Cognitive therapy

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Cognitive therapy
MeSH D015928

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. [1] 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.

Contents

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. [2] 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. [3] 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. [4]

Precursors of certain fundamental aspects of cognitive therapy have been identified in various ancient philosophical traditions, particularly Stoicism. [5] For example, Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers". [6]

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. [7]

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. [8] It divides the mind beliefs in three levels: [9]

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. [10] 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. [11]

Cognitive restructuring (methods)

Cognitive restructuring involves four steps: [12]

  1. 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 [13]
  2. Identification of the cognitive distortions in the ATs
  3. Rational disputation of ATs with the Socratic method
  4. Development of a rational rebuttal to the ATs

There are six types of automatic thoughts: [12]

  1. Self-evaluated thoughts
  2. Thoughts about the evaluations of others
  3. Evaluative thoughts about the other person with whom they are interacting
  4. Thoughts about coping strategies and behavioral plans
  5. Thoughts of avoidance
  6. Any other thoughts that were not categorized

Other major techniques include:

Socratic questioning

Socratic questions are the archetypal cognitive restructuring techniques. These kinds of questions are designed to challenge assumptions by: [16] [17]

  • 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 [18] 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

False assumptions are based on ‘cognitive distortions’, such as: [19]

  • 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.”

Awfulizing and Must-ing

Rational emotive behavior therapy (REBT) includes awfulizing, when a person causes themselves disturbance by labelling an upcoming situation as 'awful', rather than envisaging how the situation may actually unfold, and Must-ing, when a person places a false demand on themselves that something 'must' happen (e.g. 'I must get an A in this exam'.)

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 erroneous or 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) and its "third wave"
a system of approaches drawing from both the cognitive and behavioral systems of psychotherapy. [20] CBT is an umbrella term for a group of therapies, where as CT is a discrete form of therapy. [21] A numbers of treatments have developed that have been derived from CBT and are often labelled as the "third wave" of CBT by its advocates [22] : acceptance and commitment therapy, cognitive behavioral analysis system of psychotherapy, dialectical behavior therapy, EMDR, metacognitive therapy, metacognitive training.

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. [23]

Beck's negative triad holds that depressed people have negative thoughts about themselves, their experiences in the world, and the future. [24] 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. [23]

In 2008 Beck proposed an integrative developmental model of depression [25] that aims to incorporate research in genetics and neuroscience of depression. [26] 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. [27]

Other applications

Cognitive therapy has been applied to a very wide range of behavioral health issues including:

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. [38]

See also

Related Research Articles

Cognitive behavioral therapy Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing unhelpful cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Albert Ellis American psychologist

Albert Ellis was an American psychologist and psychotherapist who founded Rational Emotive Behavior Therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was certified by the American Board of Professional Psychology (ABPP). He also founded, and was the President of, the New York City-based Albert Ellis Institute. He is generally considered to be one of the originators of the cognitive revolutionary paradigm shift in psychotherapy and an early proponent and developer of cognitive-behavioral therapies.

Aaron T. Beck American psychiatrist

Aaron Temkin Beck is an American psychiatrist who is professor emeritus in the department of psychiatry at the University of Pennsylvania. He is regarded as the father of both cognitive therapy and cognitive behavioral therapy. His pioneering theories are widely used in the treatment of clinical depression and various anxiety disorders. Beck also developed self-report measures of depression and anxiety, notably the Beck Depression Inventory (BDI) which became one of the most widely used instruments for measuring depression severity. In 1994, he and his daughter, psychologist Judith S. Beck, founded the nonprofit Beck Institute for Cognitive Behavior Therapy with the goal of providing excellence in CBT treatment, training, and research. Beck currently serves as President Emeritus of the organization.

Cognitive distortion Exaggerated or irrational thought pattern

A cognitive distortion is an exaggerated or irrational thought pattern involved in the onset or perpetuation of psychopathological states, such as depression and anxiety. Psychiatrist Aaron T. Beck laid the groundwork for the study of these distortions, and his student David D. Burns continued research on the topic. In his book Feeling Good: The New Mood Therapy, Burns described personal and professional anecdotes related to cognitive distortions and their elimination.

Rational emotive behavior therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioral problems and disturbances and to help people to lead happier and more fulfilling lives.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, over-generalization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Emotional reasoning is a cognitive process by which an individual concludes that their emotional reaction proves something is true, despite contrary empirical evidence. Emotional reasoning creates an 'emotional truth', which may be in direct conflict with the inverse 'perceptional truth'. It can create feelings of anxiety, fear, and apprehension in existing stressful situations, and as such, is often associated with or triggered by panic disorder or anxiety disorder. For example, even though a spouse has shown only devotion, a person using emotional reasoning might conclude, "I know my spouse is being unfaithful because I feel jealous."

Becks cognitive triad

Beck's cognitive triad, also known as the negative triad, is a cognitive-therapeutic view of the three key elements of a person's belief system present in depression. It was proposed by Aaron Beck in 1976. The triad forms part of his cognitive theory of depression and the concept is used as part of CBT, particularly in Beck's "Treatment of Negative Automatic Thoughts" (TNAT) approach.

Daniel David is a Romanian academic. He is "Aaron T. Beck" professor of Clinical Psychology and Psychotherapy at the Babeș-Bolyai University, Cluj-Napoca. He was the head of the Department of Clinical Psychology and Psychotherapy of the Babeş-Bolyai University between 2007 and 2012. Daniel David is also an adjunct professor at Icahn School of Medicine at Mount Sinai and is the head of the Research Program at Albert Ellis Institute in New York.

Arbitrary inference is a classic tenet of cognitive therapy created by Aaron T. Beck in 1979. He defines the act of making an arbitrary inference as the process of drawing a conclusion without sufficient evidence, or without any evidence at all. In cases of depression, Beck found that individuals may be more prone to cognitive distortions, and make arbitrary inferences more often. These inferences could be general and/or in reference to the effectiveness of their medicine or treatment. Arbitrary inference is one of numerous specific cognitive distortions identified by Beck that can be commonly presented in people with anxiety, depression, and psychological impairments.

Retman

RETMAN is a comics’ character, associated to Rational Emotive Behavior Therapy (REBT). Through it, REBT tries more efficiently address children, adolescents and the general public. This form of therapy approaches the treatment of emotional disorders and the promotion of mental health by modifying maladaptive/irrational behaviors and cognitions (thoughts).

Cognitive reframing is a psychological technique that consists of identifying and then changing the way situations, experiences, events, ideas, and/or emotions are viewed. Cognitive reframing is the process by which such situations or thoughts are challenged and then changed. In the context of cognitive therapy, cognitive reframing is referred to as cognitive restructuring.

Logic-based therapy (LBT) is a proposed modality of philosophical counseling developed by philosopher Elliot D. Cohen beginning in the mid-1980s. It is a philosophical variant of rational emotive behavior therapy (REBT), which was developed by psychologist Albert Ellis. However, there have been no independent, controlled studies to measure its therapeutic value or advantages over classical REBT.

Mike Abrams (psychologist)

Mike Abrams is an American psychologist and co-author with Albert Ellis of several works on rational emotive behavior therapy (REBT) and cognitive behavioral therapy (CBT). He is best known for extending CBT to include principles of evolutionary psychology and collaborating with the founder of CBT Albert Ellis to develop many new applications to for these clinical modalities. His new clinical method which applies evolutionary psychology and behavioral genetics to CBT is called Informed Cognitive Therapy (ICT).

Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.

Vittorio Filippo Guidano was an Italian neuropsychiatrist, creator of the cognitive procedural systemic model and contributor to post-rationalist constructivist cognitive psychotherapy. His cognitive post-rationalist model was influenced by attachment theory, evolutionary epistemology, complex systems theory, and the prevalence of abstract mental processes proposed by Friedrich Hayek. Guidano conceived the personal system as a self-organized entity, in constant development.

Homework in psychotherapy is sometimes assigned to patients as part of their treatment. In this context, homework assignments are introduced to practice skills taught in therapy, encourage patients to apply the skills they learned in therapy to real life situations, and to improve on specific problems encountered in treatment. For example, a patient with deficits in social skills may learn and rehearse proper social skills in one treatment session, then be asked to complete homework assignments before the next session that apply those newly learned skills.

Interpersonal Cognitive Behavioral Therapy (I-CBT) is a branch of cognitive behavioral therapy (CBT) that is mainly used to treat anxiety, depression, attention-deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD), and autism spectrum disorder. It was developed by Thomas Cordier of Glastonbury Connecticut, USA.

Robert L. Leahy American psychologist and author

Robert L. Leahy is a psychologist and author and editor of 28 books dedicated to cognitive behaviour therapy. He is Director of the American Institute for Cognitive Therapy in New York and Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell Medical College. He is Past President of The Association of Behavioral and Cognitive Therapies, The Academy of Cognitive Therapy, and The International Association of Cognitive Therapy. He is the former Editor of The Journal of Cognitive Psychotherapy.

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