Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one of the therapeutic approaches within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. This involves the individual working collaboratively with the therapist to develop skills for testing and modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. A tailored cognitive case conceptualization is developed by the cognitive therapist as a roadmap to understand the individual's internal reality, select appropriate interventions and identify areas of distress.
Becoming disillusioned with long-term psychodynamic approaches based on gaining insight into unconscious emotions and drives, Beck came to the conclusion that the way in which his clients perceived, interpreted and attributed meaning in their daily lives—a process scientifically known as cognition—was a key to therapy. Albert Ellis had been working on similar ideas since the 1950s (Ellis,1956). He called his approach Rational Therapy (RT) at first, then Rational Emotive Therapy (RET) and later Rational Emotive Behavior Therapy (REBT).
Beck outlined his approach in Depression: Causes and Treatment in 1967. He later expanded his focus to include anxiety disorders, in Cognitive Therapy and the Emotional Disorders in 1976, and other disorders and problems. He also introduced a focus on the underlying "schema"—the fundamental underlying ways in which people process information—about the self, the world or the future.
The new cognitive approach came into conflict with the behaviorism ascendant at the time, which denied that talk of mental causes was scientific or meaningful, rather than simply assessing stimuli and behavioral responses. However, the 1970s saw a general "cognitive revolution" in psychology. Behavioral modification techniques and cognitive therapy techniques became joined together, giving rise to cognitive behavioral therapy. Although cognitive therapy has always included some behavioral components, advocates of Beck's particular approach seek to maintain and establish its integrity as a distinct, clearly standardized form of cognitive behavioral therapy in which the cognitive shift is the key mechanism of change.
Precursors of certain fundamental aspects of cognitive therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers".
As cognitive therapy continued to grow in popularity, the Academy of Cognitive Therapy, a non-profit organization, was created to accredit cognitive therapists, create a forum for members to share emerging research and interventions, and to educate consumer regarding cognitive therapy and related mental health issues.
Therapy may consist of testing the assumptions which one makes and looking for new information that could help shift the assumptions in a way that leads to different emotional or behavioral reactions. Change may begin by targeting thoughts (to change emotion and behavior), behavior (to change feelings and thoughts), or the individual's goals (by identifying thoughts, feelings or behavior that conflict with the goals). Beck initially focused on depression and developed a list of "errors" (cognitive distortion) in thinking that he proposed could maintain depression, including arbitrary inference, selective abstraction, over-generalization, and magnification (of negatives) and minimization (of positives).
As an example of how CT might work: Having made a mistake at work, a man may believe, "I'm useless and can't do anything right at work." He may then focus on the mistake (which he takes as evidence that his belief is true), and his thoughts about being "useless" are likely to lead to negative emotion (frustration, sadness, hopelessness). Given these thoughts and feelings, he may then begin to avoid challenges at work, which is behavior that could provide even more evidence for him that his belief is true. As a result, any adaptive response and further constructive consequences become unlikely, and he may focus even more on any mistakes he may make, which serve to reinforce the original belief of being "useless." In therapy, this example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to explore and shift this cycle.
People who are working with a cognitive therapist often practice the use of more flexible ways to think and respond, learning to ask themselves whether their thoughts are completely true, and whether those thoughts are helping them to meet their goals. Thoughts that do not meet this description may then be shifted to something more accurate or helpful, leading to more positive emotion, more desirable behavior, and movement toward the person's goals. Cognitive therapy takes a skill-building approach, where the therapist helps the person to learn and practice these skills independently, eventually "becoming his or her own therapist."
The cognitive model was originally constructed following research studies conducted by Aaron Beck to explain the psychological processes in depression. It divides the mind beliefs in three levels:
In 2014, an update of the cognitive model was proposed, called the Generic Cognitive Model (GCM). The GCM is an update of Beck's model that proposes that psychiatric disorders can be differentiated by the nature of their dysfunctional beliefs. The GCM includes a conceptual framework and a clinical approach for understanding common cognitive processes of mental disorders while specifying the unique features of the speciﬁc disorders.
Consistent with the cognitive model of psychopathology, CT is designed to be structured, directive, active, and time-limited, with the express purpose of identifying, reality-testing, and correcting distorted cognition and underlying dysfunctional beliefs.
Cognitive restructuring (Methods)
- Activity monitoring and activity scheduling
- Behavioral experiments
- Catching, checking, and changing thoughts
- Collaborative empiricism: therapist and client become investigators by examining the evidence to support or reject the patient's cognitions. Empirical evidence is used to determine whether particular cognitions serve any useful purpose.
- Downward Arrow Technique
- Exposure and response prevention
- Guided discovery: therapist elucidates behavioral problems and faulty thinking by designing new experiences that lead to acquisition of new skills and perspectives. Through both cognitive and behavioral methods, the patient discovers more adaptive ways of thinking and coping with environmental stressors by correcting cognitive processing.
- Mastery and pleasure technique
- Problem solving
- Socratic questioning: involves the creation of a series of questions to a) clarify and define problems, b) assist in the identification of thoughts, images and assumptions, c) examine the meanings of events for the patient, and d) assess the consequences of maintaining maladaptive thoughts and behaviors.
- Cognitive therapy
- based on the cognitive model, stating that thoughts, feelings and behavior are mutually influenced by each other. Shifting cognition is seen as the main mechanism by which lasting emotional and behavioral changes take place. Treatment is very collaborative, tailored, skill-focused, and based on a case conceptualization.
- Rational emotive behavior therapy (REBT)
- based on the belief that most problems originate in irrational thought. For instance, perfectionists and pessimists usually suffer from issues related to irrational thinking; for example, if a perfectionist encounters a small failure, he or she might perceive it as a much bigger failure. It is better to establish a reasonable standard emotionally, so the individual can live a balanced life. This form of cognitive therapy is an opportunity for the patient to learn of his current distortions and successfully eliminate them.
- Cognitive behavioral therapy (CBT)
- a system of approaches drawing from both the cognitive and behavioral systems of psychotherapy.
Unlike Psychodynamic approaches, CBT is transparent to the individual receiving services. At the end of the therapy, an individual will often have learned the cognitive therapy skills well enough to "be their own therapist," decreasing dependence on a therapist to provide the answers.
According to Beck's theory of the etiology of depression, depressed people acquire a negative schema of the world in childhood and adolescence; children and adolescents who experience depression acquire this negative schema earlier. Depressed people acquire such schemas through a loss of a parent, rejection by peers, bullying, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles the original conditions of the learned schema in some way, the negative schemas of the person are activated.
Beck's negative triad holds that depressed people have negative thoughts about themselves, their experiences in the world, and the future. For instance, a depressed person might think, "I didn't get the job because I'm terrible at interviews. Interviewers never like me, and no one will ever want to hire me." In the same situation, a person who is not depressed might think, "The interviewer wasn't paying much attention to me. Maybe she already had someone else in mind for the job. Next time I'll have better luck, and I'll get a job soon." Beck also identified a number of other cognitive distortions, which can contribute to depression, including the following: arbitrary inference, selective abstraction, overgeneralization, magnification and minimization.
Cognitive therapy has been applied to a very wide range of behavioral health issues including:
- Academic achievement
- Anxiety disorders
- Bipolar disorder
- Low self-esteem
- Substance abuse
- Suicidal ideation
- Weight loss
A criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.
- Cognitive analytic therapy
- Cognitive bias mitigation
- David D. Burns
- History of psychotherapy
- Journal of Cognitive Psychotherapy
- Recognition primed decision
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