Cognitive Therapy
Aaron Beck
Goal
"To help people recognize and correct errors in their information-processing systems"
(Seligman & Reichenberg, 2014, p. 298)
"To help people recognize and correct errors in their information-processing systems"
(Seligman & Reichenberg, 2014, p. 298)
Theoretical Concepts
Development of Cognitive Distortions
There are many factors that contribute to dysfunctional cognitions such as people's biology and genetic predispositions, life experiences, and the accumulation of knowledge and learning (Seligman & Reichenberg, 2014, p. 295). These types of cognitions start early in life and when there is a lot of stress, the dysfunctional beliefs will overtake the person's thoughts. It's essential that people are correctly diagnosed so that the dysfunctional beliefs can be identified and the counselors can help to change them. To ensure a correct diagnosis, an interview is done before therapy commences. It's also important the counselor understands their client so that he/she can provide interventions that will target thinking, feeling, and acting.
Example : "Feelings of depression typically stem from thoughts of loss" (Seligman & Reichenberg, 2014, p. 295)
Principles of Cognitive Therapy
- Cognitive therapy is based on the finding that changes in thinking lead to changes in feeling and acting.
- Treatment requires a sound and collaborative therapeutic alliance.
- Treatment is generally short term, problem focused, and goal oriented.
- Cognitive therapy is an active and structured approach to treatment.
- It focuses on the present, although attention is paid to the past when indicated.
- Careful assessment, diagnosis, and treatment planning are essential.
- Cognitive therapy uses a broad range of strategies and interventions to help people evaluate and change their cognitions.
- Inductive reasoning and Socratic questioning are particularly important strategies.
- This is a psychoeducational model that promotes emotional health and prevents relapse by teaching people to identify, evaluate,
and modify their own cognitions.
- Task assignments, follow-up, and client feedback are important in ensuring the success of this approach.
(Beck, 1995, 2011; Beck, Freeman, & Davis, 2006)
Levels of Cognition
There are four levels of cognition: automatic thoughts, intermediate beliefs, core beliefs and schemas. "Treatment typically begins with automatic thoughts and then proceeds to identification, evaluation, and modification of intermediate and core beliefs and finally to revision of schemas" (Seligman & Reichenberg, 2014, p. 296).
Automatic thoughts
Automatic thoughts are things that run through our heads . Different thoughts flow through our head in reaction to our experiences. When people are aware of what they're thinking, they can identify and assess their thoughts. By understanding people's automatic thoughts, it helps them to change their emotions to those thoughts.
Example : "I don't ever think I'll ever be able to get all that work done" (Seligman & Reichenberg, 2014, p. 296).
Intermediate beliefs
"Extreme and absolute rules and attitudes that shape people's automatic thoughts
Example : A sister should call her family when she's in town" (Seligman & Reichenberg, 2014, p. 296).
Core beliefs
"Central ideas about ourselves that underlie many of our automatic cognitions and usually are reflected in our intermediate beliefs" (Seligman & Reichenberg, 2014, p. 296). These beliefs originate from childhood experiences; these beliefs don't have to be true and if needed, can be changed. Core beliefs can be positive or negative and represent how we see the world and others. Weak core beliefs are known as helpless core beliefs. Counselors make hypothesis about a person's core beliefs and from there, the client and counselor can work together to identify the client's core beliefs and modify, if needed.
Example : "People only care about themselves" (Seligman & Reichenberg, 2014, p. 296).
Schemas
"Hypothesized mental structure that organizes information that encompass the core beliefs" (Beck, 2011, p. 297). It is through schemas that we create expectations for certain experiences. Schemas also affect the way a person views the world and can be influenced from many different aspects (i.e. culture).
Example : Dependence (maladaptive schemas) (Seligman & Reichenberg, 2014, p. 297)
Certain stimulus activate schema and if schema has been activated, it rejects contradictory information and confirms consistent information.
Example : "When people view themselves as incompetent, they accept negative information they receive about themselves and overlook or dispute anything positive" (Seligman & Reichenberg, 2014, p. 297).
Treatment Using Cognitive Therapy
"Treatment via cognitive therapy usually is time limited, for example, 6 to 14 sessions long for relatively straightforward problems" (Beck, 2011). Therapy sessions are structured to ensure progress. To begin treatment, surveys and interviews are done to gather information about the client. During therapy, client and counselor are continuing to work on the therapeutic alliance. After the first session, sessions focus on the client's mood, changes, and learning from the previous session.
10 procedures for initial session
1. Establish an agenda that is meaningful to the client.
2. Determine and measure the intensity of the person's mood.
3. Identify and review presenting problems.
4. Elicit the person's expectations for treatment.
5. Educate the person about cognitive therapy and the role of the client.
6. Provide information about the person's difficulties and diagnosis.
7. Establish goals.
8. Recommend tasks and homework between sessions.
9. Summarize the session.
10. Obtain the client's feedback on the session.
(Beck, 2011, p. 298)
Therapeutic Alliance
The therapeutic alliance is collaborative and is based off of setting goals. The counselor helps the client to make better choices by working on the skills he/she needs. Therapists also employ Socratic questioning which is also known as guided discovery; they use this to help direct client's attention on information he/she is unaware and help him/her towards creating new thoughts.
Four stages of guided discovery
1. Socratic questioning to elicit the client's concerns
2. Active listening for clarification, inconsistencies, and emotional reactions
3. Summarization to provide feedback and enhance clarification
4. Synthesis or analytical questions that pull all of the information together, along with the client's original concern, and pose an
analytical question
(Scott & Freeman, 2010)
Case Formulation
A case formulation is done prior to implementing interventions to ensure that the counselor truly understands the client. In addition, the case formulation helps the counselor to create treatment plans that will be the most successful and reduce anxiety.
Six elements of Case Formulation
1. List of problems and concerns
2. Hypothesis about the underlying mechanism (core belief or schema)
3. Relationship of this belief to current problems
4. precipitants of current problems
5. Understanding of background relevant to development of underlying beliefs
6. Anticipated obstacles to treatment
(Persons, 1989)
Eliciting and Rating Cognitions
Once someone has a thought, it leads to other thoughts being produced. A question used to elicit people's thoughts is "What was going through your mind just then?" (Beck, 2011, p. 300). The most important thoughts are those that appear when certain experiences occur and have an impact on the person.
Six items of a dysfunctional thought record to facilitate identification and modification of thoughts
1. The situation that elicited the thoughts and its accompanying physical responses
Example : The school called to tell me that my son had been seen breaking into the school over the weekend. he was accused of
vandalizing the computer room. I felt a knot in my stomach; I felt light-headed and tense all over.
2. Date and time of the situation
Example : This happened Monday morning at 8:30 a.m.
3. Automatic thoughts and extent of belief in those thoughts rated on a 0% to 100% scale
Example : I am a failure as a parent: 95% belief rating. My son is a hopeless criminal, and it's my fault; 90% belief rating.
4. Emotions and their intensity, rated on a 0% to 100% scale
Example : Anxious: 95% intensity; sad: 85% intensity
5. Nature of distortion and ways of modifying the thoughts
6. Outcome, including revised beliefs, rating of automatic and revised thoughts, current emotions and intensity ratings, and new
actions
(Beck, 2011, p. 300)
Determining the Validity of Cognitions
During this phase, the cognitions are reviewed and evaluated for validity. The therapist can do this through Socratic dialogue to help gauge the reality of the client's thoughts. To evaluate and gauge the client's reality, experiments are used. The experiments need to be tested so the client and the counselor come up with hypotheses to be tested during the experiment.
Three-question technique
The therapist asks the client the following questions:
1. What evidence is there for the belief?
2. How else could the situation be interpreted?
3. If it is true, what would the implications be?
(Seligman & Reichenberg, 2014, p. 301)
Labeling the Distortion
By labeling the distortions, this can help with the evaluation of these thoughts. It helps people see more concretely their irrational thoughts and it shows them that they are not the only ones who have those thoughts.
All-or-nothing or polarized thinking : Viewing a situation in terms of extremes rather than on a continuum.
Example : "Either my son is innocent, or he is a hopeless criminal."
Overgeneralization : Drawing sweeping conclusions that are not justified by the evidence
"I am a failure as a parent because my son was arrested."
Mental filter (selective abstraction) : Focusing selectively on negative details and failing to see the broad picture.
"I know my son has been a good student and has not caused any problems in the past, but all I can think about is that he broke the law."
Disqualifying the positive : Paying attention only to negative information
"What good are all my efforts to be a good mother if this is the result?"
Jumping to conclusions (arbitrary inferences) : Drawing hasty and unwarranted conclusions
"My son must be guilty. Someone saw hm hanging around the school late that night."
Magnification/minimization : Making too much of the negative, devaluing positive information
Example : "My son stole a candy bar from another child when he was four. he was destined to become a
criminal."
Emotional Reasoning : Believing that something is true because it feels that way; paying no attention to contradictory evidence
"I just feel like this is my fault, and no one can convince me it isn't."
"Should" and "Must" Statements : Having definite and inflexible ideas about how we and others should behave and how life should be
"I should never have let Kevin get his driver's license. I should have made sure I met all his friends. I
should have been a better mom to him."
Labeling and Mislabeling : Attaching an extreme, broad, and unjustified label to someone
"Kevin is a hopeless criminal."
Personalization : Assuming inordinate responsibility for events or others' behaviors.
"My son and I had an argument about his curfew three days before the school break-in. If I hadn't yelled at him, this
probably never would have happened."
Catastrophizing : Predicting a negative outcome without considering other possibilities
"I just know Kevin will be sent to prison for this."
Mind reading : Attributing negative thoughts and reactions to others without checking if they are present
"My husband will never forgive Kevin for this. He'll disown him."
Tunnel vision : Focusing only on the negative aspects of a situation.
"I can't do anything right as a parent. There I was, eating dinner, while my son was breaking into the school. How could I
not have known what was going on?"
(Beck, 1976; Burns, 1999)
Assessment of Mood
Mood and emotions play an important role in this therapy. The reason that people normally go to counseling is because of their emotions and because they are unhappy. By evaluating a person's emotions, this could also show what distorted cognitions they have. On the other hand, once their mood starts to improve, it can increase the client's hope and motivation that change is possible.
There are different assessments to evaluate mood. Some of the assessments are listed below.
- Beck Depression Inventory (BDI)
- Beck Anxiety Inventory (BAI)
- Beck Hopelessness Inventory
- Beck Scale for Suicidal Ideation
(Seligman & Reichenberg, 2014, p. 303)
Strategies for Modifying Cognitions
Not only do counselors help clients to change their distorted cognitions, but once those cognitions have been changed, counselors help him/her to internalize those new cognitions. This helps the client be able to talk about his/her new thoughts.
Challenging absolute statements : Clients often use absolutes such as "never" and "always" when telling their stories
Example : "My boss is always late."
- This gives the client a chance to restate such statements to make them more accurate
Activity scheduling : Encourages people to plan and try out new behaviors and ways of thinking as well as to remain active despite feelings
of sadness or apprehension.
- These two things can help a person to have a better mood
Reattributing blame : Client often turn internally and blame themselves whenever something goes wrong in their lives. This false
attribution of blame can start a cascade of negative emotions and behaviors.
- Use of Socratic dialogue and questioning can help clients to look at the situation more clearly
Cognitive rehearsal : People mentally rehearse a new behavior and then create a cognitive model of themselves successfully performing
that behavior.
Example : Athlete using this to improve his/her skill in the sport
Diversions or distractions : Help people reduce their negative thinking
Example : Someone who has been diagnosed with a terminal illness and to distract herself from the troubling
thoughts, she mentally catalogued each item in her extensive wardrobe.
Self-talk : People repeat to themselves many times a day positive and encouraging phrases that they have identified as helpful
Example : "Don't let fear control you. You can do it."
Affirmation : A slogan that is positive and reinforcing. People post these in prominent places.
Example : "Someday you will realize your great potential."
Keeping diaries : Keeping diaries of events, realistic and distorted cognitions, emotions, and efforts to make positive change to increase
people's awareness of their inner and outer experiences.
- This not only tracks progress but provides discussion topics for counseling sessions
Letter writing : A way to explore and express thoughts and feelings
Example : The woman whose son broke into school might create a letter to her son expressing her reactions to his behavior.
Systematic assessment of alternatives (cost/benefit analysis) : Helps people make wise decisions or choices
Example : A man considering a career change used this approach to help him
decide whether to remain in his secure, well-paying position or
pursue his lifelong goal of becoming a counselor.
Relabeling or reframing experiences : This can help people think differently about experiences and perceptions.
Example : A woman who had few dating experiences at age 35 stopped thinking of herself as a failure
and instead viewed herself as a late bloomer.
Role-playing : Enables people to actualize some of the new thoughts they have about themselves
Example : A man who had developed a more positive view of his abilities role-played sharing his accomplishments with
friends, asking his supervisor for a raise, and inviting a colleague to join him for lunch.
Distancing : Projecting into the future to put a problem in perspective and diminish its importance
Example : A woman realized that getting a B in a college course would mean little to her in 10 years.
Bibliotherapy : Use of books in the counseling process can help a person to modify his/her thinking
Example : Reading a book about someone else who coped well with experiences similar to the clients.
Graded task assignments : Activities that clients complete between sessions
(Seligman & Reichenberg, 2014, p. 303-305)
Termination and Relapse Prevention
The termination process is structured to ensure that the client can apply what they have learned during counseling. In this type of therapy, counseling doesn't just abruptly stop; instead, the client is slowly weaned from sessions. By doing it this way, the client can be applying what he/she learned and when they encounter a setback, he/she can come to counseling to discuss that setback. It's important that the client knows setbacks are normal. In addition, what was learned through counseling needs to be revisited as well as showing the client his/her progress. Before counseling is terminated, the client and the counselor come up with goals and plans so that the client can continue to progress without the counselor.