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Cognitive therapy or cognitive behaviour therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, delusional disorder and other forms of mental disorder.
It involves recognising unhelpful or destructive 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 Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior 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 often, and further reduce their depression.
Thoughts as the cause of emotions
With thoughts stipulated as being the cause of emotions rather than the outcome or by-product, 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 go awry, it can take months of concerted effort to replace an irrational thought process or habit with a more reasonable, salutary 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 the growing humanistic methods at the time , and Aaron T. Beck, who followed up Ellis' approach in the 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, 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 . 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 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 that 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 low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.
- 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 more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.
Effectiveness of CBT with or without drugs for depression
Main article: Cognitive behavioral analysis system of psychotherapyA large-scale study in 2000 showed substantially higher results of response and remission when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either method was used alone.
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 Behavioral 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.
CBT has been used with children and adolescents to treat a variety of conditions with good success.
CBT is also used as a treatment modality for children who have experienced Complex Post Traumatic Stress Disorder,(chronic maltreatment), and Post Traumatic Stress Disorder. It would be one component of treatment for children with C-PTSD, along with a variety of other components, which are discussed in the Complex Post Traumatic Stress Disorder article.
References
- "What is Cognitive-Behavioral Therapy?". National Association of Cognitive-Behavioral Therapists. Retrieved 2006-06-25.
- ^ Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall. ISBN 0-13-370650-8.
{{cite book}}: Check date values in:|date=(help) - Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-8236-0990-1
- "Group Therapy". Stress and Anxiety Services of New Jersey. Retrieved 2006-06-25.
- Abramson, L., Seligman, M.E.P. & Teasdale, J. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87 pp49-74
- Abramson, L. et al: Hopelessness depression: a theory-based subtype of depression, Psychol Rev 96:358, 1989.
- Keller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioral-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.
- "Treatments: Cognitive Behavioural Therapy". depresioNet. 2004-01-08. Retrieved 2006-08-27.
{{cite web}}: External link in|publisher= - "The Depression Report: A New Deal for Depression and Anxiety Disorders". The Centre for Economic Performance's Mental Health Policy Group. 2006-06-19. Retrieved 2006-06-25.
{{cite web}}: Check date values in:|date=(help) - "Treatment Recommendations for Patients with Major Depressive Disorder (Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition)". American Psychiatric Association. 2000. Retrieved 2006-07-02.
- Kendall, Philip C. (ed)., ed. (2005-12-05). Child and Adolescent Therapy: Cognitive-Behavioral Procedures, (3rd ed.). Guilford Press. ISBN 1-59385-113-8.
- Reinecke, Mark A.; Dattilio, Frank M.; Freeman, A. (eds)., ed. (2003-05-02). Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (2nd ed.). Guilford Press. ISBN 1-57230-853-2.
{{cite book}}: CS1 maint: multiple names: editors list (link) - Briere, John; Scott, Catherine (eds)., ed. (2006). Principles of Trauma Therapy. Sage. ISBN 0-7619-2921-5.
{{cite book}}: CS1 maint: multiple names: editors list (link) (see especially Chapter 7, "Cognitive Interventions", pp. 109-119).
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 0-380-81033-6
- Tanner, Susan and Ball, Jillian. Beating the Blues: a Self-help Approach to Overcoming Depression. 1989/2001. ISBN 0-646-36622-X
- McCullough Jr., James P. Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press, 2003. ISBN 1-57230-965-2
- Albano, M. & Kearney, Ca., (2000) When children refuse school: a cognitive behavioral therapy approach: Therapist guide. Psychological Corporation.
- Deblinger, E. & Heflin, A. (1996) Treating sexually abused children and their nonoffending parents: a cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.
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
- Marks, Isaac (2003). "Review of Introducing Cognitive Analytic Therapy. Principles and Practice by Ryle and Kerr". British Journal of Psychiatry. Retrieved 2006-07-12.
- "Moodgym". Australian National University. Retrieved 2006-07-04.
{{cite web}}: External link in|publisher= - "Living Life to the Full". Retrieved 2006-07-04. (Free online CBT life skills course, sponsored by Scottish Executive Health Department Centre for Change and Innovation.)