Cognitive Therapy

[Dr. Linton Hutchinson]

What is cognitive therapy?

Cognitive therapy is a widely used form of psychotherapy that focuses on
changing dysfunctional cognitions (thoughts), emotions, and behavior. This
computerized learning program emphasizes the form of cognitive therapy
developed over the last thirty years by Aaron T. Beck and coworkers. Cognitive
therapy is based on the theory that individuals with depression, anxiety, and
other emotional disorders have maladaptive patterns of information processing
and related behavioral difficulties.

One of the primary targets of cognitive therapy is the identification of
negative or distorted automatic thoughts. These cognitions are the relatively
autonomous thoughts that occur rapidly while an individual is in the midst of a
particular situation or is recalling significant events from the past. Patients
with depression and anxiety have many more negative or fearful automatic
thoughts than control subjects, and these distorted cognitions stimulate
painful emotional reactions. In addition, negative automatic thoughts can be
associated with behaviors (e.g., helplessness, withdrawal, or avoidance) that
make the problem worse. In depression or anxiety disorders, there is often a
"vicious cycle" of dysfunctional cognitions, emotions, and behaviors.

Automatic thoughts are frequently based on faulty logic or errors in reasoning.
Cognitive therapy is directed, in part, at helping patients recognize and
change these cognitive errors (sometimes called cognitive distortions). Some of
the commonly described cognitive errors include: all or nothing thinking,
personalization, ignoring the evidence, and overgeneralization. In cognitive
therapy, patients are usually taught how to detect cognitive errors and to use
this skill in developing a more rational style of thinking.

Another focus of cognitive therapy is on underlying schemas. These cognitive
structures are thought to be the templates, or basic rules, for interpreting
information from the environment. Schemas (sometimes termed core beliefs) can
be either adaptive or maladaptive. Cognitive therapists assist patients in
modifying problematic schemas. Generally, cognitive therapy for dysfunctional
schemas is more complex and demanding than therapeutic work with automatic
thoughts.

Cognitive therapy also includes a number of behavioral interventions such as
activity scheduling and graded task assignments. These procedures are used to
reverse behavioral pathology and to influence cognitive functioning. The
relationship between cognition and behavior is considered to be a "two way
street." If behavior improves, there is usually a salutatory effect on
cognition. In a similar manner, cognitive changes can lead to behavioral gains.
Thus, cognitive therapists often combine cognitive and behavioral techniques in
clinical practice.

What is the research background of cognitive therapy?

Cognitive therapy is the most heavily researched form of psychotherapy.
Multiple well controlled outcome studies have shown cognitive therapy to be an
effective treatment for depression. Also, cognitive therapy has been found to
be a particularly useful intervention for panic disorder and social phobia.
Other conditions for which cognitive therapy has been proven useful include
psychophysiological disorders, bulimia, and cocaine abuse. Research on
cognitive therapy for a wide variety of disorders has been reviewed by Wright
and Beck (1995).

How is cognitive therapy conducted?

Usually cognitive therapy is a short-term treatment lasting from 10-20
sessions. Therapists are more active than in many other types of treatment for
emotional disorders. A strong therapeutic relationship is encouraged between
clinician and patient. This relationship has been termed collaborative
empiricism because therapist and patient work together as a team to examine: 1)
the validity of cognitions; and 2) the effectiveness of behavior patterns.

In the early phase of cognitive therapy, emphasis is placed on establishing a
good working relationship and on teaching the patient the basic principles of
this treatment approach. Usually, examples from the patient's current life
situation are used to demonstrate the effects of automatic thoughts and
cognitive errors. Therapy is most often focused on the "here and now," and is
directed at specific problems or areas of concern. Homework assignments are
used from the beginning of treatment to reinforce learning and to encourage
behavioral change.

The middle portion of therapy is devoted to modifying dysfunctional patterns of
information processing and behavior. Frequently used cognitive interventions
include thought recording, identifying cognitive errors, examining the
evidence, and developing rational alternatives. A number of behavioral
techniques may also be employed, such as activity scheduling, graded task
assignments, or desensitization procedures. The therapist asks frequent
questions designed to stimulate a more rational cognitive style. Also,
self-help is encouraged by in vivo therapeutic exercises and continued homework
assignments.

The final phase of treatment is concerned with reinforcing skills learned
earlier in therapy and in preparing patients for managing problems on their
own. One of the goals of cognitive therapy is to learn methods that will have
positive effects in reducing the risk of relapse. Thus, many cognitive
therapists help their patients prepare for stressful situations that might
trigger the return of symptoms. During the later portions of therapy, more
intensive work may be needed to revise deeply held schemas. Change in these
underlying attitudes is thought to be an important factor in the long-term
effects of cognitive therapy.