What is cognitive therapy (CT)?
Cognitive therapy, originally developed by Aaron T. Beck, is based on the view that cognition (the process of acquiring knowledge and forming beliefs) is a primary determinant of mood and behavior. Beck developed his theory while treating depressed patients. He noticed that these patients tended to distort whatever happened to them in the direction of self-blame and catastrophes. Thus, an event interpreted by a normal person as irritating and inconvenient (for example, the malfunctioning of an automobile) would be interpreted by the depressed patient as another example of the utter hopelessness of life. Beck’s central point is that depressives draw illogical conclusions and come to evaluate negatively themselves, their immediate world, and their future. They see only personal failings, present misfortunes, and overwhelming difficulties ahead. It is from these cognitions that all the other symptoms of depression derive.
It was from Beck’s early work with depressed patients that cognitive therapy was developed. Shortly thereafter, the concepts and procedures were applied to other psychological problems, with notable success.
Two concepts of particular relevance to cognitive therapy are the concepts of automatic thoughts and schemata. Automatic thoughts are thoughts that appear to be going on all the time. These thoughts are quite brief—only the essential words in a sentence seem to occur, as in a telegraphic style. Further, they seem to be autonomous, in that the person made no effort to initiate them, and they seem plausible or reasonable to the person (although they may seem far-fetched to somebody else). Thus, as a depressed person is giving a talk to a group of business colleagues, he or she will have a variety of thoughts. There will be thoughts about the content of the material. There is also a second stream of thoughts occurring. In this second channel, the person may experience such thoughts as: “This is a waste of time,” or “They think I’m dumb.” These are automatic thoughts.
Beck has suggested that although automatic thoughts are occurring all the time, the person is likely to overlook these thoughts when asked what he or she is thinking. Thus, it is necessary to train the person to attend to these automatic thoughts. Beck pointed out that when people are depressed, these automatic thoughts are filled with negative thoughts of the self, the world, and the future. Further, these automatic thoughts are quite distorted, and finally, when these thoughts are carefully examined and modified to be more in keeping with reality, the depression subsides.
The concept of schemata, or core beliefs, becomes critical in understanding why some people are prone to having emotional difficulties and others are not. The schema appears to be the root from which the automatic thoughts derive. Beck suggests that people develop a propensity to think crookedly as a result of early life experiences. He theorizes that in early life, an individual forms concepts—realistic as well as unrealistic—from experiences. Of particular importance are individuals’ attitudes toward themselves, their environment, and their future. These deeply held core beliefs about oneself are seen by Beck as critical in the causation of emotional disorders. According to cognitive theory, the reason these early beliefs are so critical is that once they are formed, the person has a tendency to distort or view subsequent experiences to be consistent with these core beliefs. Thus, an individual who, as a child, was subjected to severe, unprovoked punishment from a disturbed parent may conclude “I am weak” or “I am inferior.” Once this conclusion has been formulated, it would appear to be strongly reinforced over years and years of experiences at the hands of the parent. Thus, when this individual becomes an adult, he or she tends to interpret even normal frustrations as more proof of the original belief: “See, I really am inferior.” Examples of these negative schemata or core beliefs are: “I am weak,” “I am inferior,” “I am unlovable,” and “I cannot do anything right.” People holding such core beliefs about themselves would differ strongly in their views of a frustrating experience from those people who hold a core belief such as “I am capable.”
Another major contribution of cognitive therapy is Beck’s cognitive specificity hypothesis. Specifically, Beck has suggested that each of the emotional disorders is characterized by its own patterns of thinking. In the case of depression, the thought content is concerned with ideas of personal deficiency, impossible environmental demands and obstacles, and nihilistic expectations. For example, a depressed patient might interpret a frustrating situation, such as a malfunctioning automobile, as evidence of his or her own inadequacy: “If I were really competent, I would have anticipated this problem and been able to avoid it.” Additionally, the depressed patient might react to the malfunctioning automobile with: “This is too much, I cannot take it anymore.” To the depressed patient, this would simply be another example of the utter hopelessness of life.
While the cognitive content of depression emphasizes the negative view of the self, the world, and the future, anxiety disorders are characterized by fears of physical and psychological danger. The anxious patient’s thoughts are filled with themes of danger. These people anticipate detrimental occurrences to themselves, their family, their property, their status, and other intangibles that they value.
In phobias, as in anxiety, there is the cognitive theme of danger; however, the “danger” is confined to definable situations. As long as phobic sufferers are able to avoid these situations, they do not feel threatened and may be relatively calm. The cognitive content of panic disorder is characterized by a catastrophic interpretation of bodily or mental experiences. Thus, patients with panic disorder are prone to regard any unexplained symptom or sensation as a sign of some impending catastrophe. As a result, their cognitive processing system focuses their attention on bodily or psychological experience. For example, one patient saw discomfort in the chest as evidence of an impending heart attack.
The cognitive feature of the paranoid reaction is the misinterpretation of experience in terms of mistreatment, abuse, or persecution. The cognitive theme of the conversion disorder (a disorder characterized by physical complaints such as paralysis or blindness, where no underlying physical basis can be determined) is the conviction that one has a physical disorder. As a result of this belief, the patient experiences sensory and/or motor abnormalities that are consistent with the patient’s faulty conception of organic pathology.
The goal of cognitive therapy is to help patients evaluate their thought processes carefully, to identify cognitive errors, and to substitute more adaptive, realistic cognitions. This goal is accomplished by therapists helping patients to see their thinking about themselves (or their situation) as similar to the activity of a scientist—that they are engaged in the activity of developing hypotheses (or theories) about their world. Like a scientist, patients need to “test” their theories carefully. Thus, patients who have concluded that they are “worthless” people would be encouraged to test their “theories” rigorously to determine if this is indeed accurate. Further, in the event that the theories are not accurate, patients would be encouraged to change their theories to make them more consistent with reality (what they find in their experience).
A slightly different intervention developed by Beck and his colleagues is to help the patient identify common cognitive distortions. Beck originally identified four cognitive distortions frequently found in emotional disorders: arbitrary inference, selective abstraction, overgeneralization, and magnification or minimization. These were later expanded to ten or more by Beck’s colleagues and students.
Arbitrary inference is defined as the process of drawing a conclusion from a situation, event, or experience when there is no evidence to support the conclusion or when the conclusion is contrary to the evidence. For example, a depressed patient on a shopping trip had the thought, “The salesclerk thinks I am a nobody.” The patient then felt sad. On being questioned by the psychologist, the patient realized that there was no factual basis for this thought. Selective abstraction refers to the process of focusing on a detail taken out of context, ignoring other, more salient features of the situation, and conceptualizing the whole experience on the basis of this element. For example, a patient was praised by friends about the patient’s child-care activities. Through an oversight, however, the patient failed to have her child vaccinated during the appropriate week. Her immediate thought was, “I am a failure as a mother.” This idea became paramount despite all the other evidence of her competence.
Overgeneralization refers to patients’ patterns of drawing a general conclusion about their ability, their performance, or their worth on the basis of a single incident. For example, a student regards his poor performance on the first examination of the semester as final proof that he “will never make it in college.” Magnification and minimization refer to gross errors in evaluation. For example, a person, believing that he has completely ruined his car (magnification) when he sees that there is a slight scratch on the rear fender, regards himself as “good for nothing.” In contrast, minimization refers to minimizing one’s achievements, protesting that these achievements do not mean anything. For example, a highly successful businesswoman who was depressed concluded that her many prior successes “were nothing . . . simply luck.” Using the cognitive distortions, people are taught to examine their thoughts, to identify any distortions, and then to modify their thoughts to eliminate the distortions.
In terms of the therapeutic process, the focus is initially on the automatic thoughts of patients. Once patients are relatively adept at identifying and modifying their maladaptive automatic thoughts, the therapy begins to focus on the maladaptive underlying beliefs or schemata. As previously noted, these beliefs are fundamental beliefs that people hold about themselves. These beliefs are not as easy to identify as the automatic thoughts. Rather, they are identified in an inferential process. Common patterns are observed; for example, the person may seem to be operating by the rule: “If I am not the best _____, then I am a failure,” or “If I am not loved by my spouse or mate, then I am worthless.” As in the case of the earlier cognitive work with automatic thoughts, these beliefs are carefully evaluated for their adaptability or rationality. Maladaptive beliefs are then modified to more adaptive, realistic beliefs.
A variety of techniques have been developed by cognitive therapists for modifying maladaptive cognitions. One example of these techniques is self-monitoring. This involves the patients keeping a careful hour-by-hour record of their activities, associated moods, or other pertinent phenomena. One useful variant is to have patients record their moods on a simple zero-to-one-hundred scale, where zero represents the worst they have ever felt and one hundred represents the best. In addition, patients can record the degree of mastery or pleasure associated with each recorded activity.
A number of hypotheses can be tested using self-monitoring, such as: “It does not do any good for me to get out of bed,” “I am always miserable; it never lets up,” and “My schedule is too full for me to accomplish what I must.” By simply checking the self-monitoring log, people can easily determine if their miserable moods ever cease. A careful examination of the completed record is a far better basis for judging such hypotheses than are memories of recent events, because their recollections are almost always tainted by the depression.
As therapy progresses and patients begin to experience more elevated moods, the focus of treatment becomes more cognitive. Patients are instructed to observe and record automatic thoughts, perhaps at a specific time each evening, as well as recording when they become aware of increased dysphoria. Typically, the thoughts are negative self-referents (“I am worthless”; “I will never amount to anything”), and initially, the therapist points out their unreasonable and self-defeating nature. With practice, patients learn “distancing,” that is, dealing with such thoughts objectively and evaluating them rather than blindly accepting them. Homework assignments can facilitate distancing: Patients record each automatic thought, and next to it they write down a thought that counters the automatic thought, as the therapist might have done. According to Beck, certain basic themes soon emerge, such as being abandoned, as well as stylistic patterns of thinking, such as overgeneralization. The themes reflect the aforementioned rules, and the ultimate goal of therapy is to assist patients to modify them.
Finally, cognitive therapy has been applied to a variety of psychological disorders with striking success. For example, studies from seven independent centers have compared the efficacy of cognitive therapy to antidepressant medication, a treatment of established efficacy. Comparisons of cognitive therapy to drugs have found cognitive therapy to be superior or equal to antidepressant medication. Further, follow-up studies indicate that cognitive therapy has greater long-term effects than drug therapy. Of special significance is the evidence of greater sustained improvement over time with cognitive therapy.
Cognitive therapy has been successfully applied to panic disorder, resulting in practically complete reduction of panic attacks after twelve to sixteen weeks of treatment. Additionally, cognitive therapy has been successfully applied to generalized anxiety disorder, eating disorders, and inpatient depression.
Cognitive theory and cognitive therapy originated in Beck’s observation and treatment of depressed patients. Originally trained in psychoanalysis, Beck observed that his patients experienced specific types of thoughts, of which they were only dimly aware, that they did not report during their free associations. Beck noticed that these thoughts were frequently followed by an unpleasant effect. Further, he noted that as the patients examined and modified their thoughts, their moods began to improve.
At the time of the emergence of the cognitive model, the treatment world was dominated primarily by the psychoanalytic model (with its heavy emphasis on the unconscious processes) and to a lesser extent by the behavioral model (with its emphasis on the behavioral processes, to the exclusion of thought). The psychoanalytic model was under attack, primarily because of a lack of careful empirical support. In contrast, behavior therapists were actively demonstrating the efficacy of their approaches in carefully designed studies. Beck and his students began to develop and test cognitive procedures systematically, and they have developed an impressive body of research support for the approach.
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