.

2.        Cognitive behavioral therapy: What you can expect.   Mayo Clinic. Accessed April 13, 2012.

3.        Glombiewski JA, Sawyer AT, Gutermann J, Koenig K, Rief W, Hofmann SG. Psychological treatments for fibromyalgia: a meta-analysis. Pain. 2010;151(2):280-295.

4.        Thieme K, Gracely RH. Are psychological treatments effective for fibromyalgia pain? Curr Rheumatol Rep. 2009;11(6):443-450.

5.        Arnold LM, Clauw DJ. Fibromyalgia syndrome: practical strategies for improving diagnosis and patient outcomes. Am J Med. 2010;123(6):S2.

6.        Hauser W, Eich W, Herrmann M, Nutzinger DO, Schiltenwolf M, Henningsen P. Fibromyalgia syndrome: classification, diagnosis, and treatment. Dtsch Arztebl Int. 106(23):383-391.

7.        Goldenberg DL. Using multidisciplinary care to treat fibromyalgia. J Clin Psychiatry. 2009;70(5):e13.

8.        Arnold LM, Bradley LA, Clauw DJ, Glass JM, Goldenberg DL. Multidisciplinary care and stepwise treatment for fibromyalgia. J Clin Psychiatry. 2008;69(12):e35.

9.        Castel A, Cascon R, Padrol A, Sala J, Rull M. Multicomponent cognitive-behavioral group therapy with hypnosis for the treatment of fibromyalgia: long-term outcome. J Pain. 13(3):255-265.

10.     Woolfolk RL, Allen LA, Apter JT. Affective-cognitive behavioral therapy for fibromyalgia: a randomized controlled trial. Pain Res Treat. 2012;Article ID 937873, 6 pages. doi:10.1155/2012/937873.

11.     Miro E, Lupianez J, Martinez MP, Sanchez AI, Diaz-Piedra C, Guzman MA, Buela-Casal G. Cognitive-behavioral therapy for insomnia improves attentional function in fibromyalgia syndrome: a pilot, randomized controlled trial. J Health Psychol. 2011;16(5):770-782.

12.     Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial. Arch Intern Med. 2005;165(21):2527-2535.

13.     Morin CM, Espie CA. Insomnia: A Clinical Guide to Assessment and Treatment. New York, NY: Kluwer Academic/Plenum Publishers; 2003.

14.     Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled  trial. JAMA. 2001;285:1856-1864.

Morin CM. Psychological and behavioral treatments for primary insomnia. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia, Pa: Elsevier Saunders; 2005:726-737.

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