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

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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.

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 recognise 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 and Aaron T. Beck in the 1950s and 1960s. 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. In this case, clients participate in a group and recognize they are not alone ín suffering from their problems. Based on the protocol by Richard Heimberg.

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".

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 . 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 . 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 four column technique

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A major technique in cognitive therapy is the four column technique. It consists of a four step process. The first three steps analyze the process by which a person has become depressed or distressed. The first column records the objective situation. In the second column, the client writes down the negative thoughts which occurred to them. 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. Finally, the fourth column is used for challenging the negative thoughts on the basis of evidence from the client's experience.

Psychotherapists teach the first three columns under the name of ABC. The first column A is the activating event or objective situation. By "activating event" they mean an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking. The third column C is next explained (C for consequence) by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc. The therapist at this point picks a sample situation like getting a "B" grade in English. Some would feel good and others would be sad or angry or depressed. Therefore the A could not have caused C because all the C's would be the same. At that point B is introduced (B for Beliefs)and explained that our thinking, from column B, is our interpretation of what happened in column A. Our thinking about the event in column A causes C, not the event in column A. The last column is where the client writes a more healthy way to interpret column A. Sometimes referred to as "reframing".

Treating depression with CBASP

A relatively new version of cognitive behavioural therapy for depression is the cognitive behavioural-analysis system of psychotherapy (CBASP). When combined with appropriate antidepressants, it can be extremely effective.

A study published by Martin Keller MD of Brown University and others in the May 18, 2000 New England Journal of Medicine compared the antidepressant Serzone with the talking therapy CBASP. CBASP is largely derivative of other talking therapies such as cognitive, behavioural, and interpersonal therapy. 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 rather underwhelming - 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 study confessed to being caught by surprise by the results, acknowledging that "the rates of response and remission in the combined-treatment group were substantially higher than those that might have been anticipated."

References

1. Ellis, Albert. A Guide to Rational Living. Prentice Hall, 1975. ISBN 0-13-370650-8
2. Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-82-360990-1
3. Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74
4. Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.
5. Keller, 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.

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 0-38-081033-6
• Tanner, Susan and Ball, Jillian. Beating the Blues: a Self-help Approach to Overcoming Depression. 1989/2001. ISBN 064636622X
• McCullough Jr., James P. Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press, 2003. ISBN 1-57-230965-2

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
• NICE
• NACBT Online - What is CBT?
• An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches
• An Introduction to Rational Emotive Behaviour Therapy
• New York Institute for Cognitive and Behavioral Therapies
• Moodgym - Training CBT for preventing depression
• Living Life to the Full free online CBT life skills programme
• Patient.co.uk article on CBT

• Cognitive therapy
• Psychotherapy
• Therapy