Q: I have heard about different types of cognitive therapy such as CBT, ACT, DBT, and REBT. What are these and how are they different?

A: There is a rich and diverse tradition of cognitive-behavioral therapy approaches. Below is a very brief overview of the most popular (and well-researched) of these.

One of the first forms of cognitive-behavioral therapy was Albert Ellis's Rational Emotive Behavioral Therapy, or REBT. Dr. Ellis was originally trained as a psychoanalyst. However, in the 1950s, he began to develop a new type of therapy that he considered to be more "efficient" than psychoanalysis.

Using his REBT therapy, Ellis helped his clients to actively change self-critical thought patterns and self-defeating behaviors. He is often considered the "grandfather" of cognitive therapy, due to his pioneering work.

One of the most important approaches in REBT is the "A –> B –> C" model. According to this model, an Adversity (A) does not directly lead to emotional Consequences (C). Instead, there is an important middle-piece: our Beliefs (B).

Albert Ellis REBT ABCsAccording to REBT, it is our beliefs that directly influence our emotions, not the original adversity or event. In REBT, the therapist helps the client to change self-critical, self-defeating beliefs to self-accepting, self-supportive beliefs.

In REBT, there are a variety of beliefs that therapist and client keep an eye out for. These include such things as:

  1. Should-ing beliefs — beliefs that self-critically say, "I should be different, I should be better, I should be much more perfect than I am."
  2. Must-erbatory beliefs — beliefs that say, "I must do things differently. I must be a better person. I must do a better job at this!"
  3. Awful-izing beliefs — beliefs that say, "this is awful, and I can't stand it, and it will probably get even worse!"

In REBT, therapist and client work to change these distress-producing beliefs to peaceful, empowering new beliefs. In REBT, one of the overall goals is to help the client adopt unconditionally self-accepting beliefs. As a support for this change of beliefs, REBT includes a variety of self-supportive behavioral practices.

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The next type of cognitive therapy to be developed was Aaron Beck's Cognitive Therapy, or CT. Dr. Beck and Dr. Ellis actually corresponded and shared ideas in the development of their therapies; therefore, CT and REBT share many approaches.

Perhaps one of the most significant differences is that Beck's Cognitive Therapy was originally developed as a treatment for depression, and the emphasis was on shifting "distorted thinking" to "realistic thinking." As a support for this shift, Beck worked with his clients to identify thought distortions. These included such things as:

  • Mind-reading: "I'm sure that those people don't like me."
  • Fortune-telling: "The future will be as bad as the past."
  • All-or-nothing thinking: "If I don't do a perfect job on this, I'm a failure."
  • Personalization: "It's all my fault. I'm completely to blame for this."

In Beck's Cognitive Therapy, therapist and client identify common "automatic thoughts" that pop up frequently into the client's mind. They then identify the distorted nature of these thoughts, and work to develop realistic, self-supportive new thoughts.

Core Negative Beliefs and automatic thoughtsTherapist and client also might identify "core negative beliefs," which give rise to the flow of automatic thoughts. These core negative beliefs might include things such as, "I'm a failure," "I'm worthless," and "I'm hopeless." Therapy focuses on replacing these core negative beliefs with positive and realistic beliefs.

Over time, Beck's Cognitive Therapy began to increasingly include behavioral approaches, such as self-care activities and confidence-building practices. These days, people usually use "cognitive therapy" and "cognitive-behavioral therapy" interchangeably. Even some therapists who practice REBT simply call themselves "cognitive therapists."

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A much newer development in the cognitive-behavioral therapy tradition is Dialectical Behavioral Therapy, or DBT. Developed by Marsha Linehan in the 1990s, DBT is focused on a two-part "dialectic" of acceptance and change.

Dialectical Behavioral Therapy acceptance and changeDialectical Behavioral Therapy was originally developed as a specialized type of therapy for people with Borderline Personality Disorder. Many of Dr. Linehan's clients were emotionally overwhelmed, and found traditional cognitive therapy to be very difficult. Dr. Linehan expanded and modified cognitive therapy to include a number of emotionally soothing, self-accepting, and relationship-building practices.

DBT has proven to be not only an excellent form of treatment for Borderline Personality Disorder, but also an effective form of therapy for Bipolar Disorder and other challenges that involve intense emotions. DBT is extremely structured, and involves not only therapy sessions but also a regular "skills-building" group.

Dialectical Behavioral Therapy integrates "mindfulness" practices from the Zen Buddhist tradition — and thus, is one of the first types of cognitive-behavioral therapy to integrate spiritually-inspired practices. Since the development of DBT, additional types of spiritually-friendly CBT have been developed.

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Perhaps the newest entry in the cognitive-behavioral therapy tradition is Acceptance and Commitment Therapy, or ACT. Like Dialectical Behavioral Therapy, ACT integrates meditation-oriented mindfulness practices into therapy.

One of the key approaches in ACT is the process of "cognitive defusion." ACT therapists find that when we're upset, we usually become tightly "fused" with our thoughts. ACT teaches people how to peacefully step back and acceptingly observe what they are thinking. As clients do this, they are then able to actively move in the direction of their goals and values.

Along with DBT and Mindfulness-Based Cognitive Therapy (MBCT), ACT is considered part of a spiritually-friendly "third wave" within the cognitive-behavioral tradition.

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