Cognitive Therapy: Principle and Practice

Cognitive Therapy: Principle and Practice

     Cognitive Therapy is a form of psychotherapy and one of the types of Cognitive Behavioral Therapy currently in use today. While the terms Cognitive Therapy and Cognitive Behavioral Therapy are often used to describe the same therapy, they are not the same.

    Born in 1921 from Russian immigrant parents, Aaron Beck graduated with and M.D. from Yale Medical School in 1946. He noticed during his practice as a psychiatrist that his patients were asked how they felt but never what they thought. One of his patients, after talking for an hour, blurted out that she was afraid she had been boring him. She then admitted that she thought that many times when she was talking to people. He asked why she hadn’t said anything in all the time he had been treating her. Her reply was that it had never occurred to her to say what she was thinking and he had never asked. Working from what he learned from her and other patients he questioned regarding their thoughts, he began developing what would be become cognitive therapy and the Beck Scales.

      Dr. Beck is considered the “Father of Cognitive Therapy” and began developing it in the 1960’s initially to deal with patients suffering from depression. Dr Beck believed that there was more to emotional disorders widely accepted therapies dealing with sub-conscious emotions and drives. He believed that a negative view of self, the world and the future caused depression and other emotional disorders. Dr. Beck believed that if he could change the thinking pattern of the patient from negative to positive, then the symptoms of the disorder would lessen or disappear.

           Cognition is the processing of information in a way that helps one understand and deal with the world. It is comparable to ‘what we think creates our reality’ in that having a negative view of ourselves, the world around us and our future, we react negatively to situations or others around us. This causes the distress of depression, anxiety and other emotional disorders.

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 Dr. Beck believes that learned response and experience can effect how we respond to situations in our lives in the future and that it is possible with cognitive therapy to change the outcome of those situations with a more positive thought process. This does not mean that Beck believed that environment, income, genetics or other factors should not be taken into consideration when forming a diagnosis.

           When Dr. Beck first began his research in the 1950’s, the mainstream belief was that depression was caused by “introjected hostilities” (Beck, 1967). These hostilities were deeply rooted in the sub-conscious and manifested symptoms of depression or other emotional disorder.

        Dr. Beck believed that depression was more of a way of thinking than a manifestation of sub-conscious issues. He found that by taking the misinterpretations of situations or their sensations or feeling caused by their negative expectations and increasing their objectivity, patients could shift their thinking. This resulted in a positive change in both the effect of the situation and their behavior regarding it.

    Dr. Beck developed a combination of techniques and strategies that helped the patient change their thought processes in a more positive manner and deal more effectively with their symptoms and disorder. The most important thing for the patients was that this type of therapy enabled them to be active in their recovery and in dealing with recurrences. Dr. Beck made great advancements with depression patients. Using laboratory experiments, he proved that with successful cognitive therapy, patients with depression had a more positive mood and were increasingly optimistic and motivated.

Once his depression patients had proven his theories to be sound, he moved to other emotional disorders including anxiety disorders, phobias, panic disorders and others. He eventually applied his knowledge and practices to bi-polar and schizophrenia as well.

     While drug therapy is still necessary in some disorders, using the cognitive therapy in addition to the drug therapy has been proven much more effective than drug therapy alone.

     Dr. Beck invented the Beck Scales, which are used to today to diagnose disorders and measure severity of the disorder. His work had been especially effective in diagnosis and

evaluation of high suicide risk in patients. Dr. Beck’s is the only work that identifies suicide-prone individuals. He discovered that feelings of hopelessness were the key psychological factor for suicides. He and his colleagues proved that using cognitive therapy, these patients could be

identified early and ideally prevented from committing suicide or making another attempt in the future.

     Dr Beck created the Beck Scales which are used in cognitive therapy today. The main five currently in use are:

Beck Depression Inventory (BDI, BDI-II) – There are 3 versions of the BDI. The first BDI published in 1961, BDI-1A in 1971, which was a revision of the original and the BDI-II, published in 1996 in accordance with the DMS-II.  The BDI is currently the assessment tool most widely used by both researchers and therapists to measure the severity of depression. The questions cover everything from hopelessness, guilt and irritability to physical symptoms such as weight gain or loss, low energy and lack of sexual interest.

Beck Hopelessness Scale (BHS) – This is a twenty item inventory done by the patient to measure the three main aspect of hopelessness. These are listed as feelings about the future, loss of motivation and expectations.  The BHS can be used in correlation with the BDI-II but is less effective in helping predict suicidal behavior.
Beck Scale for Suicidal Ideation (BSS) – This test is administered when there is a high possibility of suicidal attempts or thoughts of suicide. There are 5 screening items among the 21 questions that ensure that non-suicidal types are not scrutinized as closely and may require less invasive and lengthy therapies. The BSS is used in conjunction with the BDI- II to get a full picture of the depression    and hopelessness symptoms as well. This prevents fewer false results in the aspect of   positives and negatives regarding the patient.
Beck Anxiety Inventory (BAI) – This test is used to assess the severity of a patient’s anxiety. Many people who suffer from depression also have some form of anxiety disorder. This test helps determine the division of the symptoms between depression and anxiety. The 21 item test covers subjective, somatic or panic related symptoms. This helps the therapist differentiate between the anxious and non-anxious symptoms.
Beck Youth Inventories – The aforementioned tests were designed for patients between the ages of 17 and 80. The Beck Youth Inventories are for children between the ages of 7 and 14. There are 5 different inventories and they can be used separately or together as needed for assessment. They cover depression, anxiety, anger, disruptive behavior, and self conflict. Using the 20 question format, children can describe their thoughts, feelings and behaviors in regards to questions asked by the therapist.
Cognitive therapy is used to treat a wide variety of disorders with great success. It is not a “cure all” for every type of disorder and in some cases drug treatment is required to help the patient further cope with their disorder and its symptoms.

      There are three levels of thinking that are related to understanding an emotional disorder. These are:

Negative Automatic Thoughts (NATS) – These are “situation-specific and involuntarily ‘pop into’ a person’s mind when he is experiencing emotional distress such as depression or anxiety. They appear plausible to the person and are difficult to turn off.” (Drydan,
Neenan 2004) An example of this would be running late for a social gathering, then thinking “I’m always running late. I am so unorganized. Everyone will think I’m a loser.”
Underlying Assumptions and Rules – These “guide behavior, set standards and provide rules to follow.” (Drydan, Neenan 2004)  These assumptions and rules are usually unspoken. ‘If,’ ‘then’, ‘should’ and ‘must’ are used to reinforce the behavior. If the rules are followed, the person assumes they can avoid their negative core beliefs, such as thinking they are incompetent. “Maladaptive assumptions often focus on three major issues: acceptance (e.g. ‘I’m nothing unless I’m loved’), competence (e.g. ‘I am what I accomplish’) and control (e.g. ‘I can’t ask for help’). Assumptions and rules are cross-situational and are also known as intermediate beliefs because they lie between NATS and core beliefs” (Beck, 1995).
·         Core Beliefs – These beliefs go the deepest and are over generalized and unrestricted. These are usually formed in early childhood and may not surface until a relevant situation causes it to be activated. “Once activated, negative core beliefs process information in a biased way that confirms them and disconfirms contradictory information (e.g. ‘So what

if I’m mostly on time for meetings?’). “Core beliefs can be about the self (e.g. ‘I’m unlovable’), others (e.g. ‘I can’t trust anyone’) and/or the world (e.g. ‘Everything is against me’).”(Beck, 1995)       Cognitive therapy usually begins with working at the NATS level and eventually moving into the core beliefs. The amount of time spent on each phase is determined by the severity of the disorder and the cooperation and motivation of the patient.

       As with any therapy, there can be patient resistance. Patients will miss or be late for appointments, fail to do to required homework, focusing on issues that are not relevant to the therapy, even move to one problem before progress can be noted on the previous problem. In cognitive therapy, the therapist creates a problem solving approach that will place the power of recovery back into the hands of the patient. Finding the thoughts behind the actions and changing the perspective on them can help overcome the patient’s resistance.

       Cognitive therapy is not just a matter of thinking in a positive rather than a negative manner. It is learning to view things from a different perspective. It encourages accurate, logical thinking about the patient’s life and problems rather than a negative emotional reaction.

       In the three basic phases of cognitive therapy:

     Stage One is for the patient to become aware of their thoughts. Many times, the thought is automatic and the patient notices the reaction but not the thought that caused it. The patient must focus on what the thoughts are when symptoms of their disorder erupt. Once they realized what they are telling themselves, they can move to stage two.

      Stage two involves scrutinizing whether the thoughts are inaccurate or possibly an exaggeration of the truth. Does that person really hate you or are they having a bad day? Did

they not smile back because they don’t like you or because they may not have seen you?  Once the thoughts have been looked at from another perspective they need to be compared with the original thoughts.

     In Stage Three the patient needs to decide whether or not the original thoughts fit the reality of what happened. It is a way of challenging the initial reaction and thought. Patients are taught to use this as a tool to use in everyday life, outside of therapy sessions.

     Many different problems can be treated with cognitive therapy with depression and anxiety disorders being among the most common:

·         Depression – depression is more than just a sad mood or having a bad emotional day. It includes things such as low self-esteem, weight changes, fatigue, feelings of hopelessness and feeling worthless.

·         Panic Disorder (Agoraphobia) – People with this disorder have panic attacks that cause extreme fear along with possible dizziness, rapid heartbeat, shortness of breathe, chest pain and faintness. It is not uncommon for a patient to fear dying, losing control or going crazy while a panic attack is happening. Patients with panic disorder tend to develop agoraphobia as well. Agoraphobia is a fear of certain places or situations that may trigger a panic attack.

·         Generalized Anxiety Disorder – This disorder is distinguished by persistent worry. The patient worries about all aspects of their lives on a constant basis. This can also be accompanied by muscle aches, insomnia, fatigue, concentration problems, irritability, stomach upset and restlessness.

·         Simple Phobia – The disorder is a basis irrational fear of a certain object or situation. Patients with this phobia will go to great lengths to avoid whatever it is they fear. Some the most common simple phobias are fear of heights, closed places and water.

·         Social Phobia – Patients with social phobia often avoid social gatherings, public events and even family functions. They experience an excessive ,unreasonable fear that they will             do something in that social setting that will cause them to be embarrassed or even humiliated.

·         Post-Traumatic Stress Syndrome – This disorder was once known as “shell shock” due to the amount of wartime combat veterans who were treated for it. It is not limited to veterans and can be found in many trauma victims due to rape, assault, the murder of a loved one and many others. The patient experiences intense anxiety and emotional distress following the trauma and is unable to function normally. They can also experience restlessness, jumpiness and insomnia.

Obsessive-Compulsive Disorder – Patients with this disorder are can have repetitive behavior, either in the form of thoughts or ideas or in the form of repeat behaviors. Some of the more commonly associated behaviors are excessively frequent hand washing, meticulous arrangement of personal objects and obsessive cleaning.
Other problems that are effectively treated with cognitive therapy: eating disorders, anger problems, procrastination, bereavement, assertiveness, stress disorders, hypochondriasis, sexual problems, psychosomatic disorders, marital and relationship problems.” (Sanderson, 2006)

       Cognitive therapy has several advantages over other forms of psychotherapy and can even be used in place of drug treatment in some disorders. It has been proven effectively in many emotional disorders and research is currently being done on the effectiveness of cognitive

therapy in severely disturbed mental patients. It is still too soon in the research to discover how effective this may be for these patients but the research in the cognitive therapy field never stops expanding. Another advantage is that cognitive therapy is cost effective. By focusing on teaching the patient skills to cope with the disorder and encouraging independence in their own recovery, therapists reduce the amount of time needed for treatment and reduce the amount of patients who will relapse. The long lasting benefits of cognitive therapy are one of the most outstanding advantages for the patient.

      Once they are taught ways to offset the symptoms and then come to their own conclusion as to whether it was a realistic thought or not, they have the tools they need to go on to a normal and less stressful life.

      Cognitive therapy has been proven to effective regardless of social or educational background. The therapy lends itself to the intellectual and verbal abilities of each client. It has been used effectively on the elderly, people with learning disabilities and young children.

     Cognitive therapy stresses the thought process but does not ignore the emotional aspect of the therapy. “The first cognitive therapy treatment manual, Cognitive Therapy of Depression (Beck et al.,1979), contained a chapter called ‘The role of emotions in cognitive therapy’ and stressed that the therapist ‘needs to be able to empathize with the patient’s painful emotional experiences’” (1979:35). It is the feelings most often that bring the patient to the therapist. Part of the success of cognitive therapy is that it helps reduce the negative feelings and help to build positive ones.

This, in conjunction with the thought process training, helps the patient to deal with both the thoughts and emotions that trigger the emotional and physical symptoms of the disorder.

      To begin cognitive therapy, the therapist must first put the patient at ease. There is a common misconception that therapist will force changes on the patient or make them go into their childhood to place blame for their current condition.

    Offering the patient the opportunity to ask questions before starting can help to clear up any preconceived ideas or fears. It can also give the therapist a good assessment of how motivated

the patient may be to help themselves. This can help determine the direction the initial discussion of the treatment plan will take.

     It is important to find out the patients expectations of the therapy as well. Cognitive therapy is not an “instant fix” and the patient has to understand that they will be very much involved in their own therapy and how well they will respond to the treatment.

     Once the therapist has explained how cognitive therapy works and what is expected of the patient it is up to the patient to decide if they are willing to work with the therapist on cognitive therapy. It is also helpful to the therapist to discover whether the patient has been to therapy before and if so, what type of therapy was used and what does the patient feel was the result.

      Getting background on the patient in a non-formal manner can not only put the patient at ease but also give the therapist an indication of any potential treatment obstacles, such as a lack of participation. Some patients may not be good candidates for cognitive therapy due to other issues that should be treated first, such as alcoholism or drug addiction.

     The Suitability for Short-Term Cognitive Therapy Rating Scale was created by J.D. Safran and Z.V. Segal where 10 items were used to rate the suitability of a patient for cognitive therapy. Each item was scored 0-5 with a total score of 0 being the patients least suited and up to 50 being

the best candidates. They state that the suitability is merely an indicator of the prognosis. The higher the patient score, the better prognosis is expected.

The items are:

Accessibility of automatic thoughts
Awareness and differentiation of emotions
Acceptance of personal responsibility
Compatibility with the cognitive rationale
Alliance potential (in session)
Alliance potential (outside of session)
Chronicity of problems
Security operations
Focality
Client optimism/pessimism regarding therapy (Safran, Segal 1990)
Once the suitability for cognitive therapy is established and the patient agrees to go ahead with the therapy, an agenda is set up for the next sessions. Some patients find this too structured in the beginning but soon realize that they are not being handed an agenda, they are being asked to help create one.

      The patients need to list what they consider to be their problems. Many of the problems listed by patients are different aspects of the same problem but there are people who have many

problems. When this is the case, it is up to the patient to decide which of the problems should be dealt with first. The patient and therapist should be make sure that any goals that are set are positive and specific.

          Conceptualization is the understanding of the disorder and what the therapist thinks may be underlying factors. The therapist shares the conceptualization with his client to determine its accuracy as well as to help the client understand herself and her problems better. Beck likens therapy to a journey with the conceptualization as the road map and the client’s goals as the final destination. (Beck, 1995)

      There is an extremely high success rate for cognitive therapy and relapses are low. Cognitive therapy is a well known tool for therapists to use in many cases but there are some cases who will not be helped by cognitive therapy.

       Cognitive therapy has been used on seriously mentally ill people and while it helped some of them, others did not respond to treatment. Some psychoses are too deep seated to be fully helped by a short term therapy like cognitive therapy.  Schizophrenics and Multiple Personality Disorder are two severe mental illnesses that require a combination of therapies. Severely depressed people may not benefit as fast from the therapy.

      Cognitive therapy does not claim to cure everyone, but it has been the most widely used therapy for depression and anxiety disorders for years and with ongoing research, finds new and improved ways to help people.

       By widening the scope of patient that cognitive therapy is offered to, the researchers can continue to improve the methods created by Dr. Beck and his colleagues. There are some

cognitive therapists who now work with chronic pain patients, teaching them to deal more effectively with their pain through their thoughts and feelings.

     The BDI-II does have its limitations. The testing is dependent on the honesty of the answers given by the patient and there can be a tendency to exaggerate or understate the answers.  Depending on the disorder, patients may give different answers with someone else in the room than if they were filling it out alone.

    Another problem is the suggestion that patient who also suffer from a physical illness will artificially score higher due to favoring the physical ailments rather than the emotional one. It is up to the therapist to try to make the patient comfortable and relaxed so they can get truer answers regarding their state of mind at the time. The therapist must work within the confines of the patient’s disorder in the beginning.

     Some therapists from other orientations think that cognitive therapy is a quick fix to emotional problems. They believe it only deals with the present and immediate future, while ignoring the past. They believe that cognitive therapy has no depth and therefore cannot be a reliable form of therapy. This is not true, although cognitive therapy does not delve into the sub-concious.

      It is true that for some people traditional therapy or other alternatives may be more productive. It gives credibility to the testing created to discover cognitive therapy suitability.

It has been proven to have the highest rate of success in depression and anxiety disorders and even a small measure of success on the severely mentally disturbed patients.

  It is still the only therapy with the ability to determine possible suicidal tendency with accuracy and proof of lasting results on the people who have successfully completed the therapy without a relapse.

      At the Beck Institute in Pennsylvania, Dr. Aaron Beck and his daughter, Dr. Judith Beck, continue the research he started many years ago. The Institute has created a Psychopathology Unit and received a grant to do more research into the field of suicide prevention.

      Another area of research at the Institute is using cognitive therapy in controlled trials with borderline personality disordered patients. They are also using cognitive therapy in conjunction with pharmacotherapy to treat patients with schizophrenia.

      Many workplaces are now implementing work stress release programs to try to help lower stress and hypertension among workers. A study compared 91 stressed out workers who were given cognitive therapy to a group of 79 who were given a fake program, supposedly designed to reduce stress. Those in the cognitive group showed improvement in heart rate and lowered blood pressure. Those who took the fake therapy showed no changes at all. Cognitive therapy may be a healthy alternative to reduce work stress and absenteeism due to stress induced illnesses.

      Drydan and Neenan, (2004) claim “Our experience of training and supervising cognitive therapists shows us that some individuals have either no idea of how to apply CT to themselves or no wish to – therapy is something that they do to ‘them’ (i.e. clients) and is not performed on themselves.”

         They have discovered that putting the students through cognitive therapy while they study keeps them motivated to practice with genuine conviction and also to understand the resistance

And difficulties that their patients may experience.  Dr. Beck agrees that psychiatrists who practice cognitive therapy should first go through it themselves. He has used the process in his own life and credits much of his research with learning to correct his own thinking regarding problems in his life.

     In conclusion, Cognitive Therapy has helped a great many people and the numbers reflect this. The practitioners are “practicing what they preach” by taking the therapy as well as studying it. This makes them more trustworthy to some and more capable to others.

    Research in the field will continue as the theories branch out to other styles and areas of psychiatry.

References

Needleman, L. D. (1999). Cognitive Case Conceptualization: A Guidebook for Practitioners. Mahwah, NJ: Lawrence Erlbaum Associates.

Neenan, M., ; Dryden, W. (2002). Life Coaching: A Cognitive-Behavioural Approach. East Sussex, England: Brunner-Routledge.

Neenan, M., ; Dryden, W. (2004). Cognitive Therapy:  100 Key Points. New York: Brunner-Routledge.

Olevitch, B. A. (1995). Using Cognitive Approaches with the Seriously Mentally Ill: Dialogue across the Barrier. Westport, CT: Praeger Publishers.

Scott, J., Williams, J. M., ; Beck, A. T. (Eds.). (1991). Cognitive Therapy in Clinical Practice:  An Illustrative Casebook. London: Routledge.

Sheldon, B. (1995). Cognitive-Behavioural Therapy:  Research, Practice, and Philosophy. New York: Routledge.

Weekes, J. R., Millson, W. A., Porporino, F. J., ; Robinson, D. (1994, February). Substance Abuse Program Analyzes Rates of Success. Corrections Today.

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