Limits of the Model

Cognitive therapy presents a particular model of psychopathology and treatment and is included in the broader class of psychotherapies referred to as the cognitive–behavioral therapies (K. S. Dobson, 2010). Some of the other treatment methods within this broader class include rational emotive behavior therapy, problem-solving therapy, and stress inoculation therapy. A frequent question in this field concerns the similarities and differences between cognitive therapy and CBT. Unfortunately, no definitive clarification of the boundary between these therapies can be made. The former tends to emphasize the schematic and core belief issues that underlie specific problems and symptoms, whereas CBT is somewhat broader in its focus on current adaptive functioning and development. Both approaches include cognitive and behavioral aspects in their conceptualization of problems and in their treatment technology. In some respects, cognitive therapy has “become” the field of CBT, since it dominates many of the conceptual and treatment developments. The distinction between the approaches may become a matter of linguistics rather than a practical reality.

Failure, Relapse, and Recurrence

Even while cognitive therapy enjoys considerable outcome success, one of the difficulties of the approach is the limits of its efficacy. The success rates for some anxiety disorders can reach as high as 90% (i.e., 90% of patients who complete treatment will lose their anxiety disorder diagnosis), but the success rates for other disorders are considerably lower (Epp & Dobson, 2010). Furthermore, the success rates are for patients who complete treatment; dropout is a problem in a number of treatment areas. Finally, while there is evidence that cognitive therapy reduces the likelihood of relapse in some areas, actual rates of relapse and recurrence suggest that further work is needed in modifying risk factors.

The above problems are not unique to cognitive therapy. They speak to the heterogeneity of mental disorders and the probability that any one conceptual model might not account for the expression of different disorders. A wide range of biological, psychosocial, and social risk factors have been identified for many disorders (e.g., K. S. Dobson & Dozois, 2008), and cognitive therapy probably does not adequately address all of these risk factors. Whether cognitive theory can evolve and incorporate other elements of the theory to account for the risk for various disorders more fully and whether such theoretical and treatment expansion leads to more comprehensive treatments with higher success rates or lower relapse rates remain to be seen. In the short term, the relatively high rates of treatment failure and relapse and recurrence for various disorders speak to the need for ongoing theory development, treatment expansion, and clinical trials.

Sociocultural Adaptations and Diversity Considerations

The relative success of cognitive therapy among the various schools of psychotherapy carries with it several risks. For example, the approach may be developed in one cultural context but applied to other cultures in an indiscriminate fashion. Within a specific society, a treatment technique may be developed for work with adults but applied to children in a way that may not be developmentally appropriate. Similarly, treatments developed in a predominantly female (or male) sample may not work with the other gender. A treatment model or technique may be developed for one clinical condition but applied to others without proper consideration or evaluation. All of these issues are examples of how well cognitive therapy generalizes from one culture, group, or condition to another. From another perspective, the ability to get similar results in various groups speaks to the robustness or generalizability of cognitive theory and therapy.

Humans vary dramatically in many dimensions, including age, gender, mental and physical well-being or challenges, sexual orientation and behavior, social and cultural history and experience, linguistic heritage, socioeconomic status, and more. Cognitive theory and therapy methods are most often developed in one particular context or for one particular group. Thus, it is critical that the tenets and outcomes of theory and therapy be evaluated with regard to their sociocultural appropriateness, acceptability, and efficacy when applied to other groups (Duckworth, 2009; Martell, Safren, & Prince, 2004; Pantalone, Iwamasa, & Martell, 2010; Reinecke & Simmons, 2005). The remarkable explosion of the cognitive and CBTs around the world signals that these approaches likely have considerable generalizability and can be applied broadly. However, the extent to which cultural or any other diversity consideration might limit success needs to be explored systematically. In this way, cultural or other adaptations to cognitive therapy can be made so that the approach is maximally effective wherever it is used.