Cognitive Therapy




Cognitive therapy is based on the idea that beliefs determine feelings and behavior. Albert Ellis, who along with Aaron Beck pioneered the cognitive approach to therapy, favored this quote by the Stoic philosopher Epictetus (first century A.D.): “What disturbs people’s minds is not events but their judgments on events.” Cognitive therapists use a variety of techniques and approaches to identify and then modify the cognitive distortions and irrational beliefs that clients bring to counseling. Thoughts are typically defined as distorted or irrational when they do not square with reality or cannot be supported with objective evidence, and when they cause emotional problems such as depression and anxiety.

Cognitive therapists utilize the counseling relationship to educate their clients about how thinking affects feelings and behaviors. Cognitive therapists formally or informally assess clients’ patterns of thinking and how their beliefs have contributed to their current problems. A variety of techniques can then be employed to help clients challenge and modify problematic cognitions. For example, the counselor and client often discuss the veracity of the client’s beliefs and whether they can be defended rationally. Clients also may be asked to keep records of irrational thoughts, read books or articles about the principles of cognitive therapy, and participate in role-plays with the therapist that challenge beliefs about inadequacies clients perceive in their relationships with other people. The underlying goal of these interventions is to modify the irrational or distorted thoughts that are causing problems for the client.

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Over the past several decades, cognitive therapy has been increasingly integrated with behavior counseling into a broad category labeled cognitive-behavioral therapy (CBT). Both cognitive and behavioral counseling were developed during the mid-20th century, in part because of the dissatisfaction by some with Sigmund Freud’s psychoanalysis and because of emerging research on human cognition and behavior.

Classic behavioral approaches initially rejected any attempt to incorporate the role of clients’ thoughts into counseling, but eventually were strongly influenced by the science of cognitive psychology. In a similar way, cognitive therapists such as Ellis and Beck initially focused very little attention on their clients’ behaviors and increasingly incorporated more and more behavioral elements into their approaches.

Ellis pioneered cognitive therapy with his original formulation of what he called rational-emotive therapy because of what he saw as the limitations and myths associated with psychoanalysis. He has gradually reshaped it to be an integration of both cognitive and behavioral counseling, and fittingly relabeled it rational emotive behavior therapy (REBT). Beck initially developed his brand of cognitive therapy to explain the psychological processes that led to depression. While Aaron Beck acknowledged Ellis’s influence in the development of cognitive therapy, today Beck’s approach remains unique in its primary emphasis on cognitive factors in therapy. Many theorists have influenced the development of cognitive therapy in addition to Ellis and Beck, so it has much less historical cohesion than theories dominated by a single theoretician. The remainder of this entry will focus on the counseling models of Ellis and Beck, cognitive therapy’s two most prominent theorists, and will conclude with a brief review of research and current trends in cognitive therapy.

Albert Ellis’s Rational Emotive Behavior Therapy

Ellis turned to philosophy, especially the philosophy of happiness, early in his own life because of anxieties in social situations. In some of his later writings, Ellis identified himself as having moved from a logical positivist point of view (a modern, scientific approach emphasizing what exists and is knowable) to a constructivist and postmodern philosophy (in which there is no absolute truth). Meaning is created, at least partly, by the individual observer. Despite our often strongly-held convictions, Ellis believes that we do not know reality, nor what reality will be, with absolute certainty.

Two general principles are prominent in REBT. First is the notion that thoughts play a major role in determining how an individual feels and behaves, and are the primary cause of emotional and psychological disturbances. Ellis worked with a client’s current thought patterns and spent little time exploring the history of how these thoughts developed. Central to REBT is the idea that specific types of irrational beliefs are particularly likely to lead to human misery. Some examples of irrational beliefs are those pertaining to

  • Competence and success: the irrational belief that in whatever we strive to do, we must be completely successful all the time
  • Love and approval: the irrational belief that our love must be returned by others completely and without reservation
  • Being treated unfairly: the irrational belief that if we believe we are treating someone fairly, they must reciprocate by treating us with absolute fairness at all times
  • Safety and comfort: the irrational belief that because we seek to live a safe and comfortable life, we cannot tolerate the inconveniences and setbacks that life presents

A second important principle of REBT concerns the active role played by the therapist. REBT counselors educate the people they work with about the basic principles of REBT, and they do not hesitate to confront irrational and dysfunctional beliefs displayed by the client. REBT is synonymous with the ABC method Ellis used to work with clients. The A refers to an activating event that caused a client to feel a certain way, the B refers to the beliefs that the client has about the event, and the C refers to the consequences that those belief have in terms of emotional and behavioral responses.

After ABCs are identified at the outset of counseling, the main curative effort in REBT is for the counselor to help the client dispute and change the irrational beliefs so that new effects will be realized. According to Ellis, when irrational beliefs are successfully disputed, effective new philosophies emerge and lead to healthy emotions and effective functional behaviors.

Aaron Beck’s Cognitive Therapy

Aaron Beck was originally trained as a psychoanalyst, but was influenced by both George Kelly and Albert Ellis in formulating cognitive therapy (hereafter referred to as CT). Kelly was a psychologist who developed personal construction theory, which posited that the world is perceived according to whatever meaning a person attaches to it, and that each person is free to choose different meanings in understanding the world.

Beck’s early theorizing was primarily based on an information-processing model that emphasized understanding systematic distortions of external events and internal stimuli that ultimately result in depression. He categorized and discussed these distortions in his writings, and in many ways they are similar to the types of irrational beliefs Ellis identified in REBT. Examples from cognitive therapy include arbitrary inference, coming to a conclusion, when there is no evidence, or even contrary evidence, for the conclusion; selective abstraction, paying attention to a selective piece of information, without looking at the other information or considering the situation as a whole; and overgeneralization, drawing a conclusion from very limited information.

Beck noted that underlying these distorted interpretations of events are relatively enduring cognitive structures called schemas. Schemas are core beliefs, developed throughout life, that affect people’s interpretation of events at a fundamental level. A person’s schemas dictate the types of information he or she pays attention to, and lead to the cognitive distortions and automatic thoughts about the situations a person encounters in life. Based on these ideas, Beck described the presence of a negative cognitive triad that he believed is present in depression-prone individuals: negative views about the world, negative ideas about the future, and negative thoughts about the self. Beck labeled this the cognitive specificity hypothesis, and expanded it to postulate a distinct cognitive profile for each psychiatric disorder. For example, the cognitive profile of depressed individuals may include self-devaluation, which is evident in the negative cognitive triad, while the cognitive profile for anxious individuals may include fears about their vulnerability to future threats.

As with REBT, raising the clients’ awareness of the influence that thoughts have on negative feelings is viewed as essential. One notable difference between CT and REBT is Beck’s emphasis on what he termed the collaborative empiricism between the counselor and client. Whereas an REBT counselor may take a more directive, educational stance with a client, Beck favored a more collaborative process. The counselor and client work together using whatever evidence they have to determine if a given belief is distorted.

Thought stopping, positive imagery, and positive self-talk are also often used in cognitive therapy. Thought stopping, which can be as simple as saying “stop” to oneself, is used as a way to break the negative thought cycle. Positive imagery, asking the client to imagine a positive outcome, can help challenge negative automatic thoughts. Positive self-talk, which involves saying positive, affirming things to oneself, is also a way to interrupt the negative thought cycle. Beck also suggested giving clients homework by having them attempt to modify thoughts in everyday life situations between sessions.

Research Support for Cognitive Therapy

There is considerable research evidence documenting the effectiveness of CT, which explains in part the strong continued interest in developing and refining both cognitive and cognitive-behavioral therapy. For example, support for the efficacy of REBT was found in reviews of 70 and 28 outcome studies. The efficacy of CT was the subject of a review of 14 meta-analyses, a statistical method of summarizing the results of numerous studies on the same topic. Another research review of an aggregate of 325 studies involving more than 9,000 subjects indicated that CT was effective with a number of different psychological problems including adult and adolescent depression, anxiety disorder, social phobia, and marital distress. The research support for CT and REBT is one of the reasons it is often labeled an evidence-based treatment for disorders such as anxiety and depression.

Future Directions

A number of theorists have taken core features of cognitive therapy and expanded both its theoretical underpinnings and its applicability to different types of clinical issues. Jeffrey Young and colleagues developed schema therapy, an application of CT for clients with personality disorders. They noted that personality disorders represent rigid and inflexible traits that are enduring. The general goal of schema therapy is to help clients with personality disorders repair maladaptive schemas developed early in life and to change maladaptive coping styles.

Donald Meichenbaum’s stress inoculation training (SIT) represents an important integration of cognitive and behavioral therapies. This approach attempts to “inoculate” a person from stress in a manner analogous to the way the body reacts to a virus or bacteria by forming antibodies after a vaccination. Meichenbaum uses a three-stage approach. During the conceptual phase the counselor establishes a collaborative relationship with clients, gathers information about their concerns, and provides education about the role of thinking and emotion in maintaining stress. In the skills acquisition phase clients are taught coping skills that can be used in stressful situations. For example, a client may be taught relaxation strategies and the use of positive self-statements. In the application and follow-through stage, clients implement what they have learned in life, and they work with the counselor to evaluate their effectiveness.

Zindel Segal, J. Mark G. Williams, and John D. Teasdale developed mindfulness-based cognitive therapy (MBCT) by integrating cognitive therapy with Jon Kabat-Zinn’s mindfulness-based stress reduction (MBSR) in order to prevent relapses of depressive episodes. Mindfulness in contemporary psychology has been conceptualized as nonjudgmental, present-centered awareness. Mindfulness entails acknowledging each thought, feeling, or sensation that arises nonjudgmentally and with acceptance. Kabat-Zinn’s MBSR consists of a program of eight weekly 2-hour sessions and includes such elements as meditation and yoga. In MBCT, Segal suggested that mindfulness practices be used to help individuals shift their relationship to the thoughts, feelings, and bodily sensations that contribute to depression. Rather than attempt to change the content of thoughts, as suggested in Beck’s CT, participants in MBCT are trained to view their thoughts as transient mental events that are not necessarily fundamental parts of themselves or accurate depictions of reality.

Cognitive approaches to therapy are widely used and researched. The vitality of this approach is evidenced in an extensive body of research, and in continued developments in its applicability to a wide of clinical concerns. Ellis and Beck have training institutes that offer extensive training in REBT and cognitive therapy, respectively. These institutes continue to produce trained therapists and teachers, to play an important role in establishing credentialing standards, and to provide direction for continued research on these approaches.

References:

  1. Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
  2. Butler, A. C., & Beck, A. T. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of the Norwegian Psychological Association, 37, 1-9.
  3. Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy. New York: Springer.
  4. Engles, G. I., Garnefsky, N., & Diekstra, F. W. (1993). Efficacy of rational-emotive therapy: A quantitative analysis. Journal of Consulting and Clinical Psychology, 6, 1083-1090.
  5. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York: Dell.
  6. Lyons, L. C., & Woods, P. (1991). The efficacy of rational-emotive therapy: A quantitative review of the outcome
  7. research. Clinical Psychology Review, 11, 357-369.
  8. Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.
  9. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression. New York: Guilford Press.
  10. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford Press.

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