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Distinctive activities of cognitive–behavioral therapy
Abstract
The present review examined the comparative psychotherapy process literature in order to identify the distinctive activities of cognitive-behavioral (CB) treatment. Six techniques and interventions were found to distinguish CB from psychodynamic-interpersonal (PI) therapy: (1) use of homework and outside-of-session activities; (2) direction of session activity; (3) teaching of skills used by patients to cope with symptoms; (4) emphasis on patients' future experiences; (5) providing patients with information about their treatment, disorder, or symptoms; and (6) an intrapersonal/cognitive (C) focus. Identifying the distinctive features of CB therapy can improve the measurement of process-outcome correlations by more accurately specifying and operationalizing the treatment-specific processes of CB treatment, help researchers differentiate between common and treatment-specific factors, and aid in development of more psychometrically sound instruments assessing adherence and competence in CB therapy. In addition, this review can improve training of CB therapists by providing a guide for clinical practice.
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“whether treatments work through specific factors (eg, CBT change methods) or factors common to most psychotherapies (eg, therapeutic alliance) remains a core issue in the field.11,12”
From Quantifying the association between psychotherapy content and clinical outcomes using deep learning (2020) · cites this paper as [11]
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“Blagys and Hilsenroth (2002) conducted a review of the psychotherapy process literature and found that evaluating, challenging and modifying thoughts was one of the hallmarks that distinguished CBT practice from that of other therapies.”
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“The scale we developed is based on two reviews of the comparative psychotherapy process literature (Blagys & Hilsenroth, 2000, 2002) that sought to identify core features used in PI (defined broadly to include psychodynamic, PI, and interpersonal therapies) and CB (defined broadly to include…”
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“Based on the findings of two empirical reviews of the comparative psychotherapy process literature (Blagys & Hilsenroth, 2000, 2002), the CPPS is a brief descriptive measure designed to assess therapist activity and techniques used and occurring during the therapeutic hour.”
Siefert, C. J., Hilsenroth, M. J., Weinberger, J. L., Blagys, M. D., & Ackerman, S. J. (2006) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.469 · Cited by 43
Clinical experiences in conducting cognitive-behavioral therapy for social phobia
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“The CB subscale consists of items that are significantly more characteristic of CB-oriented therapy (Blagys and Hilsenroth, 2002).”
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“For example, research has suggested that clients often struggle to implement the interpersonal skills and tools learned in cognitive behavior therapy groups to real-life scenarios (Blagys & Hilsenroth, 2002).”
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Working through: In-session processes that promote between-session thoughts and activities.
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“Indeed, Blagys and Hilsenroth (2002) have suggested that in general, although cognitive behavioural therapy (CBT) is an evidencebased practice that provides tools for effective interpersonal communication and interaction, newly learned approaches to life problems gained in CBT often do not transfer…”
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Patients' perspective on homework assignments in cognitive–behavioural therapy
Fehm, L., & Mrose, J. (2008) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.592 · Cited by 36
Luyten, P., Blatt, S. J., & Fonagy, P. (2013) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2013.6.3.265 · Cited by 38
“…thereby fostering the patient to revise earlier representations through becoming aware of their repetitive distortion of life experiences in the here-and-now of the therapeutic relationship (Blagys & Hilsenroth, 2000, 2002; Diener, Hilsenroth, & Weinberger, 2007; Luyten & Blatt, 2012).”
Kazantzis, N., & Dattilio, F. M. (2010) · Journal of Clinical Psychology · doi:10.1002/jclp.20699 · Cited by 35
de Greck, M., Scheidt, L., Bölter, A. F., Frommer, J., Ulrich, C., Stockum, E., Enzi, B., Tempelmann, C., Hoffmann, T., & Northoff, G. (2011) · The World Journal of Biological Psychiatry · doi:10.3109/15622975.2010.539269 · Cited by 35
de Greck, M., Bölter, A. F., Lehmann, L., Ulrich, C., Stockum, E., Enzi, B., Hoffmann, T., Tempelmann, C., Beutel, M. E., Frommer, J., et al. (2013) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2013.00410 · Cited by 34
“…applied in our study, aims to increase the insight and acceptance of unconscious emotions, needs and conflicts (Blagys and Hilsenroth, 2002; Leichsenring, 2005), and to enable patients to gain “mastery over his or her repressed wishes, desires, fears, or anxieties” (Blagys and Hilsenroth, 2002).”
BackgroundMethodInfluentialPatient Ratings of Psychodynamic Psychotherapy Session Activities and Their Relation to Outcome
DeFife, J. A., Hilsenroth, M. J., & Gold, J. R. (2008) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e31817cf6d0 · Cited by 35
“The CPPS was developed based on 2 extensive reviews of the empirical comparative psychotherapy process literature (Blagys and Hilsenroth, 2000, 2002), which sought to more specifically identify significant differences between the techniques employed in PI (defined broadly to include psychodynamic,…”
MethodCalver, L., Tickle, A., Moghaddam, N. G., & Biswas, S. (2017) · European Journal of Cancer Care · doi:10.1111/ecc.12789 · Cited by 37
“While psychoeducation is a common component of broader psychological interventions (such as cognitive-behavioural therapy; CBT; Blagys & Hilsenroth, 2002), standalone psychoeducation was not considered to be equitably comparable to these more comprehensive (multifaceted and psychological theory-based) interventions.”
BackgroundDie Wirksamkeit psychodynamischer Psychotherapie
Shedler, J. (2011) · Psychotherapeut · doi:10.1007/s00278-011-0819-2 · Cited by 32
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Adherence, flexibility, and outcome in psychodynamic treatment of depression.
Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. J. (2018) · Journal of Counseling Psychology · doi:10.1037/cou0000299 · Cited by 32
“The scale is based upon the findings of two reviews of the empirical comparative psychotherapy process literature (Blagys & Hilsenroth, 2000, 2002), which identified significant differences between the techniques used in PI and CB treatments, and it is comprised of two subscales: the…”
MethodGumz, A., Treese, B., Marx, C., Strauss, B. M., & Wendt, H. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.01705 · Cited by 34
“Reviews on the subject are either concerned with selected types of techniques (e.g., transference interpretation; Høglend, 2004; Brumberg and Gumz, 2012), methodologically flawed (e.g., Blagys and Hilsenroth, 2000, 2002), or out-dated (Elliott et al., 1987).”
BackgroundPhang, C.-K., & Oei, T. P. S. (2012) · Mindfulness · doi:10.1007/s12671-011-0084-z · Cited by 30
“However, themeta-analysis by Blagys and Hilsenroth (2002) has nicely summarized the distinctive processes of CBT: (1) the use of homework outside therapy sessions, (2) the direction of session activities, (3) the teaching of skills for copingwith symptoms, (4) the focus on the client’s present and…”
MethodAffect-Focused Techniques in Psychodynamic Psychotherapy
Diener, M. J., & Hilsenroth, M. J. (2008) · Humana Press eBooks · doi:10.1007/978-1-59745-444-5_10 · Cited by 30
Ekberg, S., Barnes, R., Kessler, D. S., Mirza, S., Montgomery, A. A., Malpass, A., & Shaw, A. R. G. (2014) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465814000241 · Cited by 31
“Socialization into CBT can be achieved using techniques such as orienting clients to the structure of the session (Persons, 2001) and agenda-setting (Blagys and Hilsenrot, 2002).”
MethodWatzke, B., Rüddel, H., Koch, U., Rudolph, M., & Schulz, H. (2008) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.595 · Cited by 29
“…number of studies have analysed core process parameters and their ability to aid in differentiation between CBT and PDT (e.g., Getter, Litt, Kadden, & Cooney, 1992; Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997; Jones & Pulos, 1993; for reviews, see Blagys & Hilsenroth, 2000, 2002).”
BackgroundThe Adolescent Psychotherapy Q-Set (APQ): A Validation Study
Calderón, A., Schneider, C., Target, M., & Midgley, N. (2017) · Journal of Infant Child and Adolescent Psychotherapy · doi:10.1080/15289168.2016.1255499 · Cited by 29
“It was developed by Hilsenroth et al. (2005) based on two empirical reviews of the comparative psychotherapy process literature in adults (Blagys & Hilsenroth, 2000, 2002).”
MethodThe Poetics of Therapeutic Practice: Motivational Interviewing and the Powers of Pause
Carr, E. S., & Smith, Y. (2013) · Culture Medicine and Psychiatry · doi:10.1007/s11013-013-9352-9 · Cited by 28
Siriaraya, P., Visch, V., Boffo, M., Spijkerman, R., Wiers, R. W. H. J., Korrelboom, K., Hendriks, V. M., Salemink, E., van Dooren, M. M. M., Bas, M., et al. (2021) · JMIR Serious Games · doi:10.2196/27953 · Cited by 28
“For example, in a therapeutic activity, clients are generally presented with a list of tasks with different content (referred to as content samples) that they would need to resolve to achieve success in the therapy (eg, in the form of homework and out-of-session activities, which are common tasks in psychotherapy and…”
BackgroundOwen, J. J., Hilsenroth, M. J., & Rodolfa, E. R. (2012) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1792 · Cited by 28
Stein, M. B., Pesale, F. P., Slavin‐Mulford, J. M., & Hilsenroth, M. J. (2009) · Counselling and Psychotherapy Research · doi:10.1080/14733140903229457 · Cited by 27
Early therapy interpersonal process differentiating clients high and low in outcome expectations
Ahmed, M. S., Westra, H. A., & Constantino, M. J. (2012) · Psychotherapy Research · doi:10.1080/10503307.2012.724538 · Cited by 34
“This may be particularly relevant within CBT, which is typically more directive than other therapies (i.e., encourages therapist control; Blagys & Hilsenroth, 2002).”
BackgroundBaier‐Mosch, F., Weiher, G. M., & Kananian, S. (2025) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-025-09664-y · Cited by 26
Larsson, B., Kaldo, V., & Broberg, A. (2009) · Journal of Psychotherapy Integration · doi:10.1037/a0015446 · Cited by 38
Therapists’ techniques in the treatment of adolescent depression.
Midgley, N., Reynolds, S. A., Kelvin, R. G., Loades, M. E., Calderón, A., Martin, P., & O’Keeffe, S. (2018) · Journal of Psychotherapy Integration · doi:10.1037/int0000119 · Cited by 26
“For instance, two review papers found seven distinctive features of short-term psychodynamic psychotherapy (STPP; Blagys & Hilsenroth, 2000) and six distinctive features of cognitive-behavioural therapy (CBT; Blagys & Hilsenroth, 2002).”
Finding Psychodynamic Psychiatry's Lost Generation
Plakun, E. M. (2006) · Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry · doi:10.1521/jaap.2006.34.1.135 · Cited by 26
Successful psychotherapies with young adults: an explorative study of the participants' view
Palmstierna, V., & Werbart, A. (2013) · Psychoanalytic Psychotherapy · doi:10.1080/02668734.2012.760477 · Cited by 26
“Blagys and Hilsenroth (2002) found seven features reliably distinguishing psychodynamic therapy from other therapies: focus on affect and expression of emotion, exploration of attempts to avoid distressing thoughts and feelings, identification of recurring themes and patterns, discussion of past…”
BackgroundChanges in Object Relations over the Course of Psychodynamic Psychotherapy.
Mullin, A. S. J., Hilsenroth, M., Gold, J. R., & Farber, B. A. (2017) · Clinical Psychology and Psychotherapy · doi:10.1002/cpp.2021 · Cited by 24
Ramnerö, J., & Öst, L. (2007) · Psychotherapy Research · doi:10.1080/10503300600650852 · Cited by 24
“This might sound like an odd finding because directivity has been considered a key feature of cognitive and behavioral therapies (Blagys & Hilsenroth, 2002), but directivity was defined here from a client-centered perspective in the instrument used (i.e., as a negative characteristic of therapists).”
BackgroundNeacsiu, A. D., Eberle, J. W., Keng, S., Fang, C. M., & Rosenthal, M. Z. (2017) · Current Psychiatry Reviews · doi:10.2174/1573400513666170612122034 · Cited by 28
Ryum, T., Stiles, T. C., Svartberg, M., & McCullough, L. (2010) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2009.10.005 · Cited by 22
Goodman, G., Reed, P., & Athey-Lloyd, L. (2015) · International Journal of Play Therapy · doi:10.1037/a0038660 · Cited by 22
He, J. A., & Antshel, K. M. (2016) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2016.03.010 · Cited by 30
Cognitive Behavioral and Psychodynamic Therapies: Points of Intersection and Divergence.
Pilecki, B., Thoma, N. C., & Mckay, D. (2015) · Psychodynamic Psychiatry · doi:10.1521/pdps.2015.43.3.463 · Cited by 19
“…exercises is another key difference between CBT and psychodynamic approaches. the uSe oF homeWork The use of homework assignments has become one of the most wellknown features that distinguishes cognitive behavioral therapies with psychodynamic forms of therapy (Blagys & Hilsenroth, 2002).”
Watzke, B., Rüddel, H., Jürgensen, R., Koch, U., Kriston, L., Grothgar, B., & Schulz, H. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.04.005 · Cited by 17
Pitman, S. R., Slavin‐Mulford, J. M., & Hilsenroth, M. J. (2014) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000137 · Cited by 20
“The scale is based upon the findings of two reviews of the empirical comparative psychotherapy process literature (Blagys and Hilsenroth, 2000, 2002), which identified significant differences between the techniques used in psychodynamicinterpersonal (defined broadly to include psychodynamic,…”
BackgroundMethodDieng, M., Kasparian, N. A., Mireskandari, S., Butow, P. N., Costa, D. S. J., Morton, R. L., Mann, G. J., Menzies, S. W., & Cust, A. E. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-015195 · Cited by 19
Dieng, M., Kasparian, N. A., Morton, R. L., Mann, G. J., Butow, P. N., Menzies, S. W., Costa, D. S. J., & Cust, A. E. (2015) · BMC Psychology · doi:10.1186/s40359-015-0074-3 · Cited by 20
“…the telephone-based sessions have been developed in accordance with the latest evidence in melanoma and psycho-oncology research, (McLoone et al. 2013a) as well as core principles of brief psychodynamically-oriented psychotherapy (Abbass et al. 2009; Blagys & Hilsenroth 2002; Shedler 2010).”
MethodTherapist and client processes affecting assimilation and outcome in brief psychotherapy
Rudkin, A., Llewelyn, S. P., Hardy, G. E., Stiles, W. B., & Barkham, M. (2007) · Psychotherapy Research · doi:10.1080/10503300701216298 · Cited by 19
“(For full reviews of comparative process studies identifying differences across approaches, see Blagys & Hilsenroth, 2000, 2002.)”
BackgroundTeaching Psychodynamic Psychotherapy with the Y Model
Goldberg, D. A., & Plakun, E. M. (2013) · Psychodynamic Psychiatry · doi:10.1521/pdps.2013.41.1.111 · Cited by 19
Évaluation des effets des psychothérapies
Thurin, J.-M. (2009) · Encyclopédie médico-chirurgicale. Psychiatrie · doi:10.1016/s0246-1072(09)51470-8 · Cited by 18
“Cette possibilité a été ouverte par le travail de définition des ingrédients spécifiques de ces approches par Blagys et Hilsenroth [79, 80], chez l’adulte pour les thérapies psychodynamiques et cognitivocomportementales, Kramer, De Roten et Despland [81] pour les thérapies systémiques, McLeod et Weisz [82] pour les ps…”
BackgroundPatient early session experience and treatment outcome
Pesale, F. P., Hilsenroth, M. J., & Owen, J. J. (2012) · Psychotherapy Research · doi:10.1080/10503307.2012.662607 · Cited by 19
“Furthermore, all sessions were rated by independent raters using the Comparative Psychotherapy Process Scale (CPPS: Blagys & Hilsenroth, 2000, 2002) to assess treatment adherence.”
MethodMcLay, R. N., Webb-Murphy, J. A., Fesperman, S. F., Delaney, E. M., Gerard, S. K., Roesch, S. C., Nebeker, B. J., Pandzic, I., Vishnyak, E. A., & Johnston, S. L. (2016) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000120 · Cited by 22
Bambery, M., Porcerelli, J. H., & Ablon, J. S. (2007) · Psychotherapy · doi:10.1037/0033-3204.44.4.405 · Cited by 17
Berggraf, L., Ulvenes, P., Øktedalen, T., Hoffart, A., Stiles, T. C., McCullough, L., & Wampold, B. E. (2014) · Psychotherapy · doi:10.1037/a0036581 · Cited by 17
Metadata
- Authors
- Blagys, M. D., & Hilsenroth, M. J.
- Affiliations
- Harvard University (US)
- Adelphi University (US)
- Corresponding author
- Blagys, Matthew D.
- ORCID
- Hilsenroth, Mark J.
- Venue
- Clinical Psychology Review
- Publisher
- Elsevier BV
- Published
- 2002-06
- Volume
- 22
- Issue
- 5
- Pages
- 671-706
- ISSN
- 0272-7358 (ISSN-L)
- OpenAlex
- W1794000606
- Cited by
- 222
- References
- 81
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 4 · 2023: 6 · 2022: 5 · 2021: 6 · 2020: 8 · 2019: 5 · 2018: 12 · 2017: 10 · 2016: 17 · 2015: 15 · 2014: 11 · 2013: 17 · 2012: 17
- FWCI
- 4.85
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Clinical Psychology Review (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, therapeutic process, psychodynamic-interpersonal therapy, homework, skills training, cognitive focus, therapist adherence, therapist competence, psychotherapy training
- MeSH terms
- Adaptation, Psychological, Humans, Outcome and Process Assessment, Health Care, Personality Inventory, Professional-Patient Relations, Cognitive Behavioral Therapy, Critical Pathways
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