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ANNUAL
REVIEWS Further
Cognitive Therapy: Current
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Status and Future Directions
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• Top cited articles Aaron T. Beck1 and David J.A. Dozois2
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1
• Our comprehensive search Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania;
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email: abeck@mail.med.upenn.edu
2
Department of Psychology, University of Western Ontario, London, Ontario, Canada;
email: ddozois@uwo.ca

Annu. Rev. Med. 2011. 62:397–409 Keywords

First published online as a Review in Advance on
August 3, 2010
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cognitive vulnerability, psychotherapy, treatment outcome, cognitive
behavior therapy
Abstract
Cognitive therapy is a system of psychotherapy with a powerful theoret-
ical infrastructure, which has received extensive empirical support, and
a large body of research attesting to its efficacy for a wide range of psy-
chiatric and medical problems. This article provides a brief overview
of the conceptual and practical components of cognitive therapy and
highlights some of the empirical evidence regarding its efficacy. Cog-
nitive therapy (often labeled generically as cognitive behavior therapy)
is efficacious either alone or as an adjunct to medication and provides a
prophylaxis against relapse and recurrence.

397
 ME62CH28-Beck ARI 4 December 2010 14:36
OVERVIEW
From its inception more than 45 years ago
(1–3), cognitive therapy has been theory driven.
Cognitive schema:
a well-organized Specifically, Beck’s objectives for deriving and
cognitive structure of evaluating this system of psychotherapy in-
stored information and
volved an overall plan to construct a compre-
memories that forms
the basis of core beliefs hensive theory of psychopathology that maps
clearly onto the treatment approach, to inves-
about self and others
tigate scientific support for the theory, and
to test the efficacy of therapeutic interven-
tions (3, 4). Cognitive theory and therapy were
first developed for depression (1, 2) and later
systematically applied to suicide prevention
(5), anxiety disorders (6), personality disorders
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(7), substance abuse (8), and, most recently,
schizophrenia (9, 10).
Cognitive therapy (CT), often discussed un-
der the generic label cognitive behavior therapy
(CBT), is now widely represented in training
programs in psychology, psychiatry, medicine,
social work, nursing, and other allied health
professions that value evidence-based practice
(11). CT and CBT have been described as “the
fastest growing and most heavily researched
systems of psychotherapy on the contemporary
scene” (12, p. 332). This article provides a brief
overview of the conceptual, practical, and em-
pirical aspects of CT. After highlighting some
of its basic concepts and the research pertain-
ing to Beck’s cognitive theory, we discuss the
general approach to treatment and review the
literature on its efficacy. We conclude by out-
lining some directions for future research.
COGNITIVE THEORY
Cognitive theory is based on the presumption
that information processing is crucial for
human adaptation and survival. Without the
ability to process information from the envi-
ronment, synthesize it, and formulate a plan
for dealing with it, we would not survive. The
cognitive (or information processing) system is
intricately tied to other affective, motivational,
and behavioral repertoires. Each of these
repertoires, or systems, serves an individual
function and also operates in synchrony toward
398 Beck · Dozois
coordinated, goal-oriented strategies (e.g.,
approaching pleasure, avoiding pain) (13, 14).
The fight-flight response, for instance, arises
from four systems (13): cognitive (perception of
threat), affective (feelings of anxiety or anger),
motivational (the impulse to confront or flee
the threatening stimulus), and behavioral (the
implementation of action). In this construct,
onset of a particular condition (e.g., panic
disorder) is believed to occur when these
different systems shift from a fairly quiescent
state to a highly activated state. In the example
of panic disorder, this might occur when the
fight-flight response is activated by “false
alarms” (e.g., misperceiving bodily sensations
as harmful to the organism). Cognitive theory
suggests that psychopathology is characterized
by the activation of a conglomerate of related
or contiguous dysfunctional beliefs, meanings,
and memories that operate in coordination
with affect, motivation, behavior, and physio-
logical responses. Different psychopathological
conditions are associated with specific biases
that influence how an individual incorporates
and responds to new information.
According to Beck’s model (1–3, 6, 15, 16),
the cognitive appraisal of internal or external
stimuli influences and is, in turn, impacted by
these other systems. Thus, although cognition
plays a key role in this model (i.e., the as-
signment of meaning is crucial to understand-
ing maladaptive behavior), it is recognized that
mental health problems involve a complex in-
terplay among diverse and interrelated systems
(17).
Within the cognitive system are different
levels of cognition, ranging from surface-level
thoughts to “deeper” cognitive schemas (18,
19). Cognitive schemas are organized structures
of stored information that contain individuals’
perceptions of self and others, goals, expecta-
tions, and memories. These elements are well-
organized within the cognitive structure (20)
and influence the screening, coding, categoriza-
tion, and interpretation of incoming stimuli and
the retrieval of stored information. Schemas
are adaptive insofar as they afford efficient pro-
cessing of information; however, when they
 ME62CH28-Beck ARI 4 December 2010 14:36
become negatively biased, maladaptive, rigid,
and self-perpetuating, they can contribute to
psychopathology.
Maladaptive cognitive schemas are believed
to develop during early periods of the life
span and become increasingly consolidated and
organized as new experiences are assimilated
into the existing belief structure (3, 15). Poor
early attachment experiences and other adverse
events (e.g., childhood maltreatment), for ex-
ample, may contribute to the development of
a maladaptive belief system. Cognitive theory
is essentially a diathesis-stress model. In other
words, it is possible to have a maladaptive belief
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system and not exhibit symptoms so long as the
cognitive schema (and related systems) is not
activated. Once triggered by external events,
drugs, or endocrine factors, however, the cog-
nitive schema triggers a cascade of information-
processing biases (1, 4, 15, 16, 18). These may
be attention, memory, or interpretational bi-
ases. For instance, individuals with anxiety dis-
orders perceive themselves as vulnerable and
the world as dangerous. Such individuals at-
tend selectively to threat-pertinent information
at the expense of information that is inconsis-
tent with threat or information that suggests
one has sufficient resources for dealing with it.
An individual who is vulnerable to depression,
to consider another example, may have an un-
derlying belief that he or she is unlovable. This
belief may become especially salient when ad-
verse circumstances activate an underlying neg-
ative schema. Such an individual may then at-
tend selectively to and recall information that is
consistent with this negative view of self (e.g.,
paying attention to cues that are suggestive of
being unloved and minimizing information that
is inconsistent with that belief).
The activation of a maladaptive cognitive
schema, along with the ensuing information-
processing biases, is also apparent in more
surface-level cognitions or what are referred to
as automatic thoughts. This term refers to the
stream of positive and negative thoughts that
runs through an individual’s mind unaccom-
panied by direct, conscious deliberation. Al-
though such thoughts are more superficial and
proximal to a given situation than are other lev-
els of cognition, they are functionally related to
one’s deeper beliefs and schemas and seem to
Diathesis-stress
arise associatively as different aspects of one’s model:
core belief system are activated. a psychological theory
When negative cognitive schemas are acti- that predicts that
vated, as in depression, they are not only identi- psychiatric disorders
result from the
fiable but can be shown to have an influence on
interaction of a
information processing, as manifested by cog- predisposition (e.g.,
nitive biases, and have an impact on symptom genetic, cognitive
development. When a depressive episode has diatheses) and negative
remitted, the negative schemas are deactivated life events. When an
underlying
(or vice versa).
vulnerability is strong,
Another aspect of Beck’s model is content less stress is necessary
specificity (16, 17). That is, different emotional to trigger the behavior
experiences and forms of psychopathology are or disorder; when the
related to a unique cognitive profile or set of predisposition is weak,
a greater amount of
beliefs (see Table 1 for some examples of sys-
stress is typically
tematic biases associated with different disor- needed before an
ders). To illustrate, depression is related to individual develops the
thoughts and beliefs concerning personal loss, disorder
deprivation, and failure (15). Persons with clini- Automatic thoughts:
cally significant anxiety tend to overestimate the the flow of cognitions
probability of risk while simultaneously under- (considered the
cognitive byproducts
estimating their resources for coping with po-
of activated schemas)
tential threats. Their thoughts focus on themes that arise in our
of the self as vulnerable, the world as danger- day-to-day lives and
ous, and the future as potentially catastrophic are not accompanied
(6). A person with dependent personality disor- by direct deliberation
or volition
der has a view of the self as weak, helpless, and
incompetent (7).
The empirical literature has provided con-
siderable support for various aspects of Beck’s
cognitive theory. Hundreds of studies have
demonstrated that individuals filter informa-
tion and respond to stimuli in a way that is
consistent with their preexisting beliefs and
assumptions. Some research has also demon-
strated that negative cognitive biases precede
the development of anxious (e.g., 21) and de-
pressive (e.g., 22) symptoms. Supportive ev-
idence has been obtained for the ideas that
there are distinct levels of cognition that work
in synchrony to impact emotional and behav-
ioral responses and that an emotional experi-
ence or clinical disorder can be characterized by
a unique set of beliefs and automatic thoughts
(i.e., content specificity; see 16, 18). Schema
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 ME62CH28-Beck ARI 4 December 2010 14:36

Table 1 The cognitive profile of psychological disorders (14; reprinted with permission)
Disorder Systematic bias in processing information
Depression Negative view of self, experience, and future
Hypomania Inflated view of self and future
Anxiety disorder Sense of physical or psychological danger
Panic disorder Catastrophic interpretation of bodily/mental experiences
Phobia Sense of danger in specific, avoidable situations
Paranoid state Attribution of bias to others
Hysteria Concept of motor or sensory abnormality
Obsession Repeated warning or doubts about safety
Compulsion Rituals to ward off perceived threat
Suicidal behavior Hopelessness and deficiencies in problem solving
Anorexia nervosa Fear of being fat
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Hypochondriasis Attribution of serious medical disorder

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organization (see 18), activation (e.g., 23), and
the contribution of cognitive vulnerability to
the incidence of psychiatric disorders (e.g., 24)
have also been supported by empirical research.
COGNITIVE THERAPY
CT rests on three main propositions (25, 26):
 The access hypothesis: With appropriate
training, motivation, and attention, indi-
viduals can become aware of the content
and process of their thinking.
 The mediation hypothesis: The manner
in which individuals think about, inter-
pret, and construe events influences their
emotional and behavioral responses.
 The change hypothesis: Individuals can
become more functional and adaptive by
intentionally modifying their cognitive
and behavioral responses to the circum-
stances they face.
Cognitive therapy is a structured, collaborative
process that helps individuals to consider both
the accuracy and usefulness of their thoughts
through processes of exploration (determin-
ing one’s idiosyncratic meaning system and
maladaptive beliefs), examination (reviewing
the evidence for and against a particular be-
lief and considering alternative interpretations
or explanations), and experimentation (testing
the validity of one’s belief system) (27). This
general approach is used early in therapy to
target more proximal and surface-level cogni-
tions (e.g., automatic thoughts, dysfunctional
attitudes) and in later sessions to modify deeper
cognitive structures and core beliefs.
CT is not the replacement of negative
thoughts with positive ones; rather, it aims to
help individuals shift their cognitive appraisals
from ones that are unhealthy and maladaptive
to ones that are evidence-based and adaptive.
Essentially, patients learn how to become sci-
entific investigators of their own thinking—to
treat thoughts as hypotheses rather than as
facts and to put these thoughts to the test.
Framing a belief as a hypothesis provides an
opportunity to test its validity, affords patients
the ability to consider alternative explanations,
and permits them to gain distance from a
thought to allow more objective scrutiny (11).
Patients learn to modify their thoughts so that
they are congruent with existing evidence.
When thoughts are aligned with evidence, and
negative feelings exist, the cognitive therapist
helps patients to deal with emotional sequelae
by introducing coping strategies, fostering skill
development and/or problem solving.
Cognitive therapists help patients to move
through the process of exploration, exami-
nation, and experimentation using collabora-
tive empiricism, guided discovery, and Socratic

400 Beck · Dozois

 ME62CH28-Beck ARI 4 December 2010 14:36
dialogue. Collaborative empiricism means that
the patient and the therapist become coinvesti-
gators both in ascertaining the goals for treat-
ment and investigating the patient’s thoughts.
Methods of guided discovery are used to help
patients to test their own thinking through per-
sonal observations and experiments rather than
via cajoling or persuasion. Through this pro-
cess, patients are able to shift from “a convic-
tion mode to a questioning mode” (28, p. 216).
In addition, by collaboratively designing new
experiences to try out (called behavioral exper-
iments), patients are able to acquire a different
perspective on themselves and their situations
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(14). Socratic dialogue is a method of guided
discovery in which the therapist asks a series
of carefully sequenced questions to help define
problems, assist in the identification of thoughts
and beliefs, examine the meaning of events, or
assess the ramifications of particular thoughts
or behaviors.
CT is time limited. The average length
of CT in outcome studies is between 12 and
24 weekly sessions, although there is more
variability in clinical practice (25). The initial
sessions are often focused on enhancing the
therapeutic alliance, identifying the specific
problem(s) that brought the patient into treat-
ment, socializing the patient to the cognitive
understanding of psychopathology, and symp-
tom relief via behavioral strategies. At this time,
the therapist plays a more active role than the
patient. As therapy progresses, the emphasis
shifts from symptom amelioration to the exam-
ination and modification of the patient’s pat-
terns of thinking, and the patient assumes a
more active role in identifying problems and so-
lutions and developing homework assignments.
Toward the end of therapy, sessions are usually
spread apart so that the patient can consolidate
gains and increase his or her confidence in the
application of newly learned skills. “Booster”
sessions are frequently scheduled one or two
months after the end of therapy.
Homework assignments (also called action
plans) are an important component of CT.
Homework provides opportunities to enhance
the mastery and generalization of skills learned
in the weekly therapy session by applying them
in the “real world,” and improves treatment
outcome (29).
The specific techniques utilized in CT tend
to vary depending on the disorder being treated
and the case formulation. They typically in-
clude (a) establishing the therapy relationship,
(b) behavioral change strategies, (c) cognitive
restructuring strategies, (d ) modification of
core beliefs and schemas, and (e) prevention of
relapse/recurrence. Given that it is not possible
to describe the science and art of CT in this
brief article (interested readers are referred to
more detailed discussions in 11, 14, 25, 30), we
instead provide a capsule summary of these five
components.
The therapeutic relationship is a key in-
gredient of all psychotherapies, including CT.
There appears to be a bidirectional relationship
between the patient’s perception of the thera-
peutic alliance and outcome: The connection
between patient and therapist may facilitate
change, and symptom change, in turn, en-
hances the bond between patient and therapist
(11). Many of the basic interpersonal vari-
ables common to other psychotherapies (e.g.,
warmth, accurate empathy, unconditional pos-
itive regard) serve as an important foundation
for cognitive and symptomatic change. As Beck
et al. (15) noted, however, these characteristics
“in themselves are necessary but not sufficient
to produce an optimum therapeutic effect”
(p. 45).
Behavioral strategies are used to test and al-
ter automatic thoughts and assumptions and to
facilitate new learning. In a behavioral experi-
ment, for instance, a patient may predict an out-
come based on his or her automatic thoughts
and beliefs, conduct an agreed-upon behavior,
and evaluate the evidence in the context of the
results of this new experiment. A related ap-
proach is hypothesis testing, which has both
cognitive and behavioral components. A resi-
dent who insists, “I am not a good doctor,” for
example, can be asked to generate a list of char-
acteristics or criteria that would constitute be-
ing a good physician (e.g., ability to establish
rapport; knowledge base; capacity for making
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 ME62CH28-Beck
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decisions under pressure). The “experiment”
would then involve collecting data by monitor-
ing his or her behavior and seeking input from
colleagues and supervisors which may help to
modify this conviction (e.g., “I am a good doctor
for my level of experience and training”) (14).
Other behavioral techniques are used to alter
the patient’s reinforcement schedule (thereby
increasing pleasure or mastery), habituate to
feared stimuli (exposure therapy), relax (pro-
gressive muscle relaxation), or prepare for up-
coming situations (behavioral rehearsal). Given
that these strategies are used to foster cognitive
change, the therapist routinely assesses the pa-
tient’s perceptions, thoughts, and conclusions
after each experiment (14).
Cognitive restructuring strategies are also
used to help patients identify and test the va-
lidity of their cognitions. One important tech-
nique for eliciting and evaluating negative auto-
matic thoughts is the Daily Record of Thoughts
(DRT). A DRT entry consists of three columns
representing the situation encountered, the
emotion or symptoms experienced, and associ-
ated thoughts. Once patients are reliably able to
identify the automatic thoughts that carry the
greatest emotional charge, the process of an-
swering back to these thoughts (or putting them
on trial) can begin. This process often involves
writing down the evidence that pertains to a
particular belief and developing an alternative
thought that incorporates the facts that bear
on the belief. By writing down an activating
event, the mediating thoughts, and the ensuing
emotional response, the patient maintaining a
DRT achieves more objectivity about and dis-
tance from his or her thoughts. The evidence
pertaining to a particular belief is then exam-
ined using guided discovery and collaborative
empiricism.
Specifically, patients are asked a number of
questions, including: “What is the evidence for
or against this belief?” “What are the alter-
native ways to think about this situation?” “If
my best friend or loved one knew that I had
this thought, what would he or she say to me?”
“What would it mean about me even if this par-
ticular thought was true?” (25, 30–32). From
402 Beck · Dozois
this analysis of the evidence, patients are then
taught to generate alternative thoughts that in-
corporate the evidence and lead to a shift in
their emotional experience. If a given thought
is inconsistent with the weight of factual evi-
dence on the subject (e.g., “I am unlovable”),
the therapist helps the patient to alter and re-
align the thought so that it is evidence-based
and, consequently, more adaptive and helpful.
Sometimes collecting more information or con-
ducting a behavioral experiment is also used to
test a certain belief.
After a number of sessions using the DRT,
the therapist and patient may notice a consistent
pattern in the types of automatic thoughts that
are elicited. This is because automatic thoughts
and cognitive distortions (e.g., “If I fail at X,
then I am not worthwhile”) are functionally re-
lated to deeper core beliefs and schemas. The
modification of these core beliefs and schemas
is believed to result in the most generaliz-
able change and the greatest prevention of re-
lapse (33, 34). These “deeper” beliefs are tested
and reconfigured using Socratic dialogue and
guided discovery, role plays, behavioral exper-
iments, and other change strategies (11, 15,
25, 30).
The final sessions of treatment are focused
on consolidating the skills learned and on
the prevention of relapse/recurrence. This in-
cludes, among other things, a gradual titra-
tion of sessions and spreading apart of their
timing, reviewing the treatment strategies that
were utilized and were most helpful, creating
a plan for the future, discussing feelings about
the termination of therapy, preparing for set-
backs, identifying possible triggers of relapse,
and ensuring that the patient makes internal at-
tributions for change.
EMPIRICAL EVIDENCE FOR
COGNITIVE THERAPY
CT/CBT is one of the most actively researched
psychotherapies (35) and has received consis-
tent empirical support for a host of mental
health problems and conditions (36, 37). We
focus first on the efficacy of CT for depression,
 ME62CH28-Beck ARI 4 December 2010 14:36
as this has been most extensively studied, and
also highlight findings for other psychiatric dis-
orders and medical illnesses.
CT for Unipolar Depression
More than 75 clinical trials and numerous meta-
analyses have been published on CT for unipo-
lar depression (35). For an acute episode of
depression, the response achieved with CT is
similar to that achieved with behavior therapy
(38), other bona fide psychological treatments
(39), and antidepressant medication, and all of
these produce results superior to placebo (see
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27, 40). Early findings (41) suggesting that CT
was not effective for severe depression (42) have
generated considerable controversy among re-
searchers, and the perception that CT is not
effective for severe depression has persisted
despite compelling data to suggest otherwise
(see 11 for review). DeRubeis et al. (43), for
example, conducted a mega-analysis in which
they pooled the data from four related tri-
als and found that CT was as effective as an-
tidepressants (imipramine and nortripyline) for
the treatment of severely depressed individu-
als. More recent studies have also demonstrated
that CT and pharmacotherapy (paroxetine) are
equally effective for severe depression (44, 45).
The weight of evidence suggests that CT/CBT
is efficacious for depression, though it remains
possible that the effect may be somewhat over-
estimated as a result of publication bias (e.g.,
the file-drawer effect; see 46).
In addition to its efficacy for the acute phase
of major depressive disorder, CT also carries
an advantage, relative to antidepressant medi-
cation, for the prevention of relapse. Gloaguen
et al. (47), for instance, reported that the av-
erage risk of relapse (based on follow-up pe-
riods of one to two years) was 25% following
CT compared to 60% following antidepres-
sant medication. Some studies also indicate that
patients who receive CT alone are no more
likely to relapse after treatment than are those
who continue to receive medication (45, 48).
Hollon et al. (45) found equal outcomes be-
tween medication and CT in the acute phase of
treatment, but a lower relapse rate for CT com-
pared to continuance medication.
Consistent with these findings are studies
that have examined potential mechanisms for
the prophylactic benefits of CT. It appears that
CT and antidepressant medication may both
change certain aspects of negative thinking
(such as information processing, automatic
thoughts, and dysfunctional attitudes; e.g., 22,
33) but that CT may further modify some of
the “deeper” cognitive structures (e.g., reduced
activation of negative thinking following a
negative mood manipulation1 in CT relative
to pharmacotherapy) that give rise to relapse
and recurrence (23, 33, 34, 49). Several studies
have also assessed neuroimaging changes in
cognitive therapy (50). Goldapple et al. (51), for
example, examined neurobiological responses
to CT (in unmedicated depressed outpatients)
and compared these findings to an independent
sample of individuals treated with selective
serotonin reuptake inhibitors (SSRIs). Dif-
ferential pre- versus post-treatment changes
in brain metabolic activity (measured by
positron emission tomography) were obtained
in individuals treated with CT compared to
those treated with antidepressant medication.
These researchers proposed that a top-down
(cortical-limbic) therapeutic mechanism may
have been active in CT, whereas a bottom-up
(limbic-cortical) mechanism may have been
active in antidepressant treatment.
CT for Other Psychiatric Disorders
Butler et al. (35) reviewed meta-analyses of
treatment outcome for CT/CBT for a num-
ber of psychological disorders. A total of 16
methodologically rigorous meta-analyses were
identified from 1967 to 2004, which incorpo-
rated 9,995 research participants in 332 stud-
ies. The review focused on effect sizes found by
studies that compared outcomes of CT/CBT
1
A negative mood state is induced by prompting research
participants to think of a sad time in their lives, by listening
to sad music, etc.
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 ME62CH28-Beck
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ARI 4 December 2010 14:36
with outcomes for control groups, providing an
overview of the efficacy of CT/CBT. Large ef-
fect sizes were obtained for patients with unipo-
lar depression, generalized anxiety disorder,
panic disorder, social anxiety, and childhood
internalizing problems (the latter included de-
pressive, anxious, and somatic disorders). Mod-
erate effect sizes were found for patients treated
for couple distress, anger, childhood somato-
form disorders, and chronic pain. Small effect
sizes were obtained for recidivism in sexual of-
fenders. CBT also showed promising results as
an adjunct to medication for schizophrenia (10).
Epp & Dobson (40) recently reviewed the
treatment-outcome literature for CT/CBT and
summarized the meta-analytic data according
to absolute efficacy (the extent to which CBT
demonstrates superior outcome to no treat-
ment, waitlist controls, or treatment as usual),
efficacy relative to pharmacotherapy, and effi-
cacy compared to other forms of psychotherapy
(see Table 2). Considerable empirical support
has accumulated for the efficacy of CT/CBT.
For some disorders (e.g., some anxiety disor-
ders, bulimia nervosa), the evidence is com-
pelling enough to suggest that CT/CBT should
be considered the treatment of choice. The
literature also suggests that CT/CBT is at
least as effective as medication for a range of
problems, although direct comparisons are not
found for some disorders (e.g., bipolar disorder,
psychosis) for which CT/CBT is used adjunc-
tively (25). A recent meta-analysis of CT/CBT
in the treatment of schizophrenia, severe de-
pression, and bipolar disorder was less positive
(52), suggesting that CT/CBT is no more ef-
fective than nonspecific interventions for the
treatment of schizophrenia, although method-
ological flaws in the meta-analysis tend to vitiate
the findings (53).
CT for Medical Illnesses
CT/CBT is also effective for the treatment of
anxiety and depression that are comorbid with
medical problems (54). In addition, a number
of randomized controlled trials have reported
benefits of CT/CBT for a wide range of
404 Beck · Dozois
physical illnesses including chronic pain, back
pain, sleep disorders, fatigue and functional
impairments related to cancer, health-related
anxiety, rheumatoid arthritis, chronic fatigue
syndrome, fibromyalgia, irritable bowel syn-
drome, hypertension, tinnitus, headaches,
sexual dysfunctions, and various neurological
conditions (54, 55). CT/CBT has demon-
strated efficacy for a number of psychological
outcome variables (e.g., distress, attitudes,
adherence to treatment regime, improved
coping with pain) as well as physiological in-
dices that are impacted by stress (e.g., lowered
blood pressure, improved immune response;
see Reference 54 for review). For some ill-
nesses, there have been a sufficient number
of studies to warrant systematic reviews and
meta-analyses. This literature demonstrates
various biopsychosocial benefits of CT/CBT
for back pain (56, 57), hypochrondriasis (58),
irritable bowel syndrome (59), chronic fatigue
(58, 60), fibromyalgia (61), headache (62),
insomnia (63, 64), adjustment to cancer (65,
66), and the management of diabetes (67).
SUMMARY AND
FUTURE DIRECTIONS
Considerable empirical evidence has accumu-
lated that supports the theory and practice of
CT, and this model has been expanded over
time to incorporate evidence from experimen-
tal cognitive science and the neurosciences (13,
16, 68). Moreover, several official reports in
the United Kingdom and the United States
have recommended the use of CT/CBT for a
number of common psychiatric conditions (4).
Notwithstanding these treatment recommen-
dations and the wealth of research underlying
CT, it is not a panacea for all mental health
problems (e.g., 69). For example, more purely
behavioral interventions sometimes perform as
well as CT/CBT for depression and anxiety in
psychotherapy outcome trials. It is important
to point out, however, that the use of behav-
ioral interventions has always been part and
parcel of CT proper (15). In addition, the the-
ory states that whatever treatment is used so
 ME62CH28-Beck ARI 4 December 2010 14:36

Table 2 Summary of efficacy findings by disorder or problem (40; reprinted with permission)
Efficacy relative
Absolute Efficacy relative to other
Disorder Treatment efficacy to medications psychotherapies
Unipolar depression CBT + + 
Bipolar disorder∗ CBT + =
Specific phobia Exposure and cognitive ++ + +
restructuring
Social phobia Exposure and cognitive ++  
restructuring
Obsessive-compulsive disorder Exposure and response + +
prevention and cognitive
restructuring
Panic disorder Exposure and cognitive ++  +
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restructuring
Chronic post-traumatic stress Exposure and cognitive + =
disorder techniques
Generalized anxiety disorder CBT + + +
Bulimia nervosa CBT + + +
Binge eating disorder CBT + =
Anorexia nervosa CBT + + =
Schizophrenia∗ CBT + +
Marital distress CBT + 
Anger & violent offending CBT +
Sexual offending CBT + −∗∗ +
Chronic pain CBT + 
Borderline personality disorder CBT + 
Substance-use disorders CBT + =
Somatoform disorders CBT + + +
Sleep difficulties CBT + + +

Symbols: A blank space indicates insufficient or no evidence; –, negative evidence; +, positive evidence; = , approximate equivalence; ++, treatment of
choice;  equivocal evidence; CBT, efficacy of specific components unknown; ∗ , CBT is typically used as an adjunct to medication in these disorders;
∗∗
, efficacy relative to physical treatments (i.e., surgical castration and hormonal treatments).

that the patient improves (or if improvement
occurs via spontaneous remission), the negative
beliefs must also normalize. Indeed, Harmer
et al. (22) recently found that the administra-
tion of antidepressant medication modulated
emotional processing in depressed individuals
prior to shifts in their mood state or symptoms.
Such findings support the primacy of cognition
in therapeutic change and are consistent with
the idea that there are myriad ways in which to
modify cognition. In addition to altering infor-
mation processing, however, we contend that
CT also produces shifts in “deeper” levels of
cognition (23, 33) and that targeting this depth
of change may account for reduced relapse rates
in CT relative to medication.
There are a number of important future di-
rections for the field. During the past couple
of decades, we have witnessed a tremendous in-
crease in multiwave2 longitudinal studies that
2
Multiple points of assessment, not just pre- and post-
intervention.

www.annualreviews.org • Cognitive Therapy 405

 ME62CH28-Beck ARI 4 December 2010 14:36

have supported the diathesis-stress model of
cognitive vulnerability (18). Researchers are
also better understanding gene-environment
interactions in the context of psychopathology.
For example, a replicable relationship has been
found between negative cognitive processing
and the short version of the serotonin trans-
porter gene (68). Additional empirical work is
necessary to further elucidate how genetic, neu-
rophysiological, environmental, and cognitive
factors contribute to psychopathology and to
understand the intricate relationships among
cognitive, affective, motivational, and behav-
ioral systems. Future research will no doubt also
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clarify the important mechanisms of change in
CT. Some studies have, indeed, suggested that
cognitive change is an important mediator of
symptom change (11, 19, 33), but additional re-
search is needed to ensure that these findings
are robust and, if they are, to determine which
strategies (and psychotherapeutic doses) pro-
duce the most stable cognitive change. Enor-
mous strides have been made in understanding,
evaluating, and refining CT over the past four
and a half decades. We believe that similar fu-
ture progress will be made in improving our
knowledge base of cognitive vulnerability and
optimizing the delivery of CT.

SUMMARY POINTS
1. CT/CBT is the fastest growing and most researched contemporary system of
psychotherapy.
2. The empirical literature has provided considerable support for Beck’s cognitive theory
and therapy.
3. Three main propositions in CT are the access hypothesis (it is possible for individuals to
become aware of the content and processing of their thinking), the mediation hypothesis
(the way in which individuals think about themselves and their circumstances impacts
subsequent emotional and behavioral responses), and the change hypothesis (by modi-
fying cognitive and behavioral responses, an individual can become more functional and
adaptive).
4. The main techniques used in CT focus on establishment of the therapeutic relationship,
behavioral change strategies, cognitive restructuring, the modification of core beliefs and
schemas, and the prevention of relapse and recurrence.
5. A key advantage of CT is that it effectively treats the acute episode of psychiatric disorders
(with or without medication) and provides a prophylaxis against relapse.

DISCLOSURE STATEMENT
Aaron T. Beck is President Emeritus of the Beck Institute for Cognitive Therapy, a nonprofit
organization. He has no financial interest in this organization.

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Cognitive Therapy: Current Status and Future Directions
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Indexes

Cumulative Index of Contributing Authors, Volumes 58–62 p p p p p p p p p p p p p p p p p p p p p p p p p p p 475

Cumulative Index of Chapter Titles, Volumes 58–62 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 479

Errata

An online log of corrections to Annual Review of Medicine articles may be found at

http://med.annualreviews.org/errata.shtml

Contents vii