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Issue Focus

Applying Cognitive Behavioral Therapy to Promote Positive Change

08/2015

Cognitive behavioral therapy (CBT) has proved effective for a variety of problems in hundreds of studies over the past 25 years. The approach integrates elements of various therapeutic models that began to emerge in the 1970s, blending cognitive and behavioral theories. Cognitive therapy takes aim at thoughts and beliefs that undermine mental health and turns the focus toward solutions. Behavioral therapy concentrates on changing unhelpful habitual responses and reinforcing positive behaviors. Combining the two is especially effective, given the human cycle of thoughts that lead to emotions, which lead to behaviors, which reinforce those thoughts and emotions. Dozens of treatment models rely on these basic principles — even as research continues on CBT’s long-term benefits for various conditions.

A common form of psychotherapy for depression and anxiety, CBT has also become a popular component of programs that seek to address antisocial thoughts and actions, including violence and criminality, substance abuse, and other risky behaviors. Its power stems from the idea that troubled behavior can be traced back to patterns of thought and distorted perceptions that are learned rather than inherent, and therefore have the potential to change.

In the criminal justice system, CBT has been found to decrease an individual’s likelihood of returning to prison within a year by an average of 25 percent; the most effective programs cut recidivism by more than 50 percent. And as a treatment for depression and post-traumatic stress disorder in young people, randomized trials have shown CBT outperforming other approaches, reducing symptoms and behavioral difficulties among children and adolescents of diverse cultural and socioeconomic backgrounds. In general, stronger effects have been shown when implementation closely follows a structured curriculum.

MDRC is leading the implementation and evaluation of a range of projects that use various models of CBT with the goals of reducing recidivism, promoting employment, and fostering trauma recovery in adults and children. All CBT interventions use specific curricula and a set of therapeutic techniques aimed at “restructuring cognition” — learning to self-monitor one’s thinking is usually the first step — but the methods and supplementary components, such as social skills training or relapse prevention planning, vary according to the problem and circumstances.

Changing Attitudes and Motivation in Parolees (CHAMPS) involves two interventions with the goal of reducing recidivism. The Next Generation of Parole Supervision model, developed by the National Institute of Corrections (NIC), seeks to change the way parole officers interact with parolees, training the officers to use strengths-based approaches to help their clients address risk factors that may lead to problem behaviors. In the other intervention, treatment providers work with the same clients using a combination of Motivational Enhancement Therapy, which consists of four to nine individual counseling sessions aiming to help parolees resolve their ambivalence about giving up criminal behavior, and Thinking for a Change, a structured CBT curriculum developed by NIC. The latter involves 25 lessons, delivered in small group sessions, and includes cognitive restructuring and the development of social and problem-solving skills. The CHAMPS project begins with an intensive pilot implementation period, during which MDRC will use observational and quantitative techniques to evaluate whether the chosen sites can put the interventions into practice and whether those practices differ from usual parole supervision.

Bridges to Pathways. Part of the multisite Subsidized and Transitional Employment Demonstration, Bridges to Pathways enrolls young men between 17 and 21 who have been involved with the justice system in Chicago. The program combines academic education (geared toward earning a diploma or GED certificate), social-emotional learning, and workforce development with the aim of reducing recidivism, increasing graduation, and improving employment and earnings. Mentors integrate social-emotional learning, using the Thinking for a Change curriculum discussed above, into community service projects and job training, including a three-month worksite placement. MDRC will use a random assignment design to assess the program’s implementation and effectiveness at improving short-term outcomes.

Cognitive Behavioral Employment. Using a curriculum now being developed by the University of Cincinnati Corrections Institute, this new initiative integrates CBT with traditional employment approaches for individuals in the court system who are judged to be at high risk of recidivism and in great need of employment. A series of group workshops will emphasize cognitive restructuring and cognitive-behavioral coping skills, particularly in managing high-risk situations in a work environment. At the same time, program staff will receive training in effective techniques for interacting with clients. The intervention is designed to provide a real-life opportunity for people to practice the skills they are learning and for the staff to reinforce the skill development. The new curriculum will allow for flexibility across various service settings, but MDRC’s pilot implementation evaluation is planned for an intensive transitional employment program.

Children’s Institute Inc. offers clinical mental health treatment and other supports to children and families in Los Angeles County who have been affected by abuse or trauma. MDRC is evaluating its use of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), a method appropriate for children with post-traumatic stress disorder, depression, and anxiety. The therapist works with the child on managing the effect of the trauma, and the parent or caregiver learns how to better support the child. A key component involves the child sharing a narrative about the trauma with his or her caregiver. Therapists also impart relaxation techniques, coping strategies, guidance in managing and processing emotional reactions, and gradual exposure to trauma reminders to help children learn to control their responses. MDRC is working with a team of researchers using an observational method to assess the organization’s implementation of TF-CBT through coding of audio-recorded therapy sessions.

Adolescent Behavioral Learning Experience (ABLE) at Rikers Island. Financed by the nation’s first operational Social Impact Bond, ABLE focused on personal responsibility education and counseling, with the goal of reducing the likelihood of reincarceration among 16- to 18-year-olds passing through the jail complex at Rikers Island. In designing the intervention, MDRC chose Moral Reconation Therapy, a CBT curriculum developed for use in the correctional system. The program was incorporated into the school day, using a workbook with exercises to guide as many as 40 classrooms of about 15 participants each through eight stages of moral development, addressing their beliefs and reasoning in a systematic, step-by-step way. Unfortunately, in the challenging context of Rikers, ABLE did not meet the recidivism reduction goals called for in the Social Impact Bond, and the program was discontinued in August 2015.

In addition, CBT is part of a larger comprehensive approach being used in other programs MDRC is evaluating, such as the Youth Villages Transitional Living Program and PACE Center for Girls.