Cognitive therapy

This article is about cognitive therapy. For the behaviourist technique, see behaviour modification.

Cognitive therapy or cognitive behaviour therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder.

It involves recognising unhelpful patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that typically clinical depression is associated with (although not necessarily caused by) 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-Behavioural Therapists:

"There are several approaches to cognitive-behavioural therapy, including Rational Emotive Behaviour Therapy, Rational Behaviour Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy."

A related approach, Cognitive Analytic Therapy, can be regarded as a form of integrative therapy, integrating insights of both psychodynamic (especially Kleinian) therapy with a broad cognitive approach to therapy. Another approach, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), developed specifically to treat the chronically depressed adult, has been shown in a large-scale trial to provide highly significant response rates when combined with medication.

The basics

Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) all interact together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative 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 their mood and makes them feel depressed; then they worsen the problem by reacting to avoid activities. As a result they reduce their chance of successful experience, which reinforces their 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 to work together to change this. This is done by addressing the way the client thinks in response to similar situations and by helping them think more flexibly, along with reducing their avoidance of activities. If as a result they escape the negative thought pattern, they will already feel less depressed. They may hopefully also then become more active, succeed more, and further reduce their depression.

Thoughts as the cause of emotions

With thoughts stipulated as being the cause of emotions rather than vice-versa, 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 are going awry, it can take months of concerted effort to replace an irrational thought with a more reasonable one. With patience and a good therapist, however, cognitive therapy can be a valuable tool in recovery.

Cognitive behavioural 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 humanistic methods , and Aaron T. Beck, who followed up Ellis' approach in the 1960sBeck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-82-360990-1 . It rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies it was often contrasted with behavioural treatments to see which was most effective. However, in recent years, cognitive and behavioural techniques have often been combined into cognitive behavioural treatment. This is arguably the primary type of psychological treatment being studied in research today.

Cognitive behavioural group therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg. In this case, clients participate in a group and recognize they are not alone in suffering from their problems.

A sub-field of cognitive behaviour 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 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 depression.

Cognitive Therapy and/or Cognitive Behavioural 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 behaviour); and measureable goal-attainment.

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".

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 Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74. 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 Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.. 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 clinicial depression as are causal attributions.

The ABCs of Irrational Beliefs

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. 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 which occurred to them.

C - Consequence. The third column is for the negative feelings and dysfunctional behaviours 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 C on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that if she does not have perfect grades, she will not be able to go to college. The Consequence, C, is that Gina feels that she is worthless, depressed, and that she had ruined her life.

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 positive light. This helps the client to develop more rational beliefs and healthy coping strategies.

Treating depression with CBASP

A relatively new version of cognitive behavioural therapy for depression is the cognitive behavioural-analysis system of psychotherapy (CBASP), developed (and patented) by James P. McCullough Jr, and partly based on Piaget's theory of cognitive development. It uses a structured exercise called "situational analysis" to help the patient redevelop the ability to see the cause and effect relationships in interpersonal interactions, and then remedy thinking patterns; it may involve "disciplined personal involvement" of the therapist with the patient (See ). When combined with appropriate antidepressants, it can be extremely effective.

A large-scale study, published in 2000 by Martin Keller MD of Brown University and othersKeller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioural-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., compared the (then available) antidepressant Serzone with CBASP. Six hundred and eighty-one patients with severe chronic depression (some with other psychiatric illnesses) were enrolled in the trial, and were assigned to either Serzone, CBASP, or combination Serzone-CBASP for 12 weeks. The response rates to either Serzone or CBASP alone were 55 percent and 52 percent, respectively, for the 76 percent who completed the study. In other words, a little more than half of the completers in those two arms of the trial reduced their depression by 50 percent or better.

The Serzone findings roughly correspond with many other trial results for antidepressants, and underscore a major weakness in these drugs — that while they are effective, the benefit is often marginal and the treatment outcome problematic. Similarly, the CBASP findings validate other studies finding talking therapy about equal in efficacy to taking antidepressants.

The results for the combination drug-therapy group, however, were surprising, with 85 percent of the completing patients achieving a 50 percent reduction in symptoms or better. 42 percent in the combination group achieved remission (a virtual elimination of all depressive symptoms) compared to 22 percent in the Serzone group and 24 percent in the CBASP group.

The authors of the frequently cited study noted that "the rates of response and remission in the combined-treatment group were substantially higher than those that might have been anticipated on the basis of the outcomes of previous trials in similar patients." Their figures are important, because they show that treating depression with a combination of both an anti-depressant drug and a form of cognitive behaviour therapy can be highly effective, giving substantially better results than other methods of dealing with depression.

Overall effectiveness of CBT (with or without drugs) for depression

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 Behavioural Therapy.

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, 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 .

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 at Northwestern University in the Clinical Psychology program in Chicago.

Criticisms

CBT is claimed to be a treatment for mental illness. CBT suggests that mental illness is within the control of the sufferer or that the sufferer is the cause of the mental illness. Many sufferers from chronic mental illness disorders such as bipolar or schizophrenia reject this approach since it implies that they are the fault of their biologically based disorder.

References

External links

American Institute for Cognitive Therapy
The Beck Institute for Cognitive Therapy and Research
The Academy of Cognitive Therapy
The Albert Ellis Foundation -- The Home of REBT
REBT-CBT NET- The Internet Guide to Rational Emotive Behavior Therapy and Cognitive Behavior Therapy
An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches
An Introduction to Rational Emotive Behaviour Therapy
Patient.co.uk article on CBT
(Free online CBT training program for preventing depression.)
(Free online CBT life skills course, sponsored by Scottish Executive Health Department Centre for Change and Innovation.)

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