Cognitive Therapy

Cognitive therapy is a psychosocial therapy that assumes that faulty cognitive, or thought, patterns cause maladaptive behavior and emotional responses. The treatment focuses on changing thoughts in order to adjust psychological and personality problems.

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Purpose

Psychologist Aaron Beck developed the cognitive therapy concept in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted viewpoint of the situation. Cognitive therapy focuses on changing these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.

Cognitive therapy is a treatment option for a number of mental disorders, including agoraphobia, Alzheimer's disease, anxiety or panic disorder, attention deficit-hyperactivity disorder (ADHD), eating disorders, mood disorders, obsessive-compulsive disorder (OCD), personality disorders, post-traumatic stress disorder (PTSD), psychotic disorders, schizophrenia, social phobia, and substance abuse disorders. It can be useful in helping individuals with anger management problems, and has been reported to be effective in treating insomnia. It is also frequently prescribed as an adjunct, or complementary, therapy for patients suffering from back pain, cancer, rheumatoid arthritis, and other chronic pain conditions.

Treatment techniques

Cognitive therapy is usually administered in an out-patient setting (clinic or doctor's office) by a therapist trained or certified in cognitive therapy techniques. Therapy may be in either individual or group sessions, and the course of treatment is short compared to traditional psychotherapy (often 12 sessions or less). Therapists are psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. trained in psychiatry).

Therapists use several different techniques in the course of cognitive therapy to help patients examine thoughts and behaviors. These include:

• Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
• Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to successfully cope with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to deal with it.
• Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
• Journaling. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behavior that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
• Homework. In order to encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling (see above), review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
• Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.

Cognitive-behavioral therapy (CBT) integrates features of behavioral modification into the traditional cognitive restructuring approach. In cognitive-behavioral therapy, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, which are flawed, and are having a negative impact on the patient's behavior and functioning. For example, a patient suffering from depression may develop a social phobia because he/she is convinced he/she is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends that care for him/her and enjoy his/her company. By showing the patient that others value him/her, the therapist exposes the irrationality of the patient's assumption and also provides a new model of thought for the patient to change his/her previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations in order to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.

Preparation

Cognitive therapy may not be appropriate for all patients. Patients with significant cognitive impairments (e.g., patients with traumatic brain injury or organic brain disease) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.

Because cognitive therapy is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in cognitive therapy should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist's professional credentials, his/her approach to treatment, and other relevant issues.

In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.

Typical results

Because cognitive therapy is employed for such a broad spectrum of illnesses, and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. Cognitive and cognitive behavior treatments have been among those therapies not likely to be evaluated, however, and efficacy is well-documented for some symptoms and problems.

Some studies have shown that cognitive therapy can reduce relapse rates in depression and in schizophrenia, particularly in those patients who respond only marginally to antidepressant medication. It has been suggested that this is because cognitive therapy focuses on changing the thoughts and associated behavior underlying these disorders rather than just relieving the distressing symptoms associated with them.