Cognitive therapy

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This article is about cognitive therapy. For the behaviorist technique, see behavior modification.
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Cognitive therapy or cognitive behavior therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, delusional disorder and other forms of mental disorder.

It involves recognizing unhelpful or destructive patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that clinical depression is typically associated with negatively biased thinking and irrational thoughts. Cognitive therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS. According to the U.S.-based National Association of Cognitive-Behavioral Therapists:

"There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy."<ref>Template:Cite web</ref>


[edit] The basics

Cognitive Behavior Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior. Therefore, negative - and unrealistic - thoughts can cause us distress and result in problems.

One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on mood, making the person feel depressed; the problem may be worsened if the individual reacts by avoiding activities. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks in response to similar situations and by developing more flexible thought patterns, along with reducing the avoidance of activities. If, as a result, the client escapes the negative thought pattern, the feelings of depression may be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.

[edit] Thoughts as the cause of emotions

With thoughts stipulated as being the cause of emotions rather than the outcome or by-product, cognitive therapists reverse the causal order more generally used by psychotherapists. Therefore, the therapy is to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts.

Cognitive therapy is not an overnight process. Even after patients have learned to recognize when and where their thought processes go awry, it can take months of concerted effort to replace an irrational thought process or habit with a more reasonable, salutary one. With patience and a good therapist, however, cognitive therapy can be a valuable tool in recovery.

[edit] Cognitive behavioral therapy

While similar views of emotion have existed for millennia, cognitive therapy was developed in its present form by Albert Ellis,who developed his Rational Emotive Behavioral Therapy, or REBT, in the early 1950s, as a reaction against popular psychoanalytic and increasingly humanistic methods at the time <ref name="ellis">Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall. ISBN 0-13-370650-8.</ref>, and Aaron T. Beck, who followed up Ellis' approach in the 1960s<ref name="beck">Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-8236-0990-1</ref>. It rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.

Cognitive behavioral group therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg<ref>Template:Cite web</ref>. In this case, clients participate in a group and recognize they are not alone in suffering from their problems.

A sub-field of cognitive behavior therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. (The specific technique, Exposure with Response Prevention (ERP) has been demonstrated to be more effective than the use of medication--typically SSRIs--alone.) CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia and Panic Disorder. In recent years, CBT has been used to treat symptoms of schizophrenia, such as delusions and hallucinations, has been developed in the UK by Douglas Turkington and David Kingdon.

CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse and has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.

Cognitive Therapy and/or Cognitive Behavioral Therapy most closely ally with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measureable goal-attainment.

[edit] Depression

Negative thinking in depression can result from biological sources (i.e., endogenous depression), modelling from parents, peers or other sources. The depressed person experiences negative thoughts as being beyond their control: the negative thought pattern can become automatic and self-perpetuating.

Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.

Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad."

[edit] Attributional style

An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First put forth by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves <ref name="AbramsonSeligmanTeasdale">Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74</ref>. There is considerable evidence that depressives do exhibit such an attributional style; but it is important to remember that Abramson et al. do not claim that an attributional style of this nature is necessarily going to cause depression — only that it will lead to clinical depression if combined with a negative event. This theory is sometimes known as a revised version of learned helplessness theory.

In 1989, this theory was challenged by Hopelessness Theory <ref name="Abramson-EtAl">Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.</ref>. This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions.

[edit] The ABCs of Irrational Beliefs

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs<ref name="ellis"/>. The first three steps analyse the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

  • A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
  • B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to them.
  • C - Consequence. The third column is for the negative feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc.

For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.

  • Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.

From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.

Another way of viewing the ABC's of Cognitive Behavioral Therapy

  • A - Activating Stimulus This is the stimulus that activates the irrational fear or anxiety in the person.
  • B - Blank This is the blank process that lies in between the stimulus and the irrational thinking. The person would have to identify this gap and create a bridge in their thought process in order to be able to be treated.
  • C - Conditioned Response This is the irrational fear or anxiety with which the person has conditioned themself to respond with to the stimulus.

The way the treatment works is that by going back and thinking over what the stimulus was and the irrational reaction to it and then try to follow the chain of events that led from one to another, thereby filling in the blank in between, the person can identify what causes their thinking to become irrational.

For example;

A person walks out of his home and hears an ambulance siren. The person gets anxious from this and runs back into his home. The Activating Stimulus was the ambulance siren. The Conditioned Response was severe anxiety and running into his home. The person now has to fill in the Blank and try to understand what was the exact thought process that went through his mind that caused the irrational response to take place. By bridging this gap in his thought, he is identifying the faulty thought process that caused the extreme response. The person can now work on replacing these faulty thoughts with realistic ones, thereby correcting the undesired chain of thoughts and activating a functional one.

[edit] Effectiveness of CBT with or without drugs for depression

A large-scale study in 2000<ref>Keller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression. New England Journal of Medicine Volume 342:1462-1470 May 18, 2000.</ref> showed substantially higher results of response and remission when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either method was used alone.

The effectiveness of combination therapy is endorsed by the Australian depressioNet group:

Currently the most effective treatment for major (clinical) depression is considered to be a combination of antidepressant medication and Cognitive Behavioral Therapy.<ref>Template:Cite web</ref>

For more general results confirming that CBT alone can provide lower but nonetheless valuable levels of relief from depression, and result in increased ability for the patient to stay in employment, see The Depression Report<ref>Template:Cite web</ref>, which states:

The typical short-term success rate for CBT is about 50%. In other words, if 100 people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work.

The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal therapy had the best-documented efficacy for treatment of major depressive disorder, although they noted that rigorous evaluative studies had not been published <ref>Template:Cite web</ref>.

[edit] CBT with children and adolescents

The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression, anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder. Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago.

CBT has been used with children and adolescents to treat a variety of conditions with good success<ref> (2005-12-05) Kendall, Philip C. (ed).: Child and Adolescent Therapy: Cognitive-Behavioral Procedures, (3rd ed.). Guilford Press. ISBN 1-59385-113-8.</ref><ref> (2003-05-02) Reinecke, Mark A.; Dattilio, Frank M.; Freeman, A. (eds).: Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (2nd ed.). Guilford Press. ISBN 1-57230-853-2.</ref>.

CBT is also used as a treatment modality for children who have experienced Complex Post Traumatic Stress Disorder, chronic maltreatment, and Post Traumatic Stress Disorder<ref> (2006) Briere, John; Scott, Catherine (eds).: Principles of Trauma Therapy. Sage. ISBN 0-7619-2921-5. (see especially Chapter 7, "Cognitive Interventions", pp. 109-119).</ref>. It would be one component of treatment for children with C-PTSD, along with a variety of other components, which are discussed in the Complex Post Traumatic Stress Disorder article. In addition, many approaches to treating such children, such as Dyadic Developmental Psychotherapy incorporate Cognitive therapy methods and principles into treatment<ref> (2005) Becker-Weidman, A., & Shell, D. (eds).: Creating Capacity for Attachment. Wood 'N' Barnes. ISBN 1-885473-72-9.</ref>

[edit] References


[edit] Further reading

  • Dryden, Windy. Ten Steps to Positive Living. Sheldon Press, 1994.
  • Burns, David D. Feeling Good: The New Mood Therapy. Revised Edition. Avon, 1999. ISBN 0-380-81033-6
  • Tanner, Susan and Ball, Jillian. Beating the Blues: a Self-help Approach to Overcoming Depression. 1989/2001. ISBN 0-646-36622-X [1]
  • McCullough Jr., James P. Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press, 2003. ISBN 1-57230-965-2
  • Albano, M. & Kearney, Ca., (2000) When children refuse school: a cognitive behavioral therapy approach: Therapist guide. Psychological Corporation.
  • Deblinger, E. & Heflin, A. (1996) Treating sexually abused children and their nonoffending parents: a cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.

[edit] External links

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Cognitive therapy

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