37 Cognitive Therapy

G. Padma Priya

1. Introduction

Cognitive therapy, a system developed by Aaron Beck (1960), stresses the importance of belief systems and thinking in determining behavior and feelings. Human beings have cognitions. We can think, we process information coming in through our five senses, and we make interpretations, inferences and evaluations about that information in this way we interact with our environment. These cognitions are believed to be linked to feelings, behavior and physiology. Thus if a situation is perceived (cognition) as a threat by someone adrenalin will be released into the body increasing the heart and breathing rates (physiology), the person will feel fear (affect or emotion) and will react (‘flight or flight’ behavior). Cognitions are available to our conscious minds – we can think about our thoughts and therefore we can change them. Cognitive therapy is based on the cognitive model which we have seen relates the way we think to our emotions and behaviours. The focus of cognitive therapy is on understanding distorted beliefs and using techniques to change maladaptive thinking, while also incorporating affective and behavioral methods. In the therapeutic process, attention is paid to thoughts that individuals may be unaware of and to important belief systems. Working collaboratively with clients, cognitive therapists take an educational role, helping clients understand distorted beliefs and suggesting methods for changing these beliefs.

2. Objective:

• Define terms specific to Cognitive therapy.
• Learn and apply principles, strategies of Cognitive therapy.
• Discuss the goals of Cognitive therapy therapeutic approaches.
• To learn the language and concepts underlying Cognitive therapy.
• To analyze our relationships with one another in terms of Cognitive therapy.

   3. History

Aaron Beck had noticed that the dreams and thoughts of his depressed clients were focused on unrealistic negative ideas, and in 1963 and 1964 published two seminal papers on the relationship between thinking and depression. He analyzed the dreams and psychotherapeutic found evidence of negative bias in their thinking. He later called this bias the negative cognitive triad; depressed people typically have a negative view of themselves, the world and the future. Beck hypothesized that depression was a form of ‘thought disorder’ and concluded that psychoanalytic theory was inadequate to account for his findings.

Over the next decade, Beck extended his ideas to other psychological disorders in particular anxiety. In 1976 he published Cognitive Therapy and the Emotional Disorders in which he described his model of cognitive processing and therapy which focused on teaching his clients to identify and change their thought patterns. Since then Beck’s original model has been extended and adapted to the treatment of all forms of psychological problems including depression, anorexia, phobias, schizophrenia, chronic fatigue syndrome and tinnitus. In Britain researchers, such as Blackburn, Teasdale and Clarke have developed and evaluated Beck’s cognitive therapy and in the USA his daughter Judith has extended his ideas (J.S.Beck, 1995). Beck’s therapy is the most evidence-based, influential and popular of cognitive approaches in use today.

4.  Key concepts in the formation of Psychological Disorders 4.1 Formation Psychological Disorders

As Beck (1967, 1991) has said, psychological distress can be caused by a combination of biological, environmental, and social factors, interacting in a variety of ways, so that there is rarely a single cause for a disorder. Sometimes early childhood events may lead to later cognitive distortions. Lack of experience or training may lead to ineffective or maladaptive ways of thinking, such as setting unrealistic goals or making inaccurate assumption. Regardless of the cause of the psychological disturbance, automatic thought are likely to be a significant part of the processing of the perceived distress.

4.2 Foundations of Cognitive Development

   Cognitive therapists view individual beliefs as beginning in early childhood and developing throughout life. Early childhood experiences lead to basic beliefs about oneself and one’s world. Normally, individuals experiences support and love from parents which in turn lead to positive views of themselves in adulthood and those with healthy functioning, negative experiences in their lives that may lead to beliefs such as “I am unlovable” and “I am inadequate”. These development experiences, along with critical incidents or traumatic experiences, influences’ belief systems. negative experiences, such as being ridicules by a teacher, may lead to conditional beliefs such as “If others don’t like what I do, I am not valuable”. Such beliefs may become basic to the individual as negative cognitive schemas.

4.3 Automatic Thoughts

As mentioned previously, the automatic thought is a key concept in Beck’s cognitive psychotherapy. Such thoughts occur spontaneously, without effort or choice. In psychological disorders, automatic thoughts are often distorted, extreme, or otherwise inaccurate.

4.4 Cognitive Schemas

How individuals think about their world and their important beliefs and assumptions about people, events and the environment constitute schemas. There are two basic types of cognitive schemas: positive (adaptive) and negative (maladaptive). What can be an adaptive schema in one situation may be maladaptive in another. Schemas develop early in life from personal experience and interaction with others. Some of the schemas are associated with cognitive vulnerability or a predisposition to psychological distress.

4.5 Cognitive Distortions

An individual’s important beliefs or schemas are subject to cognitive distortion. Cognitive distortions appear when information processing is inaccurate or ineffective. Several significant cognitive distortions that can be identified in the thought processes of depressed people. Common cognitive distortions that can be found in different psychological disorders are Dichotomous thinking, Selective abstraction, Arbitrary inference, Catastrophizing, Overgeneralization, Labeling and Mislabeling, Magnification or Minimization and Personalization.

4.5.1 Dichotomous thinking: By thinking that something has to be either exactly as we want it or it is a failure, we are engaging in all or nothing, or dichotomous, thinking.

4.5.2 Selective abstraction: Sometimes individual pick out an idea or fact from an event to support their depressed or negative thinking.

4.5.3 Arbitrary inference: Referring to coming to a conclusion that contradicts or is not supported by evidence or facts, arbitrary inferences are of two types: mind reading and negative prediction. Mind reading refers to the idea that we know what another person is thinking about us. Negative prediction means that an individual believes that something bad is going to happen, although there is no evidence to support this. Thus, both mind reading and negative prediction involve making negative inference based on lack of attention to and/or distortion of available data.

4.5.4 Catastrophizing: In this cognitive distortion, individual take one event that they are concerned about and exaggerate it so that they become fearful.

4.5.5 Overgeneralization: Making a rule based on a few negative events, individuals distort their thinking through overgeneralization.

4.5.6 Labeling and Mislabeling: A negative view of oneself is created by self-labeling based on some errors or mistakes.

4.5.7 Magnification or Minimization: Cognitive distortions can occur when individuals magnify imperfections or minimize good points.

4.5.8 Personalization: Taking an event that is unrelated to the individual and making it meaningful produces the cognitive distortion of personalization.

If they occur frequently, such cognitive distortions can lead to psychological distress or disorders. Making inference and drawing conclusions from a behavior are important parts of human functioning. Individuals must monitor what they do and assess the likelihood of outcomes to make plans about their social lives, romantic lives and careers. When there are frequent cognitive distortions, individuals can no longer do this successfully and may experience depression, anxiety or other disturbances. Cognitive therapists look for cognitive distortions and help their patients understand their mistakes and make changes in their thinking.

5.  Process of Cognitive Therapy 5.1 Goals of Therapy

The basic goal of cognitive therapy is to remove biases or distortions in thinking so that individuals may function more effectively. Attention is paid to the way individuals process information, which may maintain feelings ad behaviors that are not adaptive. Patients’ cognitive distortions are challenged, tested and discussed to bring about more positive feelings, behaviors and thinking. In establishing goals, cognitive therapists focus on being specific, prioritizing goals and working collaboratively with clients. The goals may have affective, behavioral and cognitive components. The clear and more concrete the goals, the easier it is for therapists to select methods to use in helping individuals change their belief systems and also their feelings and behaviors.

5.2 Assessment in Cognitive Therapy

Careful attention is paid to assessment of client problems and cognitions, both at the beginning of therapy and throughout the entire process in order that the therapist may clearly conceptualize and diagnose the client’s problems. As assessment proceeds, it focuses not only on the specific thoughts, feelings and behaviors of the client but also on the effectiveness of therapeutic techniques as they affect these thoughts, feeling and behaviors. In this section the various assessment techniques used by cognitive therapists are client interviews, self-monitoring, thought sampling and self-report questionnaires.

5.2.1 Interviews: in the initial evaluation, the cognitive therapist may wish to get an overview of a variety of topics, while at the same time creating a good working relationship with the client. The topics covered are a developmental history (including family, school, career and social relationships), past traumatic experiences, medical and psychiatric history and client goals. Open-ended questions are used to yield more accurate information.

5.2.2 Self-monitoring: Self monitoring is used for assessing client thoughts emotions and behaviors clients keep a record of events, feelings and/ or thoughts. This could be done in a diary, on an audiotape or by filling out a questionnaire.

5.2.3 Thought sampling: Inspecting the tone sound at a random interval at home and then recording thoughts is one way to get a sample of cognitive patterns. Clients may then recording thoughts is one way to get a sample of book. Thought sampling can be useful in getting data that is related to specific situations, such as work and school.

5.2.4 Scales and questionnaires: In addition to these techniques, previously developed self-report questionnaires or rating scales can be used to assess irrational beliefs, self-statements or cognitive distortions.

5.3 The Therapeutic Process

Cognitive therapy is structured in its approach. The initial session or sessions deals with assessment of the problem, development of a collaborative relationship and case conceptualization. As therapy progresses, a guided discovery approach are used to help clients learn about their inaccurate thinking. Other important aspects of the therapeutic process are methods to identify automatic thoughts and the assignment of homework, which is done throughout therapy. As clients reach their goals, termination is planned and clients work on how they will use what they have learned when therapy has stopped. As therapeutic work progresses, clients move from developing insight into their beliefs to moving toward change.

5.4 Therapeutic techniques used by cognitive therapists

A wide variety of cognitive techniques are used in helping clients achieve their goals. Some of the techniques focus on eliciting and challenging automatic thoughts, others on maladaptive assumptions or ineffective cognitive schemes. The general approach in cognitive therapy is not to interpret automatic thoughts or irrational beliefs, but to examine them through either experimentation or logical analysis.

5.4.1 Understanding idiosyncratic meaning: Often it is not enough for therapists to assume that they know what the client means by certain words. For example, depressed people are often likely to use vague words such as upset, loser, depressed or suicidal. Interrogation helps both therapist and client to understand the client’s thinking process.

5.4.2 Challenging absolutes: Clients often present their distress through making extreme statements such as “Everyone at work is smarter than I am”. Often it is helpful for the therapist to question or challenge the absolute statement so that it can be presented more accurately by the client.

5.4.3 Reattribution: Clients may attribute responsibility for situations or events to themselves when they have little responsibility for the event. Using the technique of reattribution, therapists help clients fairly distribute responsibility for an event.

5.4.4 Labeling of distortions: Dichotomous thinking, overgeneralization, labeling such distortions can be helpful to clients in categorizing automatic thoughts that interfere with their reasoning.

5.4.5 Decatastrophizing: Clients may be very afraid of an outcome that is unlikely to happen.

5.4.6 Challenging dichotomous thinking: Sometimes clients describe things as all or nothing or as all black or all white.

5.4.7 Listings advantages and disadvantages: Sometimes it is helpful for patients to write down the advantages and disadvantages of their particular beliefs or behaviors.

5.4.8 Cognitive rehearsal: Use of imagination in dealing with upcoming events can be helpful.

6. Treatment of psychological disorders using cognitive therapy

Cognitive therapists have probably developed explanations and specific treatments for most psychological disorders. Particularly two disorders for depression and general anxiety, they have provided a detailed approach to treatment and have been able to test these approaches through the application of outcome research. The type of cognitive distortions that patients experience can vary within each disorders.

6.1 Overview of Cognitive Therapy

Cognitive therapy is based on the formulation that how one thinks largely determines how one feels and behaves. Therapy is a collaborative process of empirical investigation, experimentation, reality testing and collaborative problem solving between therapist and client. The client’s maladaptive conceptions, interpretations and conclusions are subject to scientific scrutiny and hypothesis testing. Cognitive and behavioral experiments as well as verbal techniques “are used to explore alternative interpretations and to generate contradictory evidence that supports more adaptive beliefs and leads to therapeutic change” in the client.

6.2 Relaxation Training and Relaxation Therapy

The development of effective relaxation strategies has played an important role in the emergence of cognitive therapy as a visible system of helping. Modern problems commonly amenable to remediation through relaxation training and relaxation therapy include stress, anxiety, physiological problems and pressures related to the workplace and the fast pace of modern lifestyles.

One example of the effective use of relaxation therapy would be helping a client with no organic disorders whose presenting problem is headaches and vomiting attributed to severe test anxiety. Relaxation therapy would be used to teach the client how to

1)  Relax all muscle groups and put the whole body in a state of complete physical relaxation

2) Relax mentally (cognitively)

3) Reduce anxiety while being totally relaxed

4) Keep out extraneous background cognitions while working on the test anxiety, and

5) Use self-relaxation permanently to control not only test anxiety but other debilitating stresses as well.

The theoretical principle underlying relaxation therapy is that it is not possible for the human organism to be in a state of complete physical relaxation and at the same time be emotionally anxious. Thus, the therapist applying the cognitive strategy of relaxation assumes the client is physically relaxed in a way that associates that relaxed feeling and image with being cognitively relaxed in the examination room.

6.3 Cognitive Modeling

Cognitive modeling was developed by a number of therapists who wanted to find ways to help clients learn what to say to themselves to ensure that they would avoid self-defeating thoughts and behaviors while performing tasks that they want to complete. Cognitive modeling (Beck, 1976) is a combination of overt and covert strategies. In a structured, systematic series of modeling episodes, the therapist usually employs five steps, such as those demonstrated in the following example, to help the client learn and independently use cognitive modeling. Consider the example of a therapist helping a male graduate student overcome the fear and intimidation that keep him from asking his advisory committee chair to step down so that he may acquire a different chair. Here, the five steps of cognitive modeling are as follows:

1. The therapist serves as a model (taking the role of the student);
2. The client is instructed to perform the task (as modeled by the therapist) while the therapist instructs the client aloud;
3. The client is asked to perform the same task again while instructing himself aloud;
4. The client whispers the instructions while performing the task of confronting the imaginary advisory chair; and
5. The client performs the task while instructing himself covertly. In the final step, the student confronts his advisory chair entirely by himself and in a purely cognitive mode. He performs, under instruction of the therapist describe as cognitive modeling with cognitive self-instruction.

6.4 Covert Modeling

Covert modeling has been used extensively to teach clients mentally to envision a model (preferably themselves performing an imaginary task) successfully accomplishing a desired goal.

Covert modeling provides a variety of effective, efficient and creative ways to help clients visualize themselves engaging in positive and successful actions. It is similar to cognitive modeling except that the client does not model or perform overtly. All the steps of the modeling, which are similar to the steps in cognitive modeling, are described aloud by the therapist, with the client relaxed and being verbally instructed to imagine the scenes the therapist presents.

6.5 Thought Stopping

Thought stopping has been widely used to help clients control unproductive, debilitating and self-defeating thoughts and images through both sudden and progressively systematic elimination of maladaptive thoughts and emotions. The procedure involves instructing clients to focus on the unwanted thoughts trial. After several days of practice the client can maintain control covertly by shouting “stop” each time the unwanted thought occurs as soon as the client becomes familiar enough with the strategy to exercise self-control autonomously, he or she is given homework assignments of practicing self-control through thought stopping in situations outside therapy.

6.6 Neurolinguistic Programming

Neurolinguistic programming (NLP) is the name derived from a communication theory whereby people wield five sensory channels, referred to as representational systems, to process information. These channels are termed (1) visual (sight), (2) auditory (hearing), (3) kinesthetic (feeling), (4) olfactory (smell), and (5) gustatory (taste). For communication and therapy purposes, the visual, auditory and kinesthetic channels are the most important.

Neurolinguistic programming is a powerful tool for the therapist to use in effectively establishing rapport and maintaining an empathic relationship with clients. When the therapist can identify and utilize the sensory channel that the client predominantly uses, he or she can match or pace the client’s inner experience. For example, different clients might use different predicate verbs to indicate sensory ways of communicating (mapping) their inner experience: (1) visual (“I see that….”); (2) auditory (“I hear that …”); or (3) kinesthetic (“I feel that…”).

Lankton notes that the therapist who can match the predicates of clients “will literally be speaking the client’s language”(p.19). NLP can be effectively used to pace the client’s verbal and nonverbal cues, thus allowing the therapist to understand more fully the client. Pacing involves synchrony between the therapist and the client’s verbal and nonverbal behavior.

7. Conclusion:

Developed by Aaron Beck, from his observations about the impact of patients’ belief systems on their psychological functioning, cognitive therapy examines the effect of maladaptive thinking on psychological disorders, while at the same time acknowledging the importance of affect and behavior on psychological functioning. As cognitive therapy has developed, it has continued to draw on psychological research into individuals’ belief systems, as well as on the study of how people process information from their environment.

Cognitive therapy has been used with all ages, from children to the elderly. Beck reports that several controlled studies have shown it to be at least as effective as antidepressant medication in treating elderly depressed clients. Cognitive therapy has been used for group work with families. Some newer applications of cognitive therapy include working with clients with schizophrenia, post-traumatic stress disorders, substance abuse problems, hypertension and dissociative disorders as well as with clients who have committed sexual offences, such as exhibitionism and incest.

Although the cognitive movement is relatively new, it is rapidly developing and has a great many adherents. Cognitive behavior therapy shows great promise as a methodology for therapist and other helpers. It can help clients with assorted problems to use the full power and potential of their minds to gain control of their thinking, emotions, and behavior.

Web links

• http://www.counselling-directory.org.uk/cognitive-therapy.html
• https://www.cognitivetherapynyc.com/What-Is-Cognitive-Therapy.aspx
• http://www.cognitivetherapyguide.org/cognitive-therapy.htm