Cognitive Therapy and Research

, Volume 42, Issue 2, pp 115–120 | Cite as

Introduction to the Special Issue on Processes of Cognitive Behavioral Therapy: Does “Necessary, But Not Sufficient” Still Capture It?

  • Nikolaos Kazantzis


Research over the last four decades on cognitive behavioral therapy (CBT) is leading to a more comprehensive understanding of the mechanisms that underpin its efficacy. This introduction to the next generation of research on process offers a brief account of the evolution in the scientific foundations of CBT, to our current focus on treatment and in-session processes. It also provides a generic model for linking techniques with their target, uses, and treatment processes. In addition, how each component can be adapted according to CBT-specific elements of the client-therapist relationship (collaboration, empiricism, and Socratic dialogue) in a manner that is guided by the case conceptualization provides a more complex and comprehensive understanding of treatment delivery. The various research studies included within this special issue make important contributions to our understanding of the different ways in which both treatment and in-session processes are important to CBT.


Cognitive behavioral therapy Process Review 


The processes of Cognitive Behavioral Therapy (CBT; Beck et al. 1979) have historically received far less research attention than its outcomes. This is partly due to the necessary scientific work required in evaluating the efficacy of a psychotherapy and its modifications for various clinical disorders and populations (see reviews of meta-analyses in Butler et al. 2006; Hofmann et al. 2012). However, the client-therapist interaction was also conceived as something that exists as a facilitator of client progress towards treatment goals. Indeed, the facilitative behaviors of the therapist in themselves were deemed “necessary, but not sufficient to produce an optimum therapeutic effect” (Beck et al. 1979, p. 45).

Almost four decades later, there remains an ongoing discussion in the broader psychotherapy literature regarding the factors that account for most of the change in therapy; technique or relationship (Laska et al. 2014; Marcus et al. 2014; Tolin 2010). Both sides of the common factors debate now acknowledge that treatment outcome is determined both by technical and in-session process factors (DeRubeis and Lorenzo-Luaces 2017; Hofmann and Barlow 2014; Wampold et al. 2017). There is a need to move towards testable models that account for the intersection of technique and in-session process in order to fully understand treatment mechanisms.

Treatment Processes

The various treatments within the broad family of CBTs (Kazantzis et al. 2010), each emphasize somewhat different processes (Hayes and Hofmann 2017, 2018; Klepac et al. 2012), and there are suggestions of processes that can occur in the absence of cognition (Mennin et al. 2013, and see review in; Lorenzo-Luaces et al. 2015). The past two decades have witnessed some further advances, whereby core dimensions in psychopathology have been linked to treatment processes that are broadly relevant to the typical case presentation in the consultation office; where either full or partial DSM criteria for multiple disorders are met. Unified protocols that enable the therapist to both (1) develop an individual case formulation, and (2) select techniques that target those treatment processes to address the needs of each individual client (e.g., Barlow et al. 2011, 2017) have enhanced the richness and complexity of therapeutic work in clinical trials and brought them closer to practice guidelines for case formulation-driven CBT (Beck 2011; Persons 2012).

In-Session Processes

Ongoing empirical work on the alliance, as a generic (or common) element of the therapeutic interaction, has added sophistication to our understanding of the role of in-session process in CBT. For example, the alliance may be moderated by pre-existing client factors (Lorenzo-Luaces et al. 2014; Zalaznik et al. 2017), and may temporally precede symptoms in predicting subsequent symptomatic levels through treatment (Zilcha-Mano et al. 2014). Most recently, therapists adopting an alliance focused protocol in CBT facilitated changes in interpersonal process, and some of those improvements were linked to outcome (Muran et al. 2017).

However, few studies have sought to examine CBT-specific elements of the therapeutic relationship (i.e., collaborative-empiricism and Socratic dialogue, Kazantzis et al. 2017). The “Cognitive Therapy Scale” (CTS; Young and Beck 1980) that was originally developed to assess clinician skill in CBT delivery, and remains central to accreditation (i.e., Academy of Cognitive Therapy), includes several interpersonally focused items (i.e., feedback, understanding, interpersonal effectiveness, collaboration, and guided discovery). In addition, ratings of “excellent” on other CTS items (i.e., agenda, homework) are reserved for instances where there were optimal levels of client input or collaboration. However, many of these elements of the therapeutic interaction still lack focused assessment and empirical study. For example, while studies have considered the causal benefits of including homework in CBT (Kazantzis et al. 2010), correlational adherence-outcome relations (Kazantzis et al. 2016; Mausbach et al. 2010), and session-by-session benefits associated with homework adherence (Conklin and Strunk 2015), more research is needed on the in-session therapist behaviors that can facilitate engagement (Conklin et al. 2017; Startup and Edmonds 1994; and see; Shaw et al. 1999 for evidence of competence in structuring sessions as a predictor of outcomes). Similarly, existing measures may not fully capture the definition of collaboration in CBT (Kazantzis et al. 2015; Tryon and Winograd 2011), the evidence for Socratic dialogue is just emerging (Braun et al. 2014), and study of feedback processes has centered on symptom assessments (Knaup et al. 2009; Lambert and Shimokawa 2011).

The Nested Nature of Treatment and In-Session Processes

If, as researchers, our intention is to accurately define and measure all the processes that occur within the consultation room, so that we might understand their true relations in order to ultimately provide an empirical basis for informing their ideal configuration for a particular client at that particular point in therapy, then to begin, we need a means of describing the nested nature of techniques within processes, nested within therapy goals. While our techniques do not define our therapy (Petrik et al. 2013), the specific treatment processes within those techniques do. For example, a therapist elected to support a client through their emotional distress with the use of a thought record, which was targeted towards a specific automatic thought, and was used in four ways: (1) to link the thought with the predominant emotion in the situation; (2) understand the role of her beliefs in maintaining her mood state; (3) encourage an active approach in situations; and (4) identify the consequence of withdrawing from the situation. However, it would have also been possible for the same technique to be used to target situational antecedents and consequences in the client’s behavior, or the processes of thinking (or distortions). Furthermore, a therapist may have decided to use the technique to support different change processes, such as linking the client’s interpretation in the situation to their values, evaluate alternative behaviors/coping strategies, or encourage non-judgmental contact with cognition.

A further complexity is that the clinician will explain the rationale for the technique in different ways depending on the client, and indeed, collaborate with a client to a different extent in selecting and using the intervention. For example, at least initially, a more client-lead process may be indicated for an individual who has a history of being subject to control and other forms of abuse (i.e., a reduction in “team-work” or collaboration as defined in CBT, Dattilio and Hanna 2012). On the other hand, a client who has a strong sense of entitlement may benefit more from greater limit setting and a 50:50 balance in contributions, decision making, and responsibility for providing feedback, along with other behavioral expressions of collaboration (Kazantzis et al. 2017). Indeed, other CBT elements of in-session process, such as empiricism and use of Socratic dialogue also require adaptation based on the client’s relational history and belief system.

Figure 1 presents “the matrioshka process” (Kazantzis et al. 2017), which is a testable model of the use of techniques within CBT, while taking into account both treatment and in-session processes. The term “matrioshka process” originates from matryoshka dolls, which are Russian nesting dolls. The matrioshka process is composed of several observable in-session therapist behaviors in how techniques are used, in the same way that the matryoshka dolls are nested inside one another. The center of the technique would be the target (in the above example the patient’s automatic thought) which should be clearly linked to all the uses in the technique. The outermost context includes the clarity with which the therapist provides an overt rationale for the technique (treatment process) and their attention to alliance and CBT specific elements of the relationship. This level of clarity in the components that make up a technique’s mechanism for action is not only useful for the practicing clinician, it can enable more detailed assessments of treatment integrity.

Fig. 1

a Standard CBT session elements. b The Matrioshka process—an integrated process model of cognitive behavior therapy (Kazantzis et al. 2017)

Introducing the Articles in This Special Issue

The articles in this Special Issue of Cognitive Therapy and Research reflect the latest scientific work on treatment and in-session processes in CBT. The paper by Renna et al. (2018) presents two studies on attention shifting among those with generalized anxiety disorder, with implications for attention training in treatment. Then, a series of three papers are included that examine the alliance: (1) relationship between expectancies and outcome within unified and single diagnosis treatment protocols, and role of the working alliance as a mediator (Sauer-Zavala et al. 2018); (2) pretreatment client interpersonal problems as moderators of alliance-outcome relations (Zilcha-Mano et al. 2018); and (3) an examination of the state like nature of the alliance (Zilcha-Mano et al. 2018).

Two articles then examine the process of facilitating engagement with therapeutic tasks, also referred to as homework in CBT. The paper by Crawford et al. (2018) reviews homework compliance and the processes involved in maximizing compliance in CBT for anxious youth, including the alliance and therapist behaviors. The paper by Hoet et al. (2018) utilizes experience sampling in a study of skill use in relation to depressed individuals’ emotional state and treatment type.

Turning to other in-session processes, the paper by Westra and Norouzian (2018) presents a review of the research on resistance and ambivalence, particularly with reference to the role of motivational strategies in CBT. Then, the paper by Hooke et al. (2018) examines a collaborative approach to collecting symptom information as feedback in CBT. Finally, an in-depth discussion of the issue’s contributions is provided by Lorenzo-Luaces and DeRubeis (2018).

Concluding Comments

While many CBT processes are yet to have been studied extensively, or at all, it is clear that a significant evidence base has been gained for those processes that have been studied. Given the compelling evidence for the overall efficacy of CBT across a range of disorder contexts, it is surprising that more research has not been undertaken to better examine time-varying and intersecting processes within CBT. Notable exceptions are the research programs represented in this special issue. We believe that we are only at the beginning of adequately studying the processes in CBT.


  1. Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74(9), 875–884. Scholar
  2. Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. New York, NY: Oxford University Press.Google Scholar
  3. Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.Google Scholar
  4. Beck, J. S. (2011). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford.Google Scholar
  5. Braun, J. D., Strunk, D. R., Sasso, K. E., & Cooper, A. A. (2014). Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression. Behaviour Research & Therapy, 70, 32–37. Scholar
  6. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. Scholar
  7. Conklin, L. R., & Strunk, D. R. (2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits? Behaviour Research & Therapy, 72, 56–62. Scholar
  8. Conklin, L. R., Strunk, D. R., & Cooper, A. A. (2017). Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression. Cognitive Therapy & Research. Scholar
  9. Crawford, E. A., Frank, H. E., Palitz, S. A., Davis, J. P., Kendall, P. C. (2018). Process factors associated with improved outcomes in CBT for anxious youth: Therapeutic content, alliance, and therapist actions. Cognitive Therapy & Research.
  10. Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavioral therapy. Journal of Clinical Psychology, 68, 146–158. Scholar
  11. DeRubeis, R. J., & Lorenzo-Luaces, L. (2017). Recognizing that the truth is unattainable and attending to the most informative research evidence. Psychotherapy Research, 27(1), 33–35. Scholar
  12. Hayes, S. C., & Hofmann, S. G. (2017). The third wave of CBT and the rise of process-based care. World Psychiatry, 16, 245–246.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Hayes, S. C., & Hofmann, S. G. (2018). Process-based CBT: The science and core clinical competencies of Cognitive Behavioral Therapy. Oakland CA: New Harbinger Publications.Google Scholar
  14. Hoet, A. C., Burgin, C. J., Eddington, K. M., & Silvia, P. J. (2018). Reports of therapy skill use and their efficacy in daily life in the short-term treatment of depression. Cognitive Therapy & Research.
  15. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy & Research, 36(5), 427–440. Scholar
  16. Hofmann, S. G., & Barlow, D. H. (2014). Evidence-based psychological interventions and the common factors approach: The beginnings of a rapprochement? Psychotherapy, 51(4), 510–513. Scholar
  17. Hooke, G. R., Sng, A. A. H., Cunningham, N. K., & Page, A. C. (2018). Methods of delivering progress feedback to optimise patient outcomes: The value of expected treatment trajectories. Cognitive Therapy & Research.
  18. Kazantzis, N., Cronin, T. J., Norton, P. J., Lai, J., & Hofmann, S. G. (2015). Reservations about the conclusions of the Interdivisional (APA Divisions 12 & 29) Task Force on Evidence-Based Therapy Relationships: What do we know, what don’t we know? Journal of Clinical Psychology, 71, 423–427. Scholar
  19. Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavior therapy: A clinician’s guide. New York: Guilford.Google Scholar
  20. Kazantzis, N., Petrik, A. M., Luong, H. K., & Hofmann, S. G. (2017). The Matrioshka process: An integrated process model of cognitive behavior therapy. Melbourne: Monash University.Google Scholar
  21. Kazantzis, N., Reinecke, M. A., & Freeman, A. (Eds.). (2010). Cognitive and behavior theories in clinical practice. New York: Guilford.Google Scholar
  22. Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17, 144–156.Google Scholar
  23. Kazantzis, N., Whittington, C. J., Zelencich, L., Norton, P. J., Kyrios, M., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47, 755–772. Scholar
  24. Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., et al. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687–697. Scholar
  25. Knaup, C., Koesters, M., Schoefer, D., Becker, T., & Puschner, B. (2009). Effect of feedback of treatment outcome in specialist mental healthcare: Meta-analysis. British Journal of Psychiatry, 195(1), 15–22. Scholar
  26. Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72–79. Scholar
  27. Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51, 467–481. Scholar
  28. Lorenzo-Luaces, L., & DeRubeis, R. J. (2018). Miles to go before we sleep: Advancing the understanding of psychotherapy by modeling complex processes. Cognitive Therapy & Research.
  29. Lorenzo-Luaces, L., DeRubeis, R. J., & Webb, C. A. (2014). Client characteristics as moderators of the relation between the therapeutic alliance and outcome in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 82(2), 368. Scholar
  30. Lorenzo-Luaces, L., German, R. E., & DeRubeis, R. J. (2015). It’s complicated: The relation between cognitive change procedures, cognitive change, and symptom change in cognitive therapy for depression. Clinical Psychology Review, 41, 3–15. Scholar
  31. Marcus, D. K., O’Connell, D., Norris, A. L., & Sawaqdeh, A. (2014). Is the dodo bird endangered in the 21st century? A meta-analysis of treatment comparison studies. Clinical Psychology Review, 34(7), 519–530. Scholar
  32. Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy & Research, 34, 429–438. Scholar
  33. Mennin, D. S., Ellard, K. K., Fresco, D. M., & Gross, J. J. (2013). United we stand: Emphasizing commonalities across cognitive-behavioral therapy. Behavior Therapy, 44, 234–248. Scholar
  34. Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2017). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology.Google Scholar
  35. Persons, J. B. (2012). The case formulation approach to cognitive-behavior therapy. New York: Guilford.Google Scholar
  36. Petrik, A. M., Kazantzis, N., & Hofmann, S. G. (2013). Distinguishing integrative from eclectic practice in cognitive behavioral therapies. Psychotherapy, 50(3), 392–397. Scholar
  37. Renna, M. E., Seeley, S. H., Heimberg, R. G., Etkin, A., Fresco, D. M., & Mennin, D. S. (2018). Increased attention regulation from emotion regulation therapy for generalized anxiety disorder. Cognitive Therapy & Research.
  38. Sauer-Zavala, S., Boswell, J. F., Bentley, K. H., Thompson-Hollands, J., Farchione, T. J., & Barlowa, D. H. (2018). Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: An investigation of mediation. Cognitive Therapy & Research.
  39. Shaw, B., Elkin, I., Yamaguchi, J., Olmsted, M., Vallis, T., Dobson, K.,.. . Imber, S. (1999). Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 67(6), 837–846. Scholar
  40. Startup, M., & Edmonds, J. (1994). Compliance with homework assignments in cognitive-behavioral psychotherapy for depression: Relation to outcome and methods of enhancement. Cognitive Therapy & Research, 18, 567–579.CrossRefGoogle Scholar
  41. Tolin, D. F. (2010). Is cognitive–behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30(6), 710–720. Scholar
  42. Tryon, G. S., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48(1), 50–57. Scholar
  43. Wampold, B. E., Flückiger, C., Del Re, A. C., Yulish, N., Frost, N., Pace, B., … Hilsenroth, M. (2017). In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy. Psychotherapy Research, 27, 14–32. Scholar
  44. Westra, H. A., & Norouzian, N. (2018). Using motivational interviewing to manage process markers of ambivalence and resistance in cognitive behavioral therapy. Cognitive Therapy & Research.
  45. Young, J. E., & Beck, A. T. (1980). Cognitive Therapy Scale: Rating manual. Philadelphia, PA: University of Pennsylvania.Google Scholar
  46. Zalaznik, D., Weiss, M., & Huppert, J. D. (2017). Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder. Psychotherapy Research, Advanced online publication.
  47. Zilcha-Mano, S., Dinger, U., McCarthy, K. S., & Barber, J. P. (2014). Does alliance predict symptoms throughout treatment, or is it the other way around? Journal of Consulting and Clinical Psychology, 82(6), 931. Scholar
  48. Zilcha-Mano, S., Lipsitz-Odess, I., & Errázuriz, P. (2018). When is it effective to focus on the alliance? Analysis of a within-client moderator. Cognitive Therapy & Research.
  49. Zilcha-Mano, S., Muran, J. C., Eubanks, C. F., Safran, J. D., & Winston, A. (2018). Not just a non-specific factor: Moderators of the effect of within- and between-clients alliance on outcome in CBT. Cognitive Therapy & Research.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cognitive Behavior Therapy Research Unit, School of Psychological Sciences and Monash Institute of Cognitive and Clinical NeurosciencesMonash UniversityMelbourneAustralia

Personalised recommendations