|
What is Cognitive Therapy?
Robert Westermeyer,
Ph.D.
The word "cognitive" or "cognition" means "to know" or "to think". Therefore,
cognitive therapy is viewed as a "psychological treatment of thoughts." Simply, cognitive therapy operates under the
assumption that thoughts, beliefs, attitudes and perceptual biases influence what emotions will be experienced and also the
intensity of those emotions. Cognitive Therapy was pioneered by Aaron Beck, M.D. for the treatment of depression. Dr. Beck
and other researchers have developed methods for applying cognitive therapy to other psychiatric problems, such as panic,
anger control problems and substance abuse. This form of therapy has received considerable research support, especially with
regard to depression.
The view that our thoughts influence our emotions and behavior is hardly new. In fact, the origins
of this idea can be traced back to the Stoic philosophers, namely Epictetus, who wrote, "Men are disturbed not by things,
but by the view which they take of them."
To illustrate this point, imagine you are asleep in bed and you are awakened
by a loud crashing sound from downstairs. How will you feel if you believe that the crash was an intruder? Probably pretty
frightened and anxious, right? Now imagine that you suddenly remember that you just acquired a new kitten that has been knocking
over just about everything in sight. How might you be feeling then? Certainly not frightened or anxious; rather, you might
be angry or even disappointed about the vase.
The nature of our feelings is largely determined by the way that we
think. In the above example the feeling (frightened or angry) was solely dependent on how the event (crashing sound) was construed.
Depression is a mood state that can be brought upon by overly negative interpretations of events. For example, imagine
two people experiencing the break up of a relationship. Imagine that both of them view themselves and the relationship in
different ways. One person conceptualizes the relationship as evidence of his worth as a person and the break up, therefore,
as evidence that he is worthless and unlovable. Further he views the break-up as being caused by his unlovable characteristics.
The second person views the relationship as a very important part of his life. However, it does not represent his sum total
worth. The second person views the break up as due to mutual incompatibility. Which of these two people would be more likely
to experience depressed mood secondary to the break up? Probably the former, right? The break-up was construed in this as
due to a flaw in his character, and since his worth was contingent on being in a relationship with that partner, the break
up affirmed his belief in himself as a worthless failure.
Self-debasing beliefs like these lead to negative emotions
like depression and anxiety. The second person didn't deny that the relationship was important. He may feel sad and frustrated
after the break up, but probably will not sink into a clinical depression. This is because his construction of the break up
was realistic and non-self-punitive.
Depression has many causes; biological changes can cause depression, rigid negative
attitudes about oneself can cause depression, catastrophic events can cause depression. But one thing occurs after onset that
is common to depression regardless of its etiology: negative thinking. Depressed people view the world in a negative manner;
they view themselves in a debasing way; and they view their future as dismal. Cognitive therapy is a treatment designed to
help people learn to identify and monitor negative ways of thinking, then to alter this tendency and think in a more realistic
manner.
When depressed people learn to identify distorted automatic thinking and to replace them with more realistic
ones, depression can be reduced. Moreover, when people become adept at altering negative thoughts and beliefs, their likelihood
of experiencing episodes of depression in the future decreases.
To some this may sound overly simplistic. You might
be thinking, "I've been depressed for years and you are trying to tell me that that all I need to do is think positively and
it will all go away?"
This is a common response to some people when they first hear about cognitive therapy. First,
though the notion of thoughts causing feelings is quite elementary, the actual information processing biases which occur in
depression are really quite complex. Volumes of research investigating biases in memory retrieval, attention and processing
structures that are activated in depressive states suggest that what happens cognitively in depression is far from simplistic.
One of the things that research has discovered is that just "thinking positively" is not going to decrease depression in a
lasting way. Though depressed people do not engage in a great deal of positive thinking, it is the negative thoughts, beliefs
and assumptions that perpetuate depressed mood. Negative thinking in depressed people largely occurs automatically and sometimes
without awareness. For cognitive therapy to be effective, depressed individuals need to learn how to identify their negative
automatic thoughts, processing biases as well as the beliefs they have about themselves and others. Depressed individuals
also need to learn to dispute their negative thoughts after they have been identified. Therefore, as opposed to positive thinking,
cognitive therapy helps people think non-negatively. For many this requires the learning of new skills: monitoring ones stream
of thoughts, identifying beliefs and attitudes and subjecting them to the laws of reason. With enough practice, these skills
become second nature, and the risk of severe depression decreases.
Therefore, cognitive therapy is more educational
than other non-directive forms of therapy. Cognitive therapy is not a "magic bullet." In order for one to benefit from it,
effort must be placed on using the skills outside of therapy. Some find the initial sessions of cognitive therapy difficult,
because the skills do not result in complete elimination of symptoms. I liken cognitive therapy to learning a foreign language.
At first the tasks of self-monitoring, activity scheduling and thought disputation feel awkward and the outcome doesn't seem
to be worth the effort. Like learning a foreign language, the more practice put into using cognitive therapy skills, the more
effective they will become, the more automatic they will become and the more lasting will relief be.
In many ways
cognitive therapy may sound like school; much of the therapy entails didactic presentation, and homework is assigned. However,
it is more accurate to view cognitive therapy as an interactive workshop. A very good self-help book on using cognitive therapy
for depression is "Feeling Good" by David Burns, M.D. In my opinion, this book is the best "self help" manual for cognitive
therapy of depression. It can also serve as a good adjunct to actual cognitive therapy. It is available in paperback and widely
available at most bookstores.
THE COGNITIVE MODEL OF DEPRESSION
The experience of depression is amorphous,
like a thick, dark fog. In cognitive therapy, depression is broken down into its symptom categories so that the tangible aspects
can be identified. As you will see, preventing certain depressive symptoms from maintaining the state is what cognitive therapy
is all about. Below are the four general symptom areas of depression.
Depressive symptoms feed one another, and this
is what prolongs the state. Consider the example of an applicant who is turned down after a job interview and comes to the
following conclusions: "I'm a loser, I'm unemployable" These self-statements will certainly make her feel sad and guilty (emotional),
which in turn will lead to a lethargic, listless physical state (physical), to which she might elect to spend all day in bed
(behavioral), leading to insomnia that night (physical). During the wakeful hours of darkness and silence, she has other thoughts
like "I can't do anything with my life" (cognitive) and to conjure ugly memories of past failures (cognitive). She'll undoubtedly
have decreased energy the next day (physical) and find it hard to concentrate (cognitive). She may elect to cancel her lunch
date with her friend (behavioral) then think thoughts like "my whole life is falling apart," (cognitive). This, in turn, will
add anxiety to her experience (emotional) which will add restlessness to her fatigue, (physical), which may lead to the decision
to cancel another scheduled job interview the following day (behavioral) and so on
Depression is a mood state with
many causes: negative life events such as divorce or cumulative stressors on the job; biological changes, as is the case with
postpartum depression and bipolar illness; or by the presence of dysfunctional beliefs such as "I'm unlovable". Though depression
has various triggers, once it is activated the symptoms are akin regardless of the cause. What is particularly insidious about
depression is that when the symptoms are allowed to cycle automatically, the state can maintain itself for weeks, even months.
This emphasizes the fact that symptoms of depression are not just by-products, but actually serve to strengthen
and prolong the depressive state. This may seem like a very discouraging model, but it also offers the logical conclusion
that if depressive symptoms perpetuate depression, the reduction of these symptoms would weaken the state. And this is exactly
what research has shown. Though depression is a self-fueling state, the cognitive and behavioral symptoms that worsen the
state are tangible, and when modified, weaken it.
Many people in the throes of clinical depression don't think that
their mood varies much, that it is always pretty much at the same miserable level. Quite the contrary; even very depressed
people experience changes in their mood throughout the day. The periods of reduced depression are far from insignificant;
they are periods when the depression is actually weakening--albeit because of the strength of the depression, these periods
don't result in any lasting improvement of mood.
Furthermore, the behaviors and attitudes associated with relief tend
to be those that counter the aforementioned behavioral and cognitive symptoms of depression (i.e., withdrawal, reduction of
pleasurable activities, inactivity, hopelessness, helplessness and worthlessness). Recovery from depression occurs gradually
as people increase these sorts of activities and consistently modify negative thinking.
One simple way of viewing
cognitive therapy of depression is that it focuses on disallowing behaviors and attitudes associated with depressed mood and
increasing the behaviors and attitudes associated with non-depressed mood. The more prolonged periods of improved mood a person
can achieve each day, the weaker the depression becomes.
To test the hypothesis that consistently reversing cognitive
and behavioral symptoms will lead to recovery from depression, it is recommended that individuals begin structuring their
days with activities associated with non-depressed mood, and monitoring their mood throughout the day. The activity monitoring/planning
form offers opportunities to rate the amount of pleasure associated with every hour of the day, as well as to gain insight
as to the activities associated with mood improvement and mood deterioration. It is also an opportunity to begin monitoring
your automatic thoughts.
Complete an activity monitoring/planning form for each day (preferably the day before). Days
should be structured as though you were not depressed (e.g., normal wake up time and bedtime, no prolonged periods of withdrawal
and sleep in the daytime). Each day should also have the three following activities: Something potentially pleasurable; something
that will bring about a sense of accomplishment; something involving others.
It's common to feel a complete lack of
interest in activities, and therefore feel hard-pressed to find pleasurable activities to assign. It is therefore recommended
that you complete a pleasurable activities inventory by listing things you used to do before you were depressed that were
associated with pleasure, and then assigning them to yourself. Also, because of the low energy and concentration impairment
of depression, it may not be possible to complete large tasks. Therefore, it is reasonable to break down accomplishment tasks
into smaller steps (for example, if bills need to be paid, an acceptable step for the day might be going to the post office
to buy stamps). Regarding social activities, it is the contact with people that is important. Being physically around positive
people is desirable, but a telephone call or an Internet dialog might be a reasonable step if this is not possible on a given
day.
In terms of the previously discussed symptoms of depression, negative thinking is the most powerful in terms
of perpetuating depression. When depressed people become proficient at identifying and countering cognitive distortions, depression
loses its strength. The aim of this program is for you to leave with this skill, which will not only result in the reduction
of your current depression, but also the ability to prevent future episodes.
Questions & Answers About Cognitive Therapy
Judith S. Beck, Ph.D.,
Q: What is cognitive therapy?
A: Cognitive therapy is one of the few forms of psychotherapy that has been
scientifically tested and found to be effective in over three hundred clinical trials for many different disorders. In contrast
to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem-solving
oriented. Indeed, much of what the patient does is solve current problems. In addition, patients learn specific skills that
they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating
to others in different ways, and changing behaviors.
Q: What is the theory behind cognitive therapy?
A: Cognitive therapy is based on the cognitive model, which is, simply that
the way we perceive situations influences how we feel emotionally. For example, one person reading this pamphlet might think,
Wow! This sounds good, its just what Ive always been looking for! and feels happy. Another person reading this information
might think, Well, this sounds good but I dont think I can do it. This person feels sad and discouraged. So it is not a situation
which directly affects how a person feels emotionally, but rather, his or her thoughts in that situation. When people are
in distress, they often do not think clearly and their thoughts are distorted in some way. Cognitive therapy helps people
to identify their distressing thoughts and to evaluate how realistic the thoughts are. Then they learn to change their distorted
thinking. When they think more realistically, they feel better. The emphasis is also consistently on solving problems and
initiating behavioral change.
Q: What can I do to get ready for therapy?
A: An important first step is to set goals. Ask yourself, How would I like
to be different by the end of therapy? Think specifically about changes youd like to make at work, at home, in your relationships
with family, friends, co-workers, and others. Think about what symptoms have been bothering you and which youd like to decrease
or eliminate. Think about other areas that would improve your life: pursuing spiritual/intellectual/cultural interests, increasing
exercise, decreasing bad habits, learning new interpersonal skills, improving management skills at work or at home. The therapist
will help you evaluate and refine these goals and help you determine which goals you might be able to work at on your own
and which ones you might want to work on in therapy.
Q: What happens during a typical therapy session?
A: Even before your therapy session begins, your therapist may have you
fill out certain forms to assess your mood. Depression, Anxiety and Hopelessness Inventories help give you and the therapist
an objective way of assessing your progress. One of the first things your therapist will do in the therapy session is to determine
how youve been feeling this week, compared to other weeks. This is what we call a mood check. The therapist will ask you what
problem youd like to put on the agenda for that session and what happened during the previous week that was important. Then
the therapist will make a bridge between the previous therapy session and this weeks therapy session by asking you what seemed
important that you discussed during the past session, what self-help assignments you were able to do during the week, and
whether there is anything about the therapy that you would like to see changed.
Next, you and the therapist will discuss the problem or problems you put
on the agenda and do a combination of problem-solving and assessing the accuracy of your thoughts and beliefs in that problematic
situation. You will also learn new skills. You and the therapist will discuss how you can make best use of what youve learned
during the session in the coming week and the therapist will summarize the important points of the session and ask you for
feedback: what was helpful about the session, what was not, anything that bothered you, anything the therapist didnt get right,
anything youd like to see changed. As you will see, both therapist and patient are quite active in this form of treatment.
Q: How long does therapy last?
A: Unless there are practical constraints, the decision about length of
treatment is made cooperatively between therapist and patient. Often the therapist will have a rough idea after a session
or two of how long it might take for you to reach the goals that you set at the first session. Some patients remain in therapy
for just a brief time, six to eight sessions. Other patients who have had long-standing problems may choose to stay in therapy
for many months. Initially, patients are seen once a week, unless they are in crisis. As soon as they are feeling better and
seem ready to start tapering therapy, patient and therapist might agree to try therapy once every two weeks, then once every
three weeks. This more gradual tapering of sessions allows you to practice the skills youve learned while still in therapy.
Booster sessions are recommended three, six and twelve months after therapy has ended.
Q: What about medication?
A: Cognitive therapists, being both practical and collaborative, can discuss
the advantages and disadvantages of medication with you. Many patients are treated without medication at all. Some disorders,
however, respond better to a combination of medication and cognitive therapy. If you are on medication, or would like to be
on medication, you might want to discuss with your therapist whether you should have a psychiatric consultation with a specialist
(a psychopharmacologist) to ensure that you are on the right kind and dosage of medication. If you are not on medication and
do not want to be on medication, you and your therapist might assess, after four to six weeks, how much youve progressed and
determine whether you might want a psychiatric consultation at that time to obtain more information about medication.
Q: How can I make the best use of therapy? A: One way is to ask your therapist
how you might be able to supplement your psychotherapy with cognitive therapy readings, workbooks, client pamphlets, etc.
A second way is to prepare carefully for each session, thinking about what you learned in the previous session and jotting
down what you want to discuss in the next session.
A third way to maximize therapy is to make sure that you try to bring the
therapy session into your everyday life. A good way of doing this is by taking notes at the end of each session or recording
the session or a summary of the session on audiotape. Make sure that you and the therapist leave enough time in the therapy
session to discuss what would be helpful for you to do during the coming week and try to predict what difficulties you might
have in doing these assignments so your therapist can help you before you leave the session.
Q: How will I know if therapy is working?
A: Most patients notice a decrease in their symptoms within three to four
weeks of therapy if they have been faithfully attending sessions and doing the suggested assignments between sessions on a
daily basis. They also see the scores on their objective tests begin to drop within several weeks
|
