Ricks Warren, PhD, ABPP

Once thought to only be associated with depression, self-criticism is a transdiagnostic risk factor for diverse forms of psychopathology.^1,2 However, research has shown that self-compassion is a robust resilience factor when faced with feelings of personal inadequacy.^3,4

Self-critical individuals experience feelings of unworthiness, inferiority, failure, and guilt. They engage in constant and harsh self-scrutiny and evaluation, and fear being disapproved and criticized and losing the approval and acceptance of others.⁵ Self-compassion involves treating oneself with care and concern when confronted with personal inadequacies, mistakes, failures, and painful life situations.^6,7Although self-criticism is the aspect of perfectionism most associated with maladjustment,⁸ one can be harshly self-critical without being a perfectionist. Most studies of self-criticism have not measured shame; however, this self-conscious emotion has been implicated in diverse forms of psychopathology.⁹ In contrast to guilt, which results from acknowledging bad behavior, shame results from seeing oneself as a bad or inadequate person.

Although self-criticism is destructive across clinical disorders and interpersonal relationships, self-compassion is associated with healthy relationships, emotional well-being, and better treatment outcomes.

Recent research shows how clinicians can teach their patients how to be less self-critical and more self-compassionate. Neff^6,7 proposes that self-compassion involves treating yourself with care and concern when being confronted with personal inadequacies, mistakes, failures, and painful life situations. It consists of 3 interacting components, each of which has a positive and negative pole:

• self-kindness vs self-judgment
• a sense of common humanity vs isolation
• mindfulness vs over-identification.

Self-kindness refers to being caring and understanding with oneself rather than harshly judgmental. Instead of attacking and berating oneself for personal shortcomings, the self is offered warmth and unconditional acceptance.

Humanity involves recognizing that humans are imperfect, that all people fail, make mistakes, and have serious life challenges. By remembering that imperfection is part of life, we feel less isolated when we are in pain.

Mindfulness in the context of self-compassion involves being aware of one’s painful experiences in a balanced way that neither ignores and avoids nor exaggerates painful thoughts and emotions.

Self-compassion is more than the absence of self-judgment, although a defining feature of self-compassion is the lack of self-judgment, and self-judgment overlaps with self-criticism. Rather, self-compassion provides several access points for reducing self-criticism. For example, being kind and understanding when confronting personal inadequacies (eg, “it’s okay not to be perfect”) can counter harsh self-talk (eg, “I’m not defective”). Mindfulness of emotional pain (eg, “this is hard”) can facilitate a kind and warm response (eg, “what can I do to take care of myself right now?”) and therefore lessen self-blame (eg, “blaming myself is just causing me more suffering”). Similarly, remembering that failure is part of the human experience (eg, “it’s normal to mess up sometimes”) can lessen egocentric feelings of isolation (eg, “it’s not just me”) and over-identification (eg, “it’s not the end of the world”), resulting in lessened self-criticism (eg, “maybe it’s not just because I’m a bad person”).

Depression

Several studies have found that self-criticism predicts depression. In 3 epidemiological studies, “feeling worthless” was among the top 2 symptoms predicting a depression diagnosis and later depressive episodes.¹⁰ Self-criticism in fourth-year medical students predicted depression 2 years later, and—in males—10 years later in their medical careers better than a history of depression.¹¹ Self-critical perfectionism also is associated with suicidal ideation and lethality of suicide attempts.¹²

Self-criticism has been shown to predict depressive relapse and residual self-devaluative symptoms in recovered depressed patients.¹³ In one study, currently depressed and remitted depressed patients had higher self-criticism and lower self-compassion compared with healthy controls. Both factors were more strongly associated with depression status than higher perfectionistic beliefs and cognitions, rumination, and maladaptive emotional regulation.¹⁴

Self-criticism and response to treatment. In the National Institute of Mental Health Treatment of Depression Collaborative Research Program,¹⁵ self-critical perfectionism predicted a poorer outcome across all 4 treatments (cognitive-behavioral therapy [CBT], interpersonal psychotherapy [IPT], pharmacotherapy plus clinical management, and placebo plus clinical management). Subsequent studies found that self-criticism predicted poorer response to CBT¹⁶ and IPT.¹⁷ The authors suggest that self-criticism could interfere with treatment because self-critical patients might have difficulty developing a strong therapeutic alliance.^18,19

Anxiety disorders

Self-criticism is common across psychiatric disorders. In a study of 5,877 respondents in the National Comorbidity Survey (NCS), self-criticism was associated with social phobia, findings that were significant after controlling for current emotional distress, neuroticism, and lifetime history of mood, anxiety, and substance use disorders.²⁰ Further, in a CBT treatment study, baseline self-criticism was associated with severity of social phobia and changes in self-criticism predicted treatment outcome.²¹ Self-criticism might be an important core psychological process in the development, maintenance, and course of social phobia. Patients with social anxiety disorder have less self-compassion than healthy controls and greater fear of negative evaluation.

In the NCS, self-criticism was associated with posttraumatic stress disorder (PTSD) even after controlling for lifetime history of affective and anxiety disorders.²⁰ Self-criticism predicted greater severity of combat-related PTSD in hospitalized male veterans,²² and those with PTSD had higher scores on self-criticism scales than those with major depressive disorder.²³ In a study of Holocaust survivors, those with PTSD scored higher on self-criticism than survivors without PTSD.²⁴ Self-criticism also distinguished between female victims of domestic violence with and without PTSD.²⁵

Self-compassion could be a protective factor for posttraumatic stress.²⁶ Combat veterans with higher levels of self-compassion showed lower levels of psychopathology, better functioning in daily life, and fewer symptoms of posttraumatic stress.²⁷ In fact, self-compassion has been found to be a stronger predictor of PTSD than level of combat exposure.²⁸

In an early study, self-criticism scores were higher in patients with panic disorder than in healthy controls, but lower than in patients with depression.²⁹ In a study of a mixed sample of anxiety disorder patients, symptoms of generalized anxiety disorder were associated with shame proneness.³⁰ Consistent with these results, Hoge et al³¹ found that self-compassion was lower in generalized anxiety disorder patients compared with healthy controls with elevated stress. Low self-compassion has been associated with severity of obsessive-compulsive disorder.³²

Eating disorders

Self-criticism is correlated with eating disorder severity.³³ In a study of patients with binge eating disorder, Dunkley and Grilo³⁴ found that self-criticism was associated with the over-evaluation of shape and weight independently of self-esteem and depression. Self-criticism also is associated with body dissatisfaction, independent of self-esteem and depression. Dunkley et al³⁵ found that self-criticism, but not global self-esteem, in patients with binge eating disorder mediated the relationship between childhood abuse and body dissatisfaction and depression. Numerous studies have shown that shame is associated with more severe eating disorder pathology.³³

Self-compassion seems to buffer against body image concerns. It is associated with less body dissatisfaction, body preoccupation, and weight worries,³⁶ greater body appreciation³⁷ and less disordered eating.^37-39 Early decreases in shame during eating disorder treatment was associated with more rapid reduction in eating disorder symptoms.⁴⁰

Interpersonal relationships

Several studies have shown that self-criticism has negative effects on interpersonal relationships throughout life.^5,41,42

• Self-criticism at age 12 predicted less involvement in high school activities and, at age 31, personal and social maladjustment.⁴³
• High school students with high self-criticism reported more interpersonal problems.⁴⁴
• Self-criticism was associated with loneliness, depression, and lack of intimacy with opposite sex friends or partners during the transition to college.⁴⁵
• In a study of college roommates,⁴⁶ self-criticism was associated with increased likelihood of rejection.
• Whiffen and Aube⁴⁷ found that self-criticism was associated with marital dissatisfaction and depression.
• Self-critical mothers with postpartum depression were less satisfied with social support and were more vulnerable to depression.⁴⁸

Self-compassion appears to enhance interpersonal relationships. In a study of heterosexual couples,⁴⁹ self-compassionate individuals were described by their partners as being more emotionally connected, as well as accepting and supporting autonomy, while being less detached, controlling, and verbally or physically aggressive than those lacking self-compassion. Because self-compassionate people give themselves care and support, they seem to have more emotional resources available to give to others.

See the Box examining the evidence on the role of self-compassion in borderline personality disorder and non-suicidal self-injury.

Achieving goals

Powers et al⁵⁰ suggest that self-critics approach goals based on motivation to avoid failure and disapproval, rather than on intrinsic interest and personal meaning. In studies of college students pursuing academic, social, or weight loss goals, self-criticism was associated with less progress to that goal. Self-criticism was associated with rumination and procrastination, which the authors suggest might have focused the self-critic on potential failure, negative evaluation from others, and loss of self-esteem. Additional studies showed the deleterious effects of self-criticism on college students’ progress on obtaining academic or music performance goals and on community residents’ weight loss goals.⁵¹

Not surprisingly, self-compassion is associated with successful goal pursuit and resilience when goals are not met⁵² and less procrastination and academic worry.⁵³ Self-compassion also is associated with intrinsic motivation, goals based on mastery rather than performance, and less fear of academic failure.⁵⁴

How self-criticism and self-compassion develop

Studies have explored the impact of early relationships with parents and development of self-criticism. Parental overcontrol and restrictiveness and lack of warmth consistently have been identified as parenting styles associated with development of self-criticism in children.⁵⁵ One study found that self-criticism fully mediated the relationship between childhood verbal abuse from parents and depression and anxiety in adulthood.⁵⁶ Reports from parents on their current parenting styles are consistent with these studies.⁵⁷ Amitay et al⁵⁷ states that “[s]elf-critics’ negative childhood experiences thus seem to contribute to a pattern of entering, creating, or manipulating subsequent interpersonal environments in ways that perpetuate their negative self-image and increase vulnerability to depression.” Not surprisingly, self-criticism is associated with a fearful avoidant attachment style.⁵⁸ Review of the developmental origins of self-criticism confirms these factors and presents findings that peer relationships also are important factors in the development of self-criticism.^59,60

Early positive relationships with caregivers are associated with self-compassion. Recollections of maternal support are correlated with self-compassion and secure attachment styles in adolescents and adults.⁶¹ Pepping et al⁶² found that retrospective reports of parental rejection, overprotection, and low parental warmth was associated with low self-compassion.

Benefits of self-compassion

A growing body of research suggests that self-compassion is strongly linked to mental health. Greater self-compassion consistently has been associated with lower levels of depression and anxiety,³ with a large effect size.⁴ Of course, central to self-compassion is the lack of self-criticism, but self-compassion still protects against anxiety and depression when controlling for self-criticism and negative affect.^6,63 Self-compassion is a strong predictor of symptom severity and quality of life among individuals with anxious distress.⁶⁴

The benefits of self-compassion stem partly from a greater ability to cope with negative emotions.^6,63,65 Self-compassionate people are less likely to ruminate on their negative thoughts and emotions or suppress them,^6,66 which helps to explain why self-compassion is a negative predictor of depression.⁶⁷

Self-compassion also enhances positive mind states. A number of studies have found links between self-compassion and positive psychological qualities, such as happiness, optimism, wisdom, curiosity, and exploration, and personal initiative.^63,65,68,69 By embracing one’s suffering with compassion, negative states are ameliorated when positive emotions of kindness, connectedness, and mindful presence are generated.

Misconceptions about self-compassion

A common misconception is that abandoning self-criticism in favor of self-compassion will undermine motivation⁷⁰; however, research indicates the opposite. Although self-compassion is negatively associated with maladaptive perfectionism, it is not correlated with self-adopted performance standards.⁶ Self-compassionate people have less fear of failure⁵⁴ and, when they do fail, they are more likely to try again.⁷¹ Breines and Chen⁷² found in a series of experimental studies that engendering feelings of self-compassion for personal weaknesses, failures, and past transgressions resulted in more motivation to change, to try harder to learn, and to avoid repeating past mistakes.

Another common misunderstanding is that self-compassion is a weakness. In fact, research suggests that self-compassion is a powerful way to cope with life challenges.⁷³

Although some fear that self-compassion leads to self-indulgence, there is evidence that self-compassion promotes health-related behaviors. Self-compassionate individuals are more likely to seek medical treatment when needed,⁷⁴ exercise for intrinsic reasons,⁷⁵ and drink less alcohol.⁷⁶ Inducing self-compassion has been found to help people stick to their diets⁷⁷ and quit smoking.⁷⁸

Self-compassion interventions

Individuals can develop self-compassion. Shapira and Mongrain⁷⁹ found that adults who wrote a compassionate letter to themselves once a day for a week about the distressing events they were experiencing showed significant reductions in depression up to 3 months and significant increases in happiness up to 6 months compared with a control group who wrote about early memories. Albertson et al⁸⁰ found that, compared with a wait-list control group, 3 weeks of self-compassion meditation training improved body dissatisfaction, body shame, and body appreciation among women with body image concerns. Similarly, Smeets et al⁸¹ found that 3 weeks of self-compassion training for female college students led to significantly greater increases in mindfulness, optimism, and self-efficacy, as well as greater decreases in rumination compared with a time management control group.

The Box^6,70,82-86 describes rating scales that can measure self-compassion and self-criticism.

Mindful self-compassion (MSC), developed by Neff and Germer,⁸⁷ is an 8-week group intervention designed to teach people how to be more self-compassionate through meditation and informal practices in daily life. Results of a randomized controlled trial found that, compared with a wait-list control group, participants using MSC reported significantly greater increases in self-compassion, compassion for others, mindfulness, and life satisfaction, and greater decreases in depression, anxiety, stress, and emotional avoidance, with large effect sizes indicated. These results were maintained up to 1 year.

Compassion-focused therapy (CFT) is designed to enhance self-compassion in clinical populations.⁸⁸ The approach uses a number of imagery and experiential exercises to enhance patients’ abilities to extend feelings of reassurance, safeness, and understanding toward themselves. CFT has shown promise in treating a diverse group of clinical disorders such as depression and shame,^8,89 social anxiety and shame,⁹⁰ eating disorders,⁹¹ psychosis,⁹² and patients with acquired brain injury.⁹³ A group-based CFT intervention with a heterogeneous group of community mental health patients led to significant reductions in depression, anxiety, stress, and self-criticism.⁹⁴ See Leaviss and Utley⁹⁵ for a review of the benefits of CFT.

Fears of developing self-compassion

It is important to note that some people can access self-compassion more easily than others. Highly self-critical patients could feel anxious when learning to be compassionate to themselves, a phenomenon known as “fear of compassion”⁹⁶ or “backdraft.”⁹⁷ Backdraft occurs when a firefighter opens a door with a hot fire behind it. Oxygen rushes in, causing a burst of flame. Similarly, when the door of the heart is opened with compassion, intense pain could be released. Unconditional love reveals the conditions under which we were unloved in the past. Some individuals, especially those with a history of childhood abuse or neglect, are fearful of compassion because it activates grief associated with feelings of wanting, but not receiving, affection and care from significant others in childhood.

Clinicians should be aware that anxiety could arise and should help patients learn how to go slowly and stabilize themselves if overwhelming emotions occur as a part of self-compassion practice. Both CFT and MSC have processes to deal with fear of compassion in their protocols,^98,99 with the focus on explaining to individuals that although such fears may occur, they are a normal and necessary part of the healing process. Individuals also are taught to focus on the breath, feeling the sensations in the soles of their feet, or other mindfulness practices to ground and stabilize attention when overwhelming feelings arise.

Clinical interventions

Self-compassion interventions that I (R.W.) find most helpful, in the order I administer them, are:

• exploring perceived advantages and disadvantages of self-criticism
• presenting self-compassion as a way to get the perceived advantages of self-criticism without the disadvantages
• discussing what it means to be compassionate for someone else who is suffering, and then asking what it would be like if they treated themselves with the same compassion
• exploring patients’ misconceptions and fears of self-compassion
• directing patients to the self-compassion Web site to get an understanding of what self-compassion is and how it differs from self-esteem
• taking an example of a recent situation in which the patient was self-critical and exploring how a self-compassionate response would differ.

Asking what they would say to a friend often is an effective way to get at this. In a later therapy session, self-compassionate imagery is a useful way to get the patient to experience self-compassion on an emotional level. See Neff¹⁰⁰ and Gilbert⁹⁸ for other techniques to enhance self-compassion.

Once thought to only be associated with depression, self-criticism is a transdiagnostic risk factor for diverse forms of psychopathology.^1,2 However, research has shown that self-compassion is a robust resilience factor when faced with feelings of personal inadequacy.^3,4

Self-critical individuals experience feelings of unworthiness, inferiority, failure, and guilt. They engage in constant and harsh self-scrutiny and evaluation, and fear being disapproved and criticized and losing the approval and acceptance of others.⁵ Self-compassion involves treating oneself with care and concern when confronted with personal inadequacies, mistakes, failures, and painful life situations.^6,7Although self-criticism is the aspect of perfectionism most associated with maladjustment,⁸ one can be harshly self-critical without being a perfectionist. Most studies of self-criticism have not measured shame; however, this self-conscious emotion has been implicated in diverse forms of psychopathology.⁹ In contrast to guilt, which results from acknowledging bad behavior, shame results from seeing oneself as a bad or inadequate person.

Although self-criticism is destructive across clinical disorders and interpersonal relationships, self-compassion is associated with healthy relationships, emotional well-being, and better treatment outcomes.

Recent research shows how clinicians can teach their patients how to be less self-critical and more self-compassionate. Neff^6,7 proposes that self-compassion involves treating yourself with care and concern when being confronted with personal inadequacies, mistakes, failures, and painful life situations. It consists of 3 interacting components, each of which has a positive and negative pole:

• self-kindness vs self-judgment
• a sense of common humanity vs isolation
• mindfulness vs over-identification.

Self-kindness refers to being caring and understanding with oneself rather than harshly judgmental. Instead of attacking and berating oneself for personal shortcomings, the self is offered warmth and unconditional acceptance.

Humanity involves recognizing that humans are imperfect, that all people fail, make mistakes, and have serious life challenges. By remembering that imperfection is part of life, we feel less isolated when we are in pain.

Mindfulness in the context of self-compassion involves being aware of one’s painful experiences in a balanced way that neither ignores and avoids nor exaggerates painful thoughts and emotions.

Self-compassion is more than the absence of self-judgment, although a defining feature of self-compassion is the lack of self-judgment, and self-judgment overlaps with self-criticism. Rather, self-compassion provides several access points for reducing self-criticism. For example, being kind and understanding when confronting personal inadequacies (eg, “it’s okay not to be perfect”) can counter harsh self-talk (eg, “I’m not defective”). Mindfulness of emotional pain (eg, “this is hard”) can facilitate a kind and warm response (eg, “what can I do to take care of myself right now?”) and therefore lessen self-blame (eg, “blaming myself is just causing me more suffering”). Similarly, remembering that failure is part of the human experience (eg, “it’s normal to mess up sometimes”) can lessen egocentric feelings of isolation (eg, “it’s not just me”) and over-identification (eg, “it’s not the end of the world”), resulting in lessened self-criticism (eg, “maybe it’s not just because I’m a bad person”).

Depression

Several studies have found that self-criticism predicts depression. In 3 epidemiological studies, “feeling worthless” was among the top 2 symptoms predicting a depression diagnosis and later depressive episodes.¹⁰ Self-criticism in fourth-year medical students predicted depression 2 years later, and—in males—10 years later in their medical careers better than a history of depression.¹¹ Self-critical perfectionism also is associated with suicidal ideation and lethality of suicide attempts.¹²

Self-criticism has been shown to predict depressive relapse and residual self-devaluative symptoms in recovered depressed patients.¹³ In one study, currently depressed and remitted depressed patients had higher self-criticism and lower self-compassion compared with healthy controls. Both factors were more strongly associated with depression status than higher perfectionistic beliefs and cognitions, rumination, and maladaptive emotional regulation.¹⁴

Self-criticism and response to treatment. In the National Institute of Mental Health Treatment of Depression Collaborative Research Program,¹⁵ self-critical perfectionism predicted a poorer outcome across all 4 treatments (cognitive-behavioral therapy [CBT], interpersonal psychotherapy [IPT], pharmacotherapy plus clinical management, and placebo plus clinical management). Subsequent studies found that self-criticism predicted poorer response to CBT¹⁶ and IPT.¹⁷ The authors suggest that self-criticism could interfere with treatment because self-critical patients might have difficulty developing a strong therapeutic alliance.^18,19

Anxiety disorders

Self-criticism is common across psychiatric disorders. In a study of 5,877 respondents in the National Comorbidity Survey (NCS), self-criticism was associated with social phobia, findings that were significant after controlling for current emotional distress, neuroticism, and lifetime history of mood, anxiety, and substance use disorders.²⁰ Further, in a CBT treatment study, baseline self-criticism was associated with severity of social phobia and changes in self-criticism predicted treatment outcome.²¹ Self-criticism might be an important core psychological process in the development, maintenance, and course of social phobia. Patients with social anxiety disorder have less self-compassion than healthy controls and greater fear of negative evaluation.

In the NCS, self-criticism was associated with posttraumatic stress disorder (PTSD) even after controlling for lifetime history of affective and anxiety disorders.²⁰ Self-criticism predicted greater severity of combat-related PTSD in hospitalized male veterans,²² and those with PTSD had higher scores on self-criticism scales than those with major depressive disorder.²³ In a study of Holocaust survivors, those with PTSD scored higher on self-criticism than survivors without PTSD.²⁴ Self-criticism also distinguished between female victims of domestic violence with and without PTSD.²⁵

Self-compassion could be a protective factor for posttraumatic stress.²⁶ Combat veterans with higher levels of self-compassion showed lower levels of psychopathology, better functioning in daily life, and fewer symptoms of posttraumatic stress.²⁷ In fact, self-compassion has been found to be a stronger predictor of PTSD than level of combat exposure.²⁸

In an early study, self-criticism scores were higher in patients with panic disorder than in healthy controls, but lower than in patients with depression.²⁹ In a study of a mixed sample of anxiety disorder patients, symptoms of generalized anxiety disorder were associated with shame proneness.³⁰ Consistent with these results, Hoge et al³¹ found that self-compassion was lower in generalized anxiety disorder patients compared with healthy controls with elevated stress. Low self-compassion has been associated with severity of obsessive-compulsive disorder.³²

Eating disorders

Self-criticism is correlated with eating disorder severity.³³ In a study of patients with binge eating disorder, Dunkley and Grilo³⁴ found that self-criticism was associated with the over-evaluation of shape and weight independently of self-esteem and depression. Self-criticism also is associated with body dissatisfaction, independent of self-esteem and depression. Dunkley et al³⁵ found that self-criticism, but not global self-esteem, in patients with binge eating disorder mediated the relationship between childhood abuse and body dissatisfaction and depression. Numerous studies have shown that shame is associated with more severe eating disorder pathology.³³

Self-compassion seems to buffer against body image concerns. It is associated with less body dissatisfaction, body preoccupation, and weight worries,³⁶ greater body appreciation³⁷ and less disordered eating.^37-39 Early decreases in shame during eating disorder treatment was associated with more rapid reduction in eating disorder symptoms.⁴⁰

Interpersonal relationships

Several studies have shown that self-criticism has negative effects on interpersonal relationships throughout life.^5,41,42

• Self-criticism at age 12 predicted less involvement in high school activities and, at age 31, personal and social maladjustment.⁴³
• High school students with high self-criticism reported more interpersonal problems.⁴⁴
• Self-criticism was associated with loneliness, depression, and lack of intimacy with opposite sex friends or partners during the transition to college.⁴⁵
• In a study of college roommates,⁴⁶ self-criticism was associated with increased likelihood of rejection.
• Whiffen and Aube⁴⁷ found that self-criticism was associated with marital dissatisfaction and depression.
• Self-critical mothers with postpartum depression were less satisfied with social support and were more vulnerable to depression.⁴⁸

Self-compassion appears to enhance interpersonal relationships. In a study of heterosexual couples,⁴⁹ self-compassionate individuals were described by their partners as being more emotionally connected, as well as accepting and supporting autonomy, while being less detached, controlling, and verbally or physically aggressive than those lacking self-compassion. Because self-compassionate people give themselves care and support, they seem to have more emotional resources available to give to others.

See the Box examining the evidence on the role of self-compassion in borderline personality disorder and non-suicidal self-injury.

Achieving goals

Powers et al⁵⁰ suggest that self-critics approach goals based on motivation to avoid failure and disapproval, rather than on intrinsic interest and personal meaning. In studies of college students pursuing academic, social, or weight loss goals, self-criticism was associated with less progress to that goal. Self-criticism was associated with rumination and procrastination, which the authors suggest might have focused the self-critic on potential failure, negative evaluation from others, and loss of self-esteem. Additional studies showed the deleterious effects of self-criticism on college students’ progress on obtaining academic or music performance goals and on community residents’ weight loss goals.⁵¹

Not surprisingly, self-compassion is associated with successful goal pursuit and resilience when goals are not met⁵² and less procrastination and academic worry.⁵³ Self-compassion also is associated with intrinsic motivation, goals based on mastery rather than performance, and less fear of academic failure.⁵⁴

How self-criticism and self-compassion develop

Studies have explored the impact of early relationships with parents and development of self-criticism. Parental overcontrol and restrictiveness and lack of warmth consistently have been identified as parenting styles associated with development of self-criticism in children.⁵⁵ One study found that self-criticism fully mediated the relationship between childhood verbal abuse from parents and depression and anxiety in adulthood.⁵⁶ Reports from parents on their current parenting styles are consistent with these studies.⁵⁷ Amitay et al⁵⁷ states that “[s]elf-critics’ negative childhood experiences thus seem to contribute to a pattern of entering, creating, or manipulating subsequent interpersonal environments in ways that perpetuate their negative self-image and increase vulnerability to depression.” Not surprisingly, self-criticism is associated with a fearful avoidant attachment style.⁵⁸ Review of the developmental origins of self-criticism confirms these factors and presents findings that peer relationships also are important factors in the development of self-criticism.^59,60

Early positive relationships with caregivers are associated with self-compassion. Recollections of maternal support are correlated with self-compassion and secure attachment styles in adolescents and adults.⁶¹ Pepping et al⁶² found that retrospective reports of parental rejection, overprotection, and low parental warmth was associated with low self-compassion.

Benefits of self-compassion

A growing body of research suggests that self-compassion is strongly linked to mental health. Greater self-compassion consistently has been associated with lower levels of depression and anxiety,³ with a large effect size.⁴ Of course, central to self-compassion is the lack of self-criticism, but self-compassion still protects against anxiety and depression when controlling for self-criticism and negative affect.^6,63 Self-compassion is a strong predictor of symptom severity and quality of life among individuals with anxious distress.⁶⁴

The benefits of self-compassion stem partly from a greater ability to cope with negative emotions.^6,63,65 Self-compassionate people are less likely to ruminate on their negative thoughts and emotions or suppress them,^6,66 which helps to explain why self-compassion is a negative predictor of depression.⁶⁷

Self-compassion also enhances positive mind states. A number of studies have found links between self-compassion and positive psychological qualities, such as happiness, optimism, wisdom, curiosity, and exploration, and personal initiative.^63,65,68,69 By embracing one’s suffering with compassion, negative states are ameliorated when positive emotions of kindness, connectedness, and mindful presence are generated.

Misconceptions about self-compassion

A common misconception is that abandoning self-criticism in favor of self-compassion will undermine motivation⁷⁰; however, research indicates the opposite. Although self-compassion is negatively associated with maladaptive perfectionism, it is not correlated with self-adopted performance standards.⁶ Self-compassionate people have less fear of failure⁵⁴ and, when they do fail, they are more likely to try again.⁷¹ Breines and Chen⁷² found in a series of experimental studies that engendering feelings of self-compassion for personal weaknesses, failures, and past transgressions resulted in more motivation to change, to try harder to learn, and to avoid repeating past mistakes.

Another common misunderstanding is that self-compassion is a weakness. In fact, research suggests that self-compassion is a powerful way to cope with life challenges.⁷³

Although some fear that self-compassion leads to self-indulgence, there is evidence that self-compassion promotes health-related behaviors. Self-compassionate individuals are more likely to seek medical treatment when needed,⁷⁴ exercise for intrinsic reasons,⁷⁵ and drink less alcohol.⁷⁶ Inducing self-compassion has been found to help people stick to their diets⁷⁷ and quit smoking.⁷⁸

Self-compassion interventions

Individuals can develop self-compassion. Shapira and Mongrain⁷⁹ found that adults who wrote a compassionate letter to themselves once a day for a week about the distressing events they were experiencing showed significant reductions in depression up to 3 months and significant increases in happiness up to 6 months compared with a control group who wrote about early memories. Albertson et al⁸⁰ found that, compared with a wait-list control group, 3 weeks of self-compassion meditation training improved body dissatisfaction, body shame, and body appreciation among women with body image concerns. Similarly, Smeets et al⁸¹ found that 3 weeks of self-compassion training for female college students led to significantly greater increases in mindfulness, optimism, and self-efficacy, as well as greater decreases in rumination compared with a time management control group.

The Box^6,70,82-86 describes rating scales that can measure self-compassion and self-criticism.

Mindful self-compassion (MSC), developed by Neff and Germer,⁸⁷ is an 8-week group intervention designed to teach people how to be more self-compassionate through meditation and informal practices in daily life. Results of a randomized controlled trial found that, compared with a wait-list control group, participants using MSC reported significantly greater increases in self-compassion, compassion for others, mindfulness, and life satisfaction, and greater decreases in depression, anxiety, stress, and emotional avoidance, with large effect sizes indicated. These results were maintained up to 1 year.

Compassion-focused therapy (CFT) is designed to enhance self-compassion in clinical populations.⁸⁸ The approach uses a number of imagery and experiential exercises to enhance patients’ abilities to extend feelings of reassurance, safeness, and understanding toward themselves. CFT has shown promise in treating a diverse group of clinical disorders such as depression and shame,^8,89 social anxiety and shame,⁹⁰ eating disorders,⁹¹ psychosis,⁹² and patients with acquired brain injury.⁹³ A group-based CFT intervention with a heterogeneous group of community mental health patients led to significant reductions in depression, anxiety, stress, and self-criticism.⁹⁴ See Leaviss and Utley⁹⁵ for a review of the benefits of CFT.

Fears of developing self-compassion

It is important to note that some people can access self-compassion more easily than others. Highly self-critical patients could feel anxious when learning to be compassionate to themselves, a phenomenon known as “fear of compassion”⁹⁶ or “backdraft.”⁹⁷ Backdraft occurs when a firefighter opens a door with a hot fire behind it. Oxygen rushes in, causing a burst of flame. Similarly, when the door of the heart is opened with compassion, intense pain could be released. Unconditional love reveals the conditions under which we were unloved in the past. Some individuals, especially those with a history of childhood abuse or neglect, are fearful of compassion because it activates grief associated with feelings of wanting, but not receiving, affection and care from significant others in childhood.

Clinicians should be aware that anxiety could arise and should help patients learn how to go slowly and stabilize themselves if overwhelming emotions occur as a part of self-compassion practice. Both CFT and MSC have processes to deal with fear of compassion in their protocols,^98,99 with the focus on explaining to individuals that although such fears may occur, they are a normal and necessary part of the healing process. Individuals also are taught to focus on the breath, feeling the sensations in the soles of their feet, or other mindfulness practices to ground and stabilize attention when overwhelming feelings arise.

Clinical interventions

Self-compassion interventions that I (R.W.) find most helpful, in the order I administer them, are:

• exploring perceived advantages and disadvantages of self-criticism
• presenting self-compassion as a way to get the perceived advantages of self-criticism without the disadvantages
• discussing what it means to be compassionate for someone else who is suffering, and then asking what it would be like if they treated themselves with the same compassion
• exploring patients’ misconceptions and fears of self-compassion
• directing patients to the self-compassion Web site to get an understanding of what self-compassion is and how it differs from self-esteem
• taking an example of a recent situation in which the patient was self-critical and exploring how a self-compassionate response would differ.

Asking what they would say to a friend often is an effective way to get at this. In a later therapy session, self-compassionate imagery is a useful way to get the patient to experience self-compassion on an emotional level. See Neff¹⁰⁰ and Gilbert⁹⁸ for other techniques to enhance self-compassion.

Once thought to only be associated with depression, self-criticism is a transdiagnostic risk factor for diverse forms of psychopathology.^1,2 However, research has shown that self-compassion is a robust resilience factor when faced with feelings of personal inadequacy.^3,4

Self-critical individuals experience feelings of unworthiness, inferiority, failure, and guilt. They engage in constant and harsh self-scrutiny and evaluation, and fear being disapproved and criticized and losing the approval and acceptance of others.⁵ Self-compassion involves treating oneself with care and concern when confronted with personal inadequacies, mistakes, failures, and painful life situations.^6,7Although self-criticism is the aspect of perfectionism most associated with maladjustment,⁸ one can be harshly self-critical without being a perfectionist. Most studies of self-criticism have not measured shame; however, this self-conscious emotion has been implicated in diverse forms of psychopathology.⁹ In contrast to guilt, which results from acknowledging bad behavior, shame results from seeing oneself as a bad or inadequate person.

Although self-criticism is destructive across clinical disorders and interpersonal relationships, self-compassion is associated with healthy relationships, emotional well-being, and better treatment outcomes.

Recent research shows how clinicians can teach their patients how to be less self-critical and more self-compassionate. Neff^6,7 proposes that self-compassion involves treating yourself with care and concern when being confronted with personal inadequacies, mistakes, failures, and painful life situations. It consists of 3 interacting components, each of which has a positive and negative pole:

• self-kindness vs self-judgment
• a sense of common humanity vs isolation
• mindfulness vs over-identification.

Self-kindness refers to being caring and understanding with oneself rather than harshly judgmental. Instead of attacking and berating oneself for personal shortcomings, the self is offered warmth and unconditional acceptance.

Humanity involves recognizing that humans are imperfect, that all people fail, make mistakes, and have serious life challenges. By remembering that imperfection is part of life, we feel less isolated when we are in pain.

Mindfulness in the context of self-compassion involves being aware of one’s painful experiences in a balanced way that neither ignores and avoids nor exaggerates painful thoughts and emotions.

Self-compassion is more than the absence of self-judgment, although a defining feature of self-compassion is the lack of self-judgment, and self-judgment overlaps with self-criticism. Rather, self-compassion provides several access points for reducing self-criticism. For example, being kind and understanding when confronting personal inadequacies (eg, “it’s okay not to be perfect”) can counter harsh self-talk (eg, “I’m not defective”). Mindfulness of emotional pain (eg, “this is hard”) can facilitate a kind and warm response (eg, “what can I do to take care of myself right now?”) and therefore lessen self-blame (eg, “blaming myself is just causing me more suffering”). Similarly, remembering that failure is part of the human experience (eg, “it’s normal to mess up sometimes”) can lessen egocentric feelings of isolation (eg, “it’s not just me”) and over-identification (eg, “it’s not the end of the world”), resulting in lessened self-criticism (eg, “maybe it’s not just because I’m a bad person”).

Depression

Several studies have found that self-criticism predicts depression. In 3 epidemiological studies, “feeling worthless” was among the top 2 symptoms predicting a depression diagnosis and later depressive episodes.¹⁰ Self-criticism in fourth-year medical students predicted depression 2 years later, and—in males—10 years later in their medical careers better than a history of depression.¹¹ Self-critical perfectionism also is associated with suicidal ideation and lethality of suicide attempts.¹²

Self-criticism has been shown to predict depressive relapse and residual self-devaluative symptoms in recovered depressed patients.¹³ In one study, currently depressed and remitted depressed patients had higher self-criticism and lower self-compassion compared with healthy controls. Both factors were more strongly associated with depression status than higher perfectionistic beliefs and cognitions, rumination, and maladaptive emotional regulation.¹⁴

Self-criticism and response to treatment. In the National Institute of Mental Health Treatment of Depression Collaborative Research Program,¹⁵ self-critical perfectionism predicted a poorer outcome across all 4 treatments (cognitive-behavioral therapy [CBT], interpersonal psychotherapy [IPT], pharmacotherapy plus clinical management, and placebo plus clinical management). Subsequent studies found that self-criticism predicted poorer response to CBT¹⁶ and IPT.¹⁷ The authors suggest that self-criticism could interfere with treatment because self-critical patients might have difficulty developing a strong therapeutic alliance.^18,19

Anxiety disorders

Self-criticism is common across psychiatric disorders. In a study of 5,877 respondents in the National Comorbidity Survey (NCS), self-criticism was associated with social phobia, findings that were significant after controlling for current emotional distress, neuroticism, and lifetime history of mood, anxiety, and substance use disorders.²⁰ Further, in a CBT treatment study, baseline self-criticism was associated with severity of social phobia and changes in self-criticism predicted treatment outcome.²¹ Self-criticism might be an important core psychological process in the development, maintenance, and course of social phobia. Patients with social anxiety disorder have less self-compassion than healthy controls and greater fear of negative evaluation.

In the NCS, self-criticism was associated with posttraumatic stress disorder (PTSD) even after controlling for lifetime history of affective and anxiety disorders.²⁰ Self-criticism predicted greater severity of combat-related PTSD in hospitalized male veterans,²² and those with PTSD had higher scores on self-criticism scales than those with major depressive disorder.²³ In a study of Holocaust survivors, those with PTSD scored higher on self-criticism than survivors without PTSD.²⁴ Self-criticism also distinguished between female victims of domestic violence with and without PTSD.²⁵

Self-compassion could be a protective factor for posttraumatic stress.²⁶ Combat veterans with higher levels of self-compassion showed lower levels of psychopathology, better functioning in daily life, and fewer symptoms of posttraumatic stress.²⁷ In fact, self-compassion has been found to be a stronger predictor of PTSD than level of combat exposure.²⁸

In an early study, self-criticism scores were higher in patients with panic disorder than in healthy controls, but lower than in patients with depression.²⁹ In a study of a mixed sample of anxiety disorder patients, symptoms of generalized anxiety disorder were associated with shame proneness.³⁰ Consistent with these results, Hoge et al³¹ found that self-compassion was lower in generalized anxiety disorder patients compared with healthy controls with elevated stress. Low self-compassion has been associated with severity of obsessive-compulsive disorder.³²

Eating disorders

Self-criticism is correlated with eating disorder severity.³³ In a study of patients with binge eating disorder, Dunkley and Grilo³⁴ found that self-criticism was associated with the over-evaluation of shape and weight independently of self-esteem and depression. Self-criticism also is associated with body dissatisfaction, independent of self-esteem and depression. Dunkley et al³⁵ found that self-criticism, but not global self-esteem, in patients with binge eating disorder mediated the relationship between childhood abuse and body dissatisfaction and depression. Numerous studies have shown that shame is associated with more severe eating disorder pathology.³³

Self-compassion seems to buffer against body image concerns. It is associated with less body dissatisfaction, body preoccupation, and weight worries,³⁶ greater body appreciation³⁷ and less disordered eating.^37-39 Early decreases in shame during eating disorder treatment was associated with more rapid reduction in eating disorder symptoms.⁴⁰

Interpersonal relationships

Several studies have shown that self-criticism has negative effects on interpersonal relationships throughout life.^5,41,42

• Self-criticism at age 12 predicted less involvement in high school activities and, at age 31, personal and social maladjustment.⁴³
• High school students with high self-criticism reported more interpersonal problems.⁴⁴
• Self-criticism was associated with loneliness, depression, and lack of intimacy with opposite sex friends or partners during the transition to college.⁴⁵
• In a study of college roommates,⁴⁶ self-criticism was associated with increased likelihood of rejection.
• Whiffen and Aube⁴⁷ found that self-criticism was associated with marital dissatisfaction and depression.
• Self-critical mothers with postpartum depression were less satisfied with social support and were more vulnerable to depression.⁴⁸

Self-compassion appears to enhance interpersonal relationships. In a study of heterosexual couples,⁴⁹ self-compassionate individuals were described by their partners as being more emotionally connected, as well as accepting and supporting autonomy, while being less detached, controlling, and verbally or physically aggressive than those lacking self-compassion. Because self-compassionate people give themselves care and support, they seem to have more emotional resources available to give to others.

See the Box examining the evidence on the role of self-compassion in borderline personality disorder and non-suicidal self-injury.

Achieving goals

Powers et al⁵⁰ suggest that self-critics approach goals based on motivation to avoid failure and disapproval, rather than on intrinsic interest and personal meaning. In studies of college students pursuing academic, social, or weight loss goals, self-criticism was associated with less progress to that goal. Self-criticism was associated with rumination and procrastination, which the authors suggest might have focused the self-critic on potential failure, negative evaluation from others, and loss of self-esteem. Additional studies showed the deleterious effects of self-criticism on college students’ progress on obtaining academic or music performance goals and on community residents’ weight loss goals.⁵¹

Not surprisingly, self-compassion is associated with successful goal pursuit and resilience when goals are not met⁵² and less procrastination and academic worry.⁵³ Self-compassion also is associated with intrinsic motivation, goals based on mastery rather than performance, and less fear of academic failure.⁵⁴

How self-criticism and self-compassion develop

Studies have explored the impact of early relationships with parents and development of self-criticism. Parental overcontrol and restrictiveness and lack of warmth consistently have been identified as parenting styles associated with development of self-criticism in children.⁵⁵ One study found that self-criticism fully mediated the relationship between childhood verbal abuse from parents and depression and anxiety in adulthood.⁵⁶ Reports from parents on their current parenting styles are consistent with these studies.⁵⁷ Amitay et al⁵⁷ states that “[s]elf-critics’ negative childhood experiences thus seem to contribute to a pattern of entering, creating, or manipulating subsequent interpersonal environments in ways that perpetuate their negative self-image and increase vulnerability to depression.” Not surprisingly, self-criticism is associated with a fearful avoidant attachment style.⁵⁸ Review of the developmental origins of self-criticism confirms these factors and presents findings that peer relationships also are important factors in the development of self-criticism.^59,60

Early positive relationships with caregivers are associated with self-compassion. Recollections of maternal support are correlated with self-compassion and secure attachment styles in adolescents and adults.⁶¹ Pepping et al⁶² found that retrospective reports of parental rejection, overprotection, and low parental warmth was associated with low self-compassion.

Benefits of self-compassion

A growing body of research suggests that self-compassion is strongly linked to mental health. Greater self-compassion consistently has been associated with lower levels of depression and anxiety,³ with a large effect size.⁴ Of course, central to self-compassion is the lack of self-criticism, but self-compassion still protects against anxiety and depression when controlling for self-criticism and negative affect.^6,63 Self-compassion is a strong predictor of symptom severity and quality of life among individuals with anxious distress.⁶⁴

The benefits of self-compassion stem partly from a greater ability to cope with negative emotions.^6,63,65 Self-compassionate people are less likely to ruminate on their negative thoughts and emotions or suppress them,^6,66 which helps to explain why self-compassion is a negative predictor of depression.⁶⁷

Self-compassion also enhances positive mind states. A number of studies have found links between self-compassion and positive psychological qualities, such as happiness, optimism, wisdom, curiosity, and exploration, and personal initiative.^63,65,68,69 By embracing one’s suffering with compassion, negative states are ameliorated when positive emotions of kindness, connectedness, and mindful presence are generated.

Misconceptions about self-compassion

A common misconception is that abandoning self-criticism in favor of self-compassion will undermine motivation⁷⁰; however, research indicates the opposite. Although self-compassion is negatively associated with maladaptive perfectionism, it is not correlated with self-adopted performance standards.⁶ Self-compassionate people have less fear of failure⁵⁴ and, when they do fail, they are more likely to try again.⁷¹ Breines and Chen⁷² found in a series of experimental studies that engendering feelings of self-compassion for personal weaknesses, failures, and past transgressions resulted in more motivation to change, to try harder to learn, and to avoid repeating past mistakes.

Another common misunderstanding is that self-compassion is a weakness. In fact, research suggests that self-compassion is a powerful way to cope with life challenges.⁷³

Although some fear that self-compassion leads to self-indulgence, there is evidence that self-compassion promotes health-related behaviors. Self-compassionate individuals are more likely to seek medical treatment when needed,⁷⁴ exercise for intrinsic reasons,⁷⁵ and drink less alcohol.⁷⁶ Inducing self-compassion has been found to help people stick to their diets⁷⁷ and quit smoking.⁷⁸

Self-compassion interventions

Individuals can develop self-compassion. Shapira and Mongrain⁷⁹ found that adults who wrote a compassionate letter to themselves once a day for a week about the distressing events they were experiencing showed significant reductions in depression up to 3 months and significant increases in happiness up to 6 months compared with a control group who wrote about early memories. Albertson et al⁸⁰ found that, compared with a wait-list control group, 3 weeks of self-compassion meditation training improved body dissatisfaction, body shame, and body appreciation among women with body image concerns. Similarly, Smeets et al⁸¹ found that 3 weeks of self-compassion training for female college students led to significantly greater increases in mindfulness, optimism, and self-efficacy, as well as greater decreases in rumination compared with a time management control group.

The Box^6,70,82-86 describes rating scales that can measure self-compassion and self-criticism.

Mindful self-compassion (MSC), developed by Neff and Germer,⁸⁷ is an 8-week group intervention designed to teach people how to be more self-compassionate through meditation and informal practices in daily life. Results of a randomized controlled trial found that, compared with a wait-list control group, participants using MSC reported significantly greater increases in self-compassion, compassion for others, mindfulness, and life satisfaction, and greater decreases in depression, anxiety, stress, and emotional avoidance, with large effect sizes indicated. These results were maintained up to 1 year.

Compassion-focused therapy (CFT) is designed to enhance self-compassion in clinical populations.⁸⁸ The approach uses a number of imagery and experiential exercises to enhance patients’ abilities to extend feelings of reassurance, safeness, and understanding toward themselves. CFT has shown promise in treating a diverse group of clinical disorders such as depression and shame,^8,89 social anxiety and shame,⁹⁰ eating disorders,⁹¹ psychosis,⁹² and patients with acquired brain injury.⁹³ A group-based CFT intervention with a heterogeneous group of community mental health patients led to significant reductions in depression, anxiety, stress, and self-criticism.⁹⁴ See Leaviss and Utley⁹⁵ for a review of the benefits of CFT.

Fears of developing self-compassion

It is important to note that some people can access self-compassion more easily than others. Highly self-critical patients could feel anxious when learning to be compassionate to themselves, a phenomenon known as “fear of compassion”⁹⁶ or “backdraft.”⁹⁷ Backdraft occurs when a firefighter opens a door with a hot fire behind it. Oxygen rushes in, causing a burst of flame. Similarly, when the door of the heart is opened with compassion, intense pain could be released. Unconditional love reveals the conditions under which we were unloved in the past. Some individuals, especially those with a history of childhood abuse or neglect, are fearful of compassion because it activates grief associated with feelings of wanting, but not receiving, affection and care from significant others in childhood.

Clinicians should be aware that anxiety could arise and should help patients learn how to go slowly and stabilize themselves if overwhelming emotions occur as a part of self-compassion practice. Both CFT and MSC have processes to deal with fear of compassion in their protocols,^98,99 with the focus on explaining to individuals that although such fears may occur, they are a normal and necessary part of the healing process. Individuals also are taught to focus on the breath, feeling the sensations in the soles of their feet, or other mindfulness practices to ground and stabilize attention when overwhelming feelings arise.

Clinical interventions

Self-compassion interventions that I (R.W.) find most helpful, in the order I administer them, are:

• exploring perceived advantages and disadvantages of self-criticism
• presenting self-compassion as a way to get the perceived advantages of self-criticism without the disadvantages
• discussing what it means to be compassionate for someone else who is suffering, and then asking what it would be like if they treated themselves with the same compassion
• exploring patients’ misconceptions and fears of self-compassion
• directing patients to the self-compassion Web site to get an understanding of what self-compassion is and how it differs from self-esteem
• taking an example of a recent situation in which the patient was self-critical and exploring how a self-compassionate response would differ.

Asking what they would say to a friend often is an effective way to get at this. In a later therapy session, self-compassionate imagery is a useful way to get the patient to experience self-compassion on an emotional level. See Neff¹⁰⁰ and Gilbert⁹⁸ for other techniques to enhance self-compassion.

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.