Cognitive Psychotherapy: Theory and Practice
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The writings of cognitive psychologist George Kelly had a prominent impact, especially his personal construct theory, which, along with Piaget's 46 idea of schemata, evolved into Beck's similar definition of schemas. The cognitive theory of emotions by Richard Lazarus, 47 the problem-solving approach by Goldfried and D'Zurilla, 48 the self-management models by Albert Bandura, 49 and Donald Meichenbaum, 50 along with cognition-oriented writers, such as Arnold Lazarus, 51 also influenced cognitive theory and therapy.
CT's emphasis on a problem-solving approach to conscious problems was also adopted by Ellis's rational-emotional-behavior therapy. The scientific approach espoused by behavior therapy contributed to diverse therapeutic procedures and strategies, such as the session structure, the greater activity by the therapist, the setting of treatment goals for the entire therapy as well as of an agenda for each session, the formulation and test of hypotheses, the elicitation of feedback, the use of problem-solving techniques and social skills training, the assignment of between-sessions homework and experiments, and the measurement of mediational variables and outcomes.
However, from a philosophical point of view, CT may be seen as much more humanistic, exploratory, as it works with constructs such as the mind, and deals with feelings and thoughts, whereas many would see behavior therapy as too mechanistic. Again, following the information-processing approach, the major principle of CT is that the way individuals perceive and process reality will influence the way they feel and behave. Thus, the therapeutic goal of CT, since its very origins, has been to reframe and correct these distorted thoughts, and collaboratively endeavor pragmatic solutions to engender behavioral change and ameliorate emotional disorders.
Cognitive therapy posits that there are thoughts at the fringe of awareness that occur spontaneously and rapidly, and are an immediate interpretation of any given situation. They are generally accepted as plausible, and their accuracy is taken for granted. Most people are not immediately aware of the presence of automatic thoughts, unless they are trained at monitoring and identifying them.
According to Beck, 52 "it is just as possible to perceive a thought, focus on it, and evaluate it as it is to identify and reflect on a sensation as pain". Some of the cognitive distortions found across different emotional disorders are summarized in Table 1. In the roots of these distorted automatic interpretations are deeper dysfunctional thoughts called schemas also called core beliefs, and used interchangeably by many authors. Once a particular basic belief is formed it may influence the subsequent formation of new related beliefs, and if they persist, they are incorporated into the enduring cognitive structure or schema.
Schemas are acquired early in an individual's development, and act as "filters" through which current information and experience is processed. These beliefs are molded by personal experiences and derived from identification with significant others and from the perception of other people's attitudes toward them. The child's environment either facilitates the emergence of particular types of schemas or tends to inhibit them.
The schemas of well-adjusted individuals allow for realistic appraisals, while those of maladjusted individuals lead to distortions of reality, fostering, in turn, psychological disorder. Schemas have a variety of properties, such as permeability, flexibility, breadth, density, and also a degree of emotional charge, 5 which may determine the difficulties or facilities encountered in the treatment process.
Even though latent or inactive at given times, schemas, e. Associated with these dysfunctional core beliefs are subjacent individual conditional beliefs that lead to assumptions such as "If I don't have a loving wife, I'm nothing " and rules such as " A man cannot live without a wife ". The activation of these schemas interferes with the capacity for objective appraisal of events, and reasoning becomes impaired. Systematic cognitive distortions e. As tentative coping strategies to avoid getting in contact with their core and underlying beliefs, patients may engage in compensatory strategies.
Although these cognitive and behavioral maneuvers alleviate their emotional suffering momentarily, in the long run compensatory strategies may reinforce and worsen dysfunctional beliefs. There is a reciprocal relationship between affect and cognition, as increasing emotional and cognitive impairment may result from one reinforcing the other.
For example, if an individual holds a cognitive vulnerability to themes of loss and failure, the emotional and behavioral consequences will include sadness, a sense of hopelessness, and social withdrawal, as found in depression. If other individuals hold danger-oriented beliefs, anxiety will prevail and predispose them to narrow their attention to perceived threat, make catastrophic interpretations of ambiguous or even neutral stimuli, 8 and engage in dysfunctional "safety behaviors"; they will be impelled to seek escapes or avoid the risk of perceived rejection, embarrassment or death.
In patients with vulnerability to themes of humiliation, unfairness or the like, anger will be the tone, and a behavioral response in a retaliatory manner might be justified as a self-defense 52 Each personality disorder is also characterized by a specific personal set of dysfunctional cognitive contents, such as defectiveness, abandonment, dependency, or need for a special status, which constitute the individual's cognitive vulnerability.
When activated by external events, drugs, or endocrine factors, these schemas tend to bias the information processing and produce the typical cognitive content of a specific disorder, with its own cognitive constellation and idiosyncratic set of beliefs.
In This Article
Beck's model of vulnerability to depression was refined 56 to suggest that predisposing beliefs could be differentiated according to whether the patient's personality was primarily autonomous or sociotropic. Autonomous individuals would more likely become depressed following an autonomous event e. CT is not a set of techniques applied mechanically as we would think at a first glance. The therapist's competence in a full range of therapeutic skills is needed to ensure efficacy to CT procedures. As Beck points out, first and primarily, to fulfill the therapeutic endeavor, it is important to establish a good working relationship with the patient, a therapeutic procedure called collaborative empiricism.
Patient and therapist work as a team of scientists in evaluating the patient's beliefs, testing them out to see whether they are accurate or not, and modifying them according to reality. Second, the therapist uses Socratic questioning as a means to guide the patient in a mindful questioning that will enable patients to have insight over their distorted thinking, a procedure called guided discovery.
Throughout the treatment, the collaborative and psychoeducational approach to treatment is used, with specific learning experiences designed to teach clients to: 1 monitor and identify automatic thoughts; 2 recognize the relationships among cognition, affect, and behavior; 3 test the validity of automatic thoughts and core beliefs; 4 correct biased conceptualizations by replacing distorted thoughts with more realistic cognitions; and 5 identify and alter beliefs, assumptions, or schemas that underlie faulty thinking patterns. In contrast to psychoanalytical therapies, CT sessions have a structure in which the cognitive therapist plays an active role in helping the patient identify and focus on important areas, proposing and rehearsing specific cognitive and behavioral techniques, and collaboratively planning between-sessions assignments.
A treatment plan for the whole therapy and the agenda for each session are discussed with the patient, and a feedback of the patient's thoughts about the ongoing session and the whole treatment is routinely asked in order to create the opportunity to treat and handle any misconceptions and misunderstandings that might arise over the course of therapy. The cognitive therapist has to be a good strategist to devise specific therapeutic procedures that have higher chances of producing specific changes for that particular patient.
CT encourages their patients to adopt the empirical problem-solving approach of scientists, and the therapist serves as a role model for their patients by instilling self-efficacy, enthusiasm and hopefulness about the challenging work of changing maladaptive cognitions. Although transference, as defined in psychoanalytic concept, is not encouraged, its manifestation might be a valuable tool in demonstrating to patients their interpersonal distortions.
Cognitive Behavioral Therapy
Similarly, any manifestation of resistance to treatment is dealt with and treated as underlying dysfunctional beliefs. From the very beginning of treatment, the therapist develops ideally in a collaborative manner, as always a cognitive conceptualization for the individual patient.
- How and Where CBT Is Used;
- Contemporary Cognitive Therapy: Theory, Research, and Practice.
Case conceptualization is an ongoing work throughout a treatment course; as new important clinical data are brought into therapy, cognitive conceptualization will be changed and updated as needed while the treatment progresses. To prepare a treatment plan, an individual case conceptualization is strongly needed, as it guides therapeutic interventions. Case conceptualization holds both a historical and prospective evaluation of thought patterns and thinking styles. It will include an understanding of the idiosyncratic set of dysfunctional beliefs, individual specific vulnerabilities, and the behavioral strategies patients use in attempting to cope with their core beliefs.
The separation of CT interventions into cognitive techniques and behavioral techniques is only for instructive purposes, in that many of the techniques affect both patient's thought processes and behavioral patterns. As we know, cognitive change fosters behavioral change, and vice-versa. A number of different techniques may be used depending on the cognitive profile of the disorder, the phase of therapy, and the specific cognitive conceptualization of a given case. Behavioral techniques might be more used in cases of severe depression in which there is a need to promote the patient's behavioral activation.
Conversely, when the patient does not primarily need behavioral activation, more purely cognitively oriented procedures may be applied. For patients with anxiety disorders, an understanding of the fundamental principles of the cognitive model will probably be necessary before the introduction of any behavioral experiment. A variety of cognitive techniques are used in CT, such as the identification, questioning, and correction of automatic thoughts, reattribution and cognitive restructuring, cognitive rehearsal, and other imagery therapeutic procedures.
Among the behavioral techniques, there are, for example, activity scheduling, mastery and pleasure ratings, graded-task behavioral assignments, reality testing experiments, role-playing, social skills training, and problem-solving techniques. We will present briefly a small sample of cognitive techniques first. Initial treatment focuses on the increase of the patients' awareness of automatic thoughts, and further work will focus on core and underlying beliefs.
Treatment may start by identifying and questioning automatic thoughts, which can be done in different ways. The therapist can guide patients to assess their automatic thoughts, especially when there is a perceived emotional arousal during the session, by simply asking: " What is going through your mind?
Cognitive distortions may be unveiled by asking, for example, " What are the evidences for your conclusion? When asked to reflect on alternative explanations, patients may realize that their initial explanations evolved through invalid inferences, which leads them to think of different interpretations of events, thus attaching new attributions and meanings to them.
Science and Practice in Cognitive Therapy: Foundations, Mechanisms, and Applications
Most people are unaware that negative automatic thoughts precede unpleasant feelings and behavioral inhibitions, and that the emotions are consistent with the content of the automatic thoughts. To increase their awareness of these thoughts, patients can learn to track them and with systematic training pinpoint what kind of thoughts occurred immediately before an emotion, a behavior, and a physiologic reaction as consequences of that thought Ellis' ABC sequence. The Dysfunctional Thought Record DTR , as depicted by Judith Beck 57 Table 4 , may be used to help track the thoughts that were activated by the stimulus situation and that generated the consequent emotion and behavior.
A DTR exercise may enable patients to discover, clarify and change the meanings they have assigned to upsetting events and compose an alternative or rational response. Sometimes, the simple task of identifying cognitive errors Table 1 , alone or in combination with the filling out of a DTR, might be a good exercise to work on at the office or as a homework assignment. For structural changes to occur, they have to go far beyond changing cognitive errors associated with a specific syndrome.
Only through the analysis and correction of the more ingrained beliefs, changing the organization of these beliefs, cognitive restructuring may be accomplished. Treatment has to focus on the patient's core beliefs, such as " I'm unlovable" , and underlying beliefs, such as " If I don't have a wife, then I'm a failure " which are re-evaluated in the same way as automatic thoughts, that means, looking for evidence that supports them and correcting them with reality testing. Cognitive rehearsal is an imagery technique devised to help patients experience their feared situations by imagining that it is occurring right at that moment.
At the office or as a between-session assignment, patients are asked to "live through" the feared situation in imagery and build up the best coping strategies to overcome it successfully. In the same manner, through imagery, patients can rehearse problem solving and assertiveness training as needed to overcome their problem situations. Behavioral techniques are integrated into a CT treatment program in many different forms.
When chronic and severely depressed patients have their activity level reduced, and are reluctant to commit themselves to any goal because they have low expectations about any achievements, behavioral activation procedures should be promoted.
For instance, a depressed woman may believe she is no more capable of preparing a Sunday dessert that her grandchildren liked so much; as a matter of fact, she even believes she is unable to stay out of bed long enough to do almost anything, let alone to prepare a dessert. To gather evidence of her expected capacity of mastery on dessert preparation and expected capacity of experiencing pleasure with her cooking skills, she is stimulated to rate her mastery and pleasure expectations before performing the task on Sunday morning and compare them to what her thoughts and feelings actually were after she completed the assigned task.
She will probably receive, as usual, many positive feedbacks, which will help her correct inaccurate mastery and pleasure ratings. Frequently depressed patients have dysfunctional expectations about their capabilities when feeling depressed, and are surprised at a much better outcome than they expected.
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As the patient puts them to test, the outcome brings a different perspective. As patients are able to appraise their thoughts more objectively, a whole set of thoughts become hypotheses that have to be submitted to reality testing. Because most patients need to proceed in small steps, a number of graded-task behavioral assignments are tailored for individual patients to progressively promote greater successful experiences without overwhelming them with tasks greater than their present coping capacities. Much of cognitive therapy is devoted to problem-solving techniques; patients will learn to follow the necessary steps, such as defining the problem, generating alternative ways of solving it and implementing alternative solutions.
Social skills training may be a necessary tool as part of the treatment plan. A patient that fears social situations and has poor social performance will benefit from role-playing the feared situation with the therapist to build up inhibited social skills and overcome the problem. The therapist acts as a role model so that patients can learn to perform socially. After sufficient role-playing at the office, patients are stimulated to perform in real life situations what they have built in the office.
Cognitive therapy has been developed for application in individual, group, couples and family formats, for adults, adolescents and children, in a variety of clinical contexts. The indications for cognitive therapy are determined by patient and therapist variables, rather than by the nature of the disorder. How effective for which disorders and for how long is CBT effective compared to other procedures?
Butler and Beck et al. A search in the literature from to pooled a total of 16 methodologically rigorous meta-analyses encompassing more than subjects from studies. Because the literature reviews generally combine studies labeled CBT and CT under the CBT scope, the findings of these reviews were pooled and, whenever possible, pinpointed the more evident CT studies. Among the limitations of the meta-analytic approach are the assumptions of uniformity across the studies in the samples, in the content of therapy, and in therapists.
The comparison-weighted grand mean effect size for these disorders when compared to no-treatment, waiting list, or placebo controls is 0.
CBT has also shown promising results as adjunct to pharmacotherapy in the treatment of schizophrenia: the average uncontrolled effect size of 1. The maintenance of the effects of CT across many disorders for substantial periods beyond the cessation of treatment was supported by the meta-analyses reviewed. Significant evidence for long-term effectiveness was found for depression, generalized anxiety, panic, social phobia, OCD, sexual offending, schizophrenia, and childhood internalizing disorders. In the cases of depression and panic, there are robust and convergent meta-analytic evidence that CT produces vastly superior long-term persistence of effects, with relapse rates half those of pharmacotherapy.
A recent study with moderately depressed subjects conducted by DeRubeis et al. Severely depressed patients had as good outcomes with CT as with ADM in a meta-analysis of 4 studies. For bipolar disorder, the application of CT as an adjunctive treatment in the prevention of relapse as well as its cost-effectiveness has also been reported. Lam et al. Randomized controlled trials have also provided strong empirical support for the efficacy of cognitive interventions, often as an adjunct to therapy, in the treatment of a broad range of medical conditions including heart disease, hypertension, cancer, headaches, chronic pain, chronic low back pain, chronic fatigue syndrome, rheumatoid arthritis, premenstrual syndrome, and irritable bowel syndrome.
In recent years, research studies found neuropsychological correlates of the dysfunctional thinking and beliefs in depression. Of note, however, is the fact that studies of this nature can greatly expand our understanding of the mind-brain relationship, and how cognitive and behavioral techniques affect brain function.
There is no doubt that Beck's cognitive approach represents a theoretical shift to the understanding and treatment of emotional disorders. New applications of CT are developed for a wide range of psychological and medical conditions, although the theoretical foundations of the cognitive model remain unchanged. Beck AT. The current state of cognitive therapy: a 40 year retrospective. Arch Gen Psychiatry. Thinking and depression. Idiosyncratic content and cognitive distortions. Thinking and depression: II theory and therapy.
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New York: Academic Press; Vygotsky LS. Thought and language. Cambridge, MA: M. Press; Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Get access to the full version of this article. View access options below. You previously purchased this article through ReadCube. Institutional Login. Log in to Wiley Online Library. Purchase Instant Access. View Preview. Learn more Check out. Abstract This article describes the history and conceptual changes wrought by the gradual development from psychodynamic therapy to behavioral therapy to cognitive—behavioral therapy.
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