Cognitive Therapy for Different Populations and in Different Settings

Given the common features of cognitive therapy and these widely differing areas of application, it is not surprising that cognitive therapy has evolved in several different formats to ensure it is acceptable and effective to a range of groups of people (children, adolescents, adults, older adults and people with learning disabilities), in different therapy formats (self-help, individual, couples, families, groups, organisations) and across different levels of service delivery (primary, secondary and tertiary care).

There is increasing interest in cognitive therapy for children, in part because the approach appears acceptable to children and adolescents and pragmatic in these service settings (Friedberg & McClure, 2001). A comprehensive review of the outcome literature for children and adolescents suggests that cognitive therapy is effective for generalised anxiety, simple phobias, depression and suicidality (Fonagy et al., 2002; Kazdin & Weisz, 1998). As with adult populations, the evidence base is particularly compelling for depression (Lewinsohn & Clarke, 1999). Cognitive therapy has been adapted for older adults (Laidlaw et al., 2003) and for people with learning disabilities and mental retardation (Kroese, Dagnan & Loumides, 1997).

Cognitive therapy has been disseminated most effectively through a range of self-help books, most notably David Burns' (1989) Feeling Good Handbook and Greenberger & Padesky's (1995) Mind Over Mood. There is some evidence that this format is effective for individuals with depression (Jamison & Scogin, 1995). More recently computerised and Web-based versions of cognitive therapy have been developed. Essentially this involves delivering cognitive therapy via an interactive computer interface, either on a PC, through the Web, or in some cases through automated telephone systems. The UK National Institute for Clinical Excellence has reviewed the evidence base for this approach, concluding that computer-aided delivery of cognitive therapy may have potential as an option in certain groups of clients, and it may be most suitably delivered as part of a stepped care protocol. It concluded that the evidence base was limited and further research is indicated. It remarked that computerised approaches potentially increase flexibility for clients about the rate and timing of therapy, overcome client-therapist relationship problems, but might present problems of literacy, cultural background and acceptability of the format to a broad group of potential clients.

Individual cognitive therapy is the most common format, although couples, family, groups and organisational consultancy formats have also been developed. In individual therapy it is common to involve spouses, friends, parents or others, either as informants or as people who can help the client change (see Baucom et al., 1998). Cognitive couple therapy has been shown to be acceptable and effective in depression in one spouse, chronic interpersonal problems, and marital problems (Baucom et al., 1998; Dattilio & Padesky, 1990; Epstein & Baucom, 1989). Cognitive therapy in group format has been shown to be acceptable and effective for depression (Robinson, Berman & Neimeyer, 1990) and social phobia (Heimberg etal., 1993).

Twenty-five years of increasingly sophisticated research suggests that cognitive therapy is effective to a clinically significant degree for a majority of patients with a variety of presenting problems in a range of populations and settings. An evidence-based conclusion is that cognitive therapy is a treatment of choice for people diagnosed with depression, generalized anxiety, panic, bulimia nervosa, psychosis and a range of somatoform disorders. More recently, preliminary outcome studies suggest cognitive therapy is a promising intervention for people diagnosed with personality disorders and substance misuse, but further research is indicated.

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