Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one of the therapeutic approaches within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. This involves the individual working collaboratively with the therapist to develop skills for testing and modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. A tailored cognitive case conceptualization is developed by the cognitive therapist as a roadmap to understand the individual's internal reality, select appropriate interventions and identify areas of distress.
History
Becoming disillusioned with long-term psychodynamic
approaches based on gaining insight into unconscious emotions and
drives, Beck came to the conclusion that the way in which his patients
perceived, interpreted and attributed meaning in their daily lives—a
process scientifically known as cognition—was a key to therapy. Albert Ellis
had been working on similar ideas since the 1950s (Ellis, 1956). He
called his approach Rational Therapy (RT) at first, then Rational
Emotive Therapy (RET) and later Rational Emotive Behavior Therapy (REBT).
Beck outlined his approach in Depression: Causes and Treatment in 1967. He later expanded his focus to include anxiety disorders, in Cognitive Therapy and the Emotional Disorders in 1976, and other disorders and problems.
He also introduced a focus on the underlying "schema"—the fundamental
underlying ways in which people process information—about the self, the
world or the future.
The new cognitive approach came into conflict with the behaviorism
ascendant at the time, which denied that talk of mental causes was
scientific or meaningful, rather than simply assessing stimuli and
behavioral responses. However, the 1970s saw a general "cognitive
revolution" in psychology. Behavioral modification techniques and cognitive therapy techniques became joined together, giving rise to cognitive behavioral therapy.
Although cognitive therapy has always included some behavioral
components, advocates of Beck's particular approach seek to maintain and
establish its integrity as a distinct, clearly standardized form of
cognitive behavioral therapy in which the cognitive shift is the key
mechanism of change.
Precursors of certain fundamental aspects of cognitive therapy
have been identified in various ancient philosophical traditions,
particularly Stoicism.
For example, Beck's original treatment manual for depression states,
"The philosophical origins of cognitive therapy can be traced back to
the Stoic philosophers".
As cognitive therapy continued to grow in popularity, the Academy
of Cognitive Therapy, a non-profit organization, was created to
accredit cognitive therapists, create a forum for members to share
emerging research and interventions, and to educate consumer regarding
cognitive therapy and related mental health issues.
Basis
Therapy may
consist of testing the assumptions which one makes and looking for new
information that could help shift the assumptions in a way that leads to
different emotional or behavioral reactions. Change may begin by
targeting thoughts (to change emotion and behavior), behavior (to change
feelings and thoughts), or the individual's goals (by identifying
thoughts, feelings or behavior that conflict with the goals). Beck
initially focused on depression and developed a list of "errors" (cognitive distortion) in thinking that he proposed could maintain depression, including arbitrary inference, selective abstraction, over-generalization, and magnification (of negatives) and minimization (of positives).
As an example of how CT might work: Having made a mistake at
work, a man may believe, "I'm useless and can't do anything right at
work." He may then focus on the mistake (which he takes as evidence that
his belief is true), and his thoughts about being "useless" are likely
to lead to negative emotion (frustration, sadness, hopelessness). Given
these thoughts and feelings, he may then begin to avoid challenges at
work, which is behavior that could provide even more evidence for him
that his belief is true. As a result, any adaptive response and further
constructive consequences become unlikely, and he may focus even more on
any mistakes he may make, which serve to reinforce the original belief
of being "useless." In therapy, this example could be identified as a
self-fulfilling prophecy or "problem cycle," and the efforts of the
therapist and patient would be directed at working together to explore
and shift this cycle.
People who are working with a cognitive therapist often practice
the use of more flexible ways to think and respond, learning to ask
themselves whether their thoughts are completely true, and whether those
thoughts are helping them to meet their goals. Thoughts that do not
meet this description may then be shifted to something more accurate or
helpful, leading to more positive emotion, more desirable behavior, and
movement toward the person's goals. Cognitive therapy takes a
skill-building approach, where the therapist helps the person to learn
and practice these skills independently, eventually "becoming his or her
own therapist."
Cognitive model
The cognitive model was originally constructed following research
studies conducted by Aaron Beck to explain the psychological processes
in depression.
It divides the mind beliefs in three levels:
- Automatic thought
- Intermediate belief
- Core belief or basic belief
In 2014, an update of the cognitive model was proposed, called the
Generic Cognitive Model (GCM). The GCM is an update of Beck's model that
proposes that mental disorders can be differentiated by the nature of their dysfunctional beliefs. The GCM includes a conceptual framework and a clinical approach for understanding common cognitive processes of mental disorders while specifying the unique features of the specific disorders.
Consistent with the cognitive theory of psychopathology, CT is
designed to be structured,
directive, active, and time-limited, with the express purpose of
identifying, reality-testing, and correcting distorted cognition and
underlying dysfunctional beliefs.
Cognitive restructuring (methods)
Cognitive restructuring involves four steps:
- Identification of problematic cognitions known as "automatic thoughts" (ATs) which are dysfunctional or negative views of the self, world, or future based upon already existing beliefs about oneself, the world, or the future
- Identification of the cognitive distortions in the ATs
- Rational disputation of ATs with the Socratic method
- Development of a rational rebuttal to the ATs
There are six types of automatic thoughts:
- Self-evaluated thoughts
- Thoughts about the evaluations of others
- Evaluative thoughts about the other person with whom they are interacting
- Thoughts about coping strategies and behavioral plans
- Thoughts of avoidance
- Any other thoughts that were not categorized
Other major techniques include:
- Activity monitoring and activity scheduling
- Behavioral experiments
- Catching, checking, and changing thoughts
- Collaborative empiricism: therapist and patient become investigators by examining the evidence to support or reject the patient's cognitions. Empirical evidence is used to determine whether particular cognitions serve any useful purpose.
- Downward arrow technique
- Exposure and response prevention
- Cost benefit analysis
- acting 'as if’
- Guided discovery: therapist elucidates behavioral problems and faulty thinking by designing new experiences that lead to acquisition of new skills and perspectives. Through both cognitive and behavioral methods, the patient discovers more adaptive ways of thinking and coping with environmental stressors by correcting cognitive processing.
- Mastery and pleasure technique
- Problem solving
- Socratic questioning: involves the creation of a series of questions to a) clarify and define problems, b) assist in the identification of thoughts, images and assumptions, c) examine the meanings of events for the patient, and d) assess the consequences of maintaining maladaptive thoughts and behaviors.
Socratic questions are the archetypal cognitive restructuring
techniques. These kinds of questions are designed to challenge
assumptions by:
- Conceiving reasonable alternatives:
‘What might be another explanation or viewpoint of the situation?
Why else did it happen?’
- Evaluating those consequences:
‘What’s the effect of thinking or believing this?
What could be the effect of thinking differently and no longer holding onto this belief?’
- Distancing:
‘Imagine a specific friend/family member in the same situation or if
they viewed the situation this way, what would I tell them?’
Examples of socratic questions are:
- ‘Describe the way you formed your viewpoint originally.‘
- ‘What initially convinced you that your current view is the best one available?‘
- ‘Think of three pieces of evidence that contradict this view, or that support the opposite view. Think about the opposite of this viewpoint and reflect on it for a moment. What's the strongest argument in favor of this opposite view?‘
- ‘Write down any specific benefits you get from holding this belief, such as social or psychological benefits. For example, getting to be part of a community of like-minded people, feeling good about yourself or the world, feeling that your viewpoint is superior to others', etc Are there any reasons that you might hold this view other than because it's true?‘
- ‘For instance, does holding this viewpoint provide some peace of mind that holding a different viewpoint would not?‘
- ‘In order to refine your viewpoint so that it's as accurate as possible, it's important to challenge it directly on occasion and consider whether there are reasons that it might not be true. What do you think the best or strongest argument against this perspective is?‘
- What would you have to experience or find out in order for you to change your ‘mind about this viewpoint?‘
- Given your thoughts so far, do you think that there may be a truer, more accurate, or more nuanced version of your original view that you could state right ‘now?‘
False assumptions are based on ‘cognitive distortions’, such as:
- Always Being Right: “We are continually on trial to prove that our opinions and actions are correct. Being wrong is unthinkable and we will go to any length to demonstrate our rightness. For example, “I don’t care how badly arguing with me makes you feel, I’m going to win this argument no matter what because I’m right.” Being right often is more important than the feelings of others around a person who engages in this cognitive distortion, even loved ones.”
- Heaven’s Reward Fallacy: “We expect our sacrifice and self-denial to pay off, as if someone is keeping score. We feel bitter when the reward doesn’t come.”
Types
- Cognitive therapy
- based on the cognitive model, stating that thoughts, feelings and behavior are mutually influenced by each other. Shifting cognition is seen as the main mechanism by which lasting emotional and behavioral changes take place. Treatment is very collaborative, tailored, skill-focused, and based on a case conceptualization.
- Rational emotive behavior therapy (REBT)
- based on the belief that most problems originate in irrational thought. For instance, perfectionists and pessimists usually suffer from issues related to irrational thinking; for example, if a perfectionist encounters a small failure, he or she might perceive it as a much bigger failure. It is better to establish a reasonable standard emotionally, so the individual can live a balanced life. This form of cognitive therapy is an opportunity for the patient to learn of his current distortions and successfully eliminate them.
- Cognitive behavioral therapy (CBT)
- a system of approaches drawing from both the cognitive and behavioral systems of psychotherapy.
Unlike Psychodynamic approaches, CBT is transparent to the individual
receiving services. At the end of the therapy, an individual will often
have learned the cognitive therapy skills well enough to "be their own
therapist," decreasing dependence on a therapist to provide the answers.
Application
Depression
According to Beck's theory of the etiology of depression, depressed people acquire a negative schema
of the world in childhood and adolescence; children and adolescents who
experience depression acquire this negative schema earlier. Depressed
people acquire such schemas through a loss of a parent, rejection by
peers, bullying, criticism from teachers or parents, the depressive
attitude of a parent and other negative events. When the person with
such schemas encounters a situation that resembles the original
conditions of the learned schema in some way, the negative schemas of
the person are activated.
Beck's negative triad holds that depressed people have negative thoughts about themselves, their experiences in the world, and the future.
For instance, a depressed person might think, "I didn't get the job
because I'm terrible at interviews. Interviewers never like me, and no
one will ever want to hire me." In the same situation, a person who is
not depressed might think, "The interviewer wasn't paying much attention
to me. Maybe she already had someone else in mind for the job. Next
time I'll have better luck, and I'll get a job soon." Beck also
identified a number of other cognitive distortions,
which can contribute to depression, including the following: arbitrary
inference, selective abstraction, overgeneralization, magnification and minimization.
In 2008 Beck proposed an integrative developmental model of depression that aims to incorporate research in genetics and neuroscience of depression.
This model was updated in 2016 to incorporate multiple levels of
analyses, new research, and key concepts (e.g., resilience) within the
framework of an evolutionary perspective.
Other applications
Cognitive therapy has been applied to a very wide range of behavioral health issues including:
- Academic achievement
- Addiction
- Anxiety disorders
- Bipolar disorder
- Low self-esteem
- Phobia
- Schizophrenia
- Substance abuse
- Suicidal ideation
- Weight loss
Criticisms
A criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind
(i.e., neither subjects nor therapists in psychotherapy studies are
blind to the type of treatment). They may be single-blinded, the rater
may not know the treatment the patient received, but neither the
patients nor the therapists are blinded to the type of therapy given
(two out of three of the persons involved in the trial, i.e., all of the
persons involved in the treatment, are unblinded). The patient is an
active participant in correcting negative distorted thoughts, thus quite
aware of the treatment group they are in.
