Cognitive Therapy: Brief Introduction to Theory and Practice

Cognitive therapy  (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. It is one of the therapeutic approaches within the larger group of  cognitive-behavioral therapies (CBT) and was first exposed 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 overcome difficulties and achieve their goals, identifying and changing useless or inaccurate thoughts, problematic behaviors and distressing emotional responses. This involves the individual working in collaboration with the therapist to develop skills to test and modify beliefs, to identify distorted thoughts, to relate to others in different ways and to change behaviors. [1]

A tailored case conceptualization ( cognitive conceptualization ) is developed by the cognitive therapist as a guide for understanding the individual’s internal reality, selecting appropriate interventions and identifying areas of suffering.

Content

  • 1.  Brief history of Cognitive Therapy
  • 2.  Some bases of Cognitive Therapy
  • 1  Cognitive Model
  • 2  Cognitive restructuring (methods)
  • 3.  Some types of cognitive-behavioral therapies
  • 4.  Applications of CT
  • 1  Depression
  • 2  Other applications
  • 5.  Criticisms of cognitive therapy
  • 6.  References

Brief history of Cognitive Therapy

The rise of cognitive therapy

Becoming disillusioned with  long-term psychodynamic approaches based on gaining insight into unconscious emotions and impulses, Aaron Beck came to the conclusion that the way his patients perceived, interpreted and attributed meaning in their daily lives – a process scientifically known as cognition – was the key to therapy. [2]

Albert Ellis had been working on similar ideas since the 1950s (Ellis, 1956). He called his approach Rational Therapy (RT) first, then Emotional Rational Therapy (TRE) and subsequently Emotional Rational Behavioral Therapy (TREC) .

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 cognitive revolution  in Psychology / Cognitive Therapy and Behaviorism

The new cognitive approach clashed with rising behaviorism  at the time, which denied that talking about mental causes was scientific or meaningful, rather than simply evaluating behavioral stimuli and responses. However, the 1970s saw a general ” cognitive revolution ” in psychology. Behavior modification techniques and cognitive therapy techniques came 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 and clearly standardized form of cognitive-behavioral therapy, in which cognitive change is the main mechanism of change. [4]

  • Differences between Cognitive Therapy and Cognitive-Behavioral Therapy

The philosophical origins of cognitive therapy

Precursors to certain fundamental aspects of cognitive therapy have been identified in several 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 Stoic philosophers.” [6]

Academy of Cognitive Therapy

As cognitive therapy continued to grow in popularity, the Academy of Cognitive Therapy, a nonprofit organization, was created to accredit cognitive therapists, create a forum for members to share emerging research and interventions, and educate the consumer in relation to cognitive therapy and related mental health problems. [7]

Some bases of Cognitive Therapy

Cognitive therapy may consist of testing the assumptions made and looking for new information that can help to change the assumptions in a way that leads to different emotional or behavioral reactions. The change can begin by directing the individual’s thoughts (to change emotion and behavior), behavior (to change feelings and thoughts) or goals (identifying thoughts, feelings or behaviors that conflict with goals). Beck initially focused on depression and developed a list of “errors” ( cognitive distortions ) in thinking that could maintain depression, including  arbitrary inference, selective abstraction, over-generalization and enlargement (of negatives) and minimization (of positives) .

  • What is cognitive dissonance? Theory and Examples

How does cognitive therapy work?

An example of how Cognitive Therapy (CT) can work: Having made a mistake at work, a man can believe: “I am useless and I cannot do anything right at work”. He can then focus on the error (which he takes as evidence that his belief is true), and his thoughts about being “useless” are likely to lead to negative emotions (frustration, sadness, hopelessness). Given these thoughts and feelings, he can 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 additional constructive consequences are unlikely, and he can focus even more on any mistakes he may make, which serve to reinforce the original belief of being “useless”. In cognitive therapy, this example could be identified as aself-fulfilling prophecy or “ problem cycle ”,

People who are working with a cognitive therapist often practice using more flexible ways of thinking and responding, learning to ask themselves if their thoughts are completely true and whether those thoughts are helping them achieve their goals. Thoughts that do not meet this description can then be exchanged for something more precise or useful, leading to more positive emotions, more desirable behaviors and movements towards the person’s goals. Cognitive therapy takes a skill-building approach, in which the therapist helps the person to learn and practice these skills independently, and the client eventually ends up “becoming his own therapist”.

Cognitive model

The cognitive model was originally built following research conducted by Aaron Beck to explain the psychological processes in depression. [8]  Divides the beliefs of the mind into three levels:  [9]

  • Automatic thoughts
  • Intermediate beliefs
  • Central  belief or basic belief  (or even nuclear belief )

In 2014, it was proposed to update the cognitive model, called the Generic Cognitive Model . The Generic Cognitive Model is an update of Beck’s model that proposes that mental disorders can be differentiated by the nature of their dysfunctional beliefs. [10]  This model includes a conceptual framework and a clinical approach to understanding the common cognitive processes of mental disorders, while specifying the unique characteristics of specific disorders.

Consistent with the cognitive theory of psychopathology, Cognitive Therapy is designed to be structured, directive, active and time-limited, with the express purpose of identifying, testing reality and correcting distorted cognition and underlying dysfunctional beliefs. [11]

Cognitive restructuring (methods)

The cognitive restructuring involves four steps:  [12]

  1. Identification of problematic cognitions known as “automatic thoughts” (PAs), which are dysfunctional or negative views of self, world or future, based on existing beliefs about yourself, the world or the future  [13]
  2. Identification of cognitive distortions in automatic thoughts
  3. Rational debate on automatic thoughts with the Socratic method ( Socratic questioning )
  4. Development of a rational refutation of automatic thoughts

There are six types of automatic thoughts:  [12]

  1. Self-evaluative thoughts
  2. Thoughts on 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. Dodge thoughts
  6. Any other thoughts that have not been categorized

Other cognitive therapy techniques are:

  • Activity monitoring and activity scheduling
  • Behavioral Experiments
  • Capture, check and change thoughts
  • Collaborative empiricism : the therapist and the patient become investigators examining the evidence to support or reject the patient’s cognitions. Empirical evidence is used to determine whether certain cognitions serve any useful purpose. [14]
  • Downward arrow technique
  • Response exposure and prevention
  • Cost-benefit analysis
  • Act “as if”  [15]
  • Guided discovery : the therapist elucidates behavioral problems and erroneous thoughts when designing new experiences that lead to the acquisition of new skills and perspectives. Through cognitive and behavioral methods, the patient discovers more adaptive ways of thinking and dealing with environmental stressors, correcting cognitive processing. [14]
  • Diary of mastery and pleasure
  • Problems solution
  • Socratic questioning : involves creating 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) evaluate the consequences of maintaining thoughts and maladaptive behaviors. [14]

Socratic issues are archetypal techniques of cognitive restructuring. These types of questions are designed to challenge assumptions. [16]  [17]

  • Devise reasonable alternatives:

“What could be another explanation or view of the situation? Why else did this happen? ”

  • Assess these consequences:

“What is the effect of thinking or believing it? What could be the effect of thinking differently and no longer clinging to that belief? ”

  • Distance:

“Imagine a friend / family member in the same situation or if they saw the situation that way, what would I say to them?”

Socratic questioning : how to do it? what questions to use?

Examples of Socratic issues  [18] are:

  • “Describe the way you originally formed your point of view.”
  • “What initially convinced you that your current view is the best available?”
  • “Think of three pieces of evidence that contradict that view or that support the opposite view. Think of the opposite of this view and reflect on that for a moment. What is the strongest argument in favor of this opposite view? ”
  • “Write down any specific benefits you gain from maintaining that belief, such as social or psychological benefits. For example, being part of a community of like-minded people, feeling good about yourself or the world, feeling that your point of view is superior to that of other people, etc. Is there any reason why you can have this vision besides why it is true? ”
  • “For example, does maintaining that point of view provide any peace of mind that a different point of view would not have?”
  • “In order to refine your point of view to be as accurate as possible, it is important to challenge it directly from time to time and consider whether there are reasons why this is not true. What do you think is the best or strongest argument against this perspective? ”
  • “What would you have to experience or discover to change your mind about that point of view?”
  • “Considering your thoughts so far, do you think there may be a more truthful, accurate or more subtle version of your original point of view that you could correctly state now?”

False assumptions are based on ” cognitive distortions “, such as:  [19]

  • Always be right: We are continually being judged to prove that our opinions and actions are correct. Being wrong is unthinkable and some people will do anything to demonstrate that they are right. For example, “I don’t care how arguing with me makes you feel, I’m going to win that argument no matter what the reason, because I’m right”. Often being right is more important than the feelings of others around you, for a person who engages in this cognitive distortion, even when it comes to loved ones.
  • The fallacy of heaven’s reward: We hope that our sacrifice and self-sacrifice will be rewarded, as if someone were scoring points. We feel bitter when the reward doesn’t come.

Some types of cognitive-behavioral therapies

Cognitive therapy

based on the cognitive model, it states that thoughts, feelings and behaviors influence each other. Cognition change is seen as the main mechanism by which lasting emotional and behavioral changes occur. The treatment is very collaborative, adapted, focused on skills and based on a case conceptualization.

Emotional rational behavioral therapy (TREC)

it is based on the belief that most problems originate in irrational thinking. For example, perfectionists and pessimists often suffer from issues related to irrational thinking; if a perfectionist finds a small flaw, he may perceive it as a much bigger failure. It is better to establish a reasonable emotional standard, so that the individual can live a balanced life. This form of cognitive therapy is an opportunity for the patient to learn about his current distortions and successfully eliminate them.

Cognitive-behavioral therapy (CBT)

a system of approaches based on the cognitive and behavioral systems of psychotherapy. [20]

Unlike psychodynamic approaches, CBT is transparent to the individual receiving the services. At the end of the therapy, the client has often learned the skills of cognitive therapy enough to “be his own therapist”, lessening the dependence on a therapist to provide the answers.

CT applications

Depression

According to Beck’s etiology theory of depression, depressed people acquire a negative schema of the world in childhood and adolescence; children and adolescents suffering from depression acquire this negative pattern earlier. Depressed people acquire such schemes through the loss of a parent, peer rejection, intimidation, criticism from teachers or parents, a parent’s depressive attitude and other negative events. When the person with such schemes encounters a situation that resembles the original conditions of the learned scheme in some way, the person’s negative schemes are activated. [21]

A  negative triad of Beck  argues that depressed people have negative thoughts about themselves, their experiences in the world and the future. [22]

For example, a depressed person might think, “I didn’t get the job because I suck 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 may think: “The interviewer was not paying much attention to me. Maybe she already had someone in mind for the job. Next time, I will have more luck and “I will get a job soon”.

Beck also identified a number of other cognitive distortions that can contribute to depression, including the following: arbitrary inference, selective abstraction, overgeneralization, minimization . [21]

In 2008, Beck proposed a model of integrative development of depression  [23]  that aims to incorporate research in genetics and neuroscience. [24]  This model was updated in 2016 to incorporate multiple levels of analysis, new research and key concepts (for example, resilience) within the framework of an evolutionary perspective. [25]

Other applications

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

  • Academic performance  [26]  [27]
  • Addiction
  • Anxiety disorders  [28]
  • Bipolar disorder  [29]
  • Low self-esteem  [30]
  • Phobia  [31]
  • Schizophrenia  [32]
  • Substance abuse  [33]
  • Suicidal ideation  [34]
  • Weight loss  [35]

Criticisms of Cognitive Therapy

A possible criticism is that clinical studies of the effectiveness of Cognitive-Behavioral Therapy (or any psychotherapy) are not double-blind (in which neither the subjects nor the therapists in the studies are blind as to the type of treatment). They may be blind at once, the evaluator may not know the treatment the patient received, but neither the patients nor the therapists are blind as to the type of therapy administered (two out of three people involved in the study, that is, all people involved in treatment, are not blinded). The patient is an active participant in the correction of negative distorted thoughts and, therefore, very aware of the treatment group in which he is.

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