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3.4 The Cognitive Model

Philip Berman, like the rest of us, has cognitive abilities—special intellectual capacities to think, remember, and anticipate. These abilities can help him accomplish a great deal in life. Yet they can also work against him. As he thinks about his experiences, Philip may misinterpret them in ways that lead to poor decisions, maladaptive responses, and painful emotions.

In the early 1960s two clinicians, Albert Ellis (1962) and Aaron Beck (1967), proposed that cognitive processes are at the center of behaviors, thoughts, and emotions and that we can best understand abnormal functioning by looking to cognition—a perspective known as the cognitive model. Ellis and Beck claimed that clinicians must ask questions about the assumptions and attitudes that color a client’s perceptions, the thoughts running through that person’s mind, and the conclusions to which they are leading. Other theorists and therapists soon embraced and expanded these ideas and techniques.

How Do Cognitive Theorists Explain Abnormal Functioning?

According to cognitive theorists, abnormal functioning can result from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes that are disturbing and inaccurate (Beck & Weishaar, 2014; Ellis, 2014). Philip Berman, for example, often seems to assume that his past history has locked him in his present situation. He believes that he was victimized by his parents and that he is now forever doomed by his past. He seems to approach all new experiences and relationships with expectations of failure and disaster.

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In Their Words

“I am so clever that sometimes I don’t understand a single word of what I am saying.”

Oscar Wilde, The Happy Prince and Other Stories

Illogical thinking processes are another source of abnormal functioning, according to cognitive theorists. Beck, for example, has found that some people consistently think in illogical ways and keep arriving at self-defeating conclusions (Beck & Weishaar, 2014). As you will see in Chapter 7, he has identified a number of illogical thought processes regularly found in depression, such as overgeneralization, the drawing of broad negative conclusions on the basis of a single insignificant event. One depressed student couldn’t remember the date of Columbus’ third voyage to America during a history class. Overgeneralizing, she spent the rest of the day in despair over her wide-ranging ignorance.

Cognitive Therapies

According to cognitive therapists, people with psychological disorders can overcome their problems by developing new, more functional ways of thinking. Because different forms of abnormality may involve different kinds of cognitive dysfunctioning, cognitive therapists have developed a number of strategies. Beck, for example, has developed an approach that is widely used, particularly in cases of depression (Beck & Weishaar, 2014).

In Beck’s approach, called simply cognitive therapy, therapists help clients recognize the negative thoughts, biased interpretations, and errors in logic that dominate their thinking and, according to Beck, cause them to feel depressed. Therapists also guide clients to challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply the new ways of thinking in their daily lives. As you will see in Chapter 8, people with depression who are treated with Beck’s approach improve much more than those who receive no treatment.

cognitive therapy A therapy developed by Aaron Beck that helps people recognize and change their faulty thinking processes.

How might your efforts to reason with a depressed friend differ from Beck’s cognitive therapy strategies for people with depression?

In the excerpt that follows, a cognitive therapist guides a depressed 26-year-old graduate student to see the link between the way she interprets her experiences and the way she feels and to begin questioning the accuracy of her interpretations:

Therapist:	How do you understand it?
Patient:	I get depressed when things go wrong. Like when I fail a test.
Therapist:	How can failing a test make you depressed?
Patient:	Well, if I fail I’ll never get into law school.
Therapist:	So failing the test means a lot to you. But if failing a test could drive people into clinical depression, wouldn’t you expect everyone who failed the test to have a depression? … Did everyone who failed get depressed enough to require treatment?
Patient:	No, but it depends on how important the test was to the person.
Therapist:	Right, and who decides the importance?
Patient:	I do.
Therapist:	And so, what we have to examine is your way of viewing the test (or the way that you think about the test) and how it affects your chances of getting into law school. Do you agree?
Patient:	Right….
Therapist:	Now what did failing mean?
Patient:	(Tearful) That I couldn’t get into law school.
Therapist:	And what does that mean to you?
Patient:	That I’m just not smart enough.
Therapist:	Anything else?
Patient:	That I can never be happy.
Therapist:	And how do these thoughts make you feel?
Patient:	Very unhappy.
Therapist:	So it is the meaning of failing a test that makes you very unhappy. In fact, believing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals “I can never be happy.”
(Beck et al., 1979, pp. 145–146)

Assessing the Cognitive Model

The cognitive model has had very broad appeal. In addition to a large number of cognitive-behavioral clinicians who apply both cognitive and learning principles in their work, many cognitive clinicians focus exclusively on client interpretations, attitudes, assumptions, and other cognitive processes. Altogether approximately 31 percent of today’s clinical psychologists identify their approach as cognitive (Prochaska & Norcross, 2013).

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In Their Words

“The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind.”

William James (1842–1910)

The cognitive model is popular for several reasons. First, it focuses on a process unique to human beings—the process of human thought—and many theorists from varied backgrounds find themselves drawn to a model that considers thought to be the primary cause of normal and abnormal behavior.

Cognitive theories also lend themselves to research. Investigators have found that people with psychological disorders often make the kinds of assumptions and errors in thinking the theorists claim (Ingram et al., 2007). Yet another reason for the popularity of this model is the impressive performance of cognitive and cognitive-behavioral therapies in formats ranging from individual and group therapy to cybertherapy (see PsychWatch below). They have proved very effective for treating depression, panic disorder, social phobia, and sexual dysfunctions, for example (Barlow, 2014; Zu et al., 2014; Clark & Beck, 2012).

Nevertheless, the cognitive model, too, has its drawbacks. First, although disturbed cognitive processes are found in many forms of abnormality, their precise role has yet to be determined. The cognitions seen in psychologically troubled people could well be a result rather than a cause of their difficulties. Second, although cognitive and cognitive-behavioral therapies are clearly of help to many people, they do not help everyone. Is it enough simply to change cognitions? Can such changes make a general and lasting difference in the way people feel and behave? A growing body of research suggests that it is not always possible to achieve the kinds of cognitive changes proposed by Beck and other cognitive therapists (Sharf, 2012).

In response to such limitations, a new group of cognitive and cognitive-behavioral therapies, sometimes called the new wave of cognitive therapies, has emerged in recent years (Prochaska & Norcross, 2013; Hollon & DiGiuseppe, 2011). These new approaches, such as the widely used Acceptance and Commitment Therapy (ACT), help clients to accept many of their problematic thoughts rather than judge them, act on them, or try fruitlessly to change them (Swain et al., 2013; Hayes & Lillis, 2012). The hope is that by recognizing such thoughts for what they are—just thoughts—clients will eventually be able to let them pass through their awareness without being particularly troubled by them.

As you will see in Chapter 5, ACT and other new-wave cognitive therapies often employ mindfulness-based techniques to help their clients achieve such acceptance. These techniques borrow heavily from a form of meditation called mindfulness meditation, which teaches individuals to pay attention to the thoughts and feelings that are flowing through their minds during meditation and to accept such thoughts in a nonjudgmental way. Early research indicates that ACT and other new-wave cognitive therapies are often helpful in the treatment of anxiety and depression (Swain et al., 2013).

A final drawback of the cognitive model is that, like the other models you have read about, it is narrow in certain ways. Although cognition is a very special human dimension, it is still only one part of human functioning. Aren’t human beings more than the sum of their thoughts, emotions, and behaviors? Shouldn’t explanations of human functioning also consider broader issues, such as how people approach life, what value they extract from it, and how they deal with the question of life’s meaning? This is the position of the humanistic-existential model.

PsychWatch

Cybertherapy: Surfing for Help

As you read in Chapter 1, computer-based treatment, or cybertherapy, has come to complement, and in some instances replace, traditional face-to-face therapy over the past few decades (Ringwood, 2013). But what exactly is cybertherapy, where did it come from, and is it useful?

The clinical field’s first journey into the digital world took the form of computer software therapy programs (Harklute, 2010; Tantam, 2006). These programs, which continue to be popular, are designed to reduce emotional distress through typed conversations between human “clients” and their computers. The software programmers try to apply the basic principles of actual therapy. One program, for example, helps people state their problems in “if-then” statements, a technique similar to that used by cognitive therapists. Moreover, as you will see later in this chapter, some software therapy programs have users interact not only with printed words or verbalizations that are being generated by the program but also with avatars, on-screen virtual human figures (Reamer, 2013).

Advocates of software therapy programs argue that many people find it easier to disclose sensitive personal information to a computer than to a therapist, and indeed research indicates that some of the programs are helpful to a degree (Emmelkamp, 2011; Harklute, 2010). Computer experts currently are working to develop software programs for recognizing clients’ faces and emotions. This development will likely increase the versatility and appeal of software therapy programs.

Another form of cybertherapy, e-mail therapy, has exploded in popularity over the past decade. Thousands of therapists have set up online services that invite people with problems to e-mail their questions and concerns (Murphy, Mitchell, & Hallett, 2011; Mulhauser, 2010). These services can cost as much as $2 to $3 per minute. Services of this kind have raised concerns about the quality of care and about confidentiality (Fenichel, 2011). Many e-mail therapists do not even have advanced clinical training. Nevertheless, the use of e-mail therapy continues to grow by leaps and bounds.

Also on the rise is visual e-therapy (Hoffman, 2011; Strong, 2010), which more closely mimics the conventional therapy experience. A client sets up an appointment with a therapist and, with the aid of Skype or a webcam, the two proceed to have a face-to-face session. The advantage? Clients can receive counseling conveniently while sitting at home or in their office, and they can have access to a counselor who is located even thousands of miles away. The key disadvantage? Once again, quality control (Fenichel, 2011).

Meeting at your place … and mine Colorado psychiatrist Robert Chalfant and his office administrator demonstrate the simple digital setup that enables him to conduct treatment with many distant clients each week.

Still more common than either e-mail therapy or visual e-therapies are Internet chat groups and “virtual” support groups. Tens of thousands of these groups are currently “in session” around the clock for everything from depression to substance abuse, anxiety, sexual dysfunctions, and eating disorders (Hucker & McCabe, 2014; Moskowitz, 2008, 2001). Like in-person self-help groups, the online chat groups provide opportunities for people with similar problems to communicate with one another and freely trade information, advice, and empathy. Of course, unlike members of in-person self-help groups, people who choose Internet chat group therapy do not know who is on the other end of the computer connection or whether the advice they receive is well intentioned or at all appropriate.

Cybertherapy is still being developed and researched, and its actual effectiveness has yet to be determined. At the same time, the rapid growth of this approach serves as a reminder that digital technology’s impact on the mental health field is as powerful and potentially useful as its impact on most other fields in our society.