44-6 What are the goals and techniques of cognitive therapy and of cognitive-behavioral therapy?

People with specific fears and problem behaviors may respond to behavior therapy. But how would you modify the wide assortment of behaviors that accompany depressive disorders? And how would you treat generalized anxiety disorders, where unfocused anxiety doesn’t lend itself to a neat list of anxiety-triggering situations? The cognitive revolution that has influenced other areas of psychology during the last half-century has influenced therapy as well.

The cognitive therapies assume that our thinking colors our feelings (FIGURE 44.2). Between an event and our response lies the mind. Self-blaming and overgeneralized explanations of bad events feed depression. Anxiety arises from an “attention bias to threat” (MacLeod & Clarke, 2015). If depressed, we may interpret a suggestion as criticism, disagreement as dislike, praise as flattery, friendliness as pity. Dwelling on such thoughts sustains negative thinking. Cognitive therapies aim to help people change their minds with new, more constructive ways of perceiving and interpreting events (Kazdin, 2015).

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Cognitive therapist Aaron Beck believes that changing people’s thinking can change their functioning. Depressed people, he found, often reported dreams with negative themes of loss, rejection, and abandonment. These thoughts extended into their waking thoughts, and even into therapy, as clients recalled and rehearsed their failings and worst impulses (Kelly, 2000). With cognitive therapy, Beck and his colleagues (1979) sought to reverse clients’ negativity about themselves, their situations, and their futures. With this technique, gentle questioning seeks to reveal irrational thinking, and then to persuade people to remove the dark glasses through which they view life (Beck et al., 1979, pp. 145–146):

Client: I agree with the descriptions of me but I guess I don’t agree that the way I think makes me depressed.

Beck: How do you understand it?

Client: I get depressed when things go wrong. Like when I fail a test.

Beck: How can failing a test make you depressed?

Client: Well, if I fail I’ll never get into law school.

Beck: 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?

Client: No, but it depends on how important the test was to the person.

Beck: Right, and who decides the importance?

Client: I do.

Beck: 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?

Client: Right.

Beck: Do you agree that the way you interpret the results of the test will affect you? You might feel depressed, you might have trouble sleeping, not feel like eating, and you might even wonder if you should drop out of the course.

Client: I have been thinking that I wasn’t going to make it. Yes, I agree.

Beck: Now what did failing mean?

Client: (tearful) That I couldn’t get into law school.

Beck: And what does that mean to you?

Client: That I’m just not smart enough.

Beck: Anything else?

Client: That I can never be happy.

Beck: And how do these thoughts make you feel?

Client: Very unhappy.

Beck: 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.”

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We often think in words. Therefore, getting people to change what they say to themselves is an effective way to change their thinking. Perhaps you can identify with the anxious students who, before an exam, make matters worse with self-defeating thoughts: “This exam’s probably going to be impossible. All these other students seem so relaxed and confident. I wish I were better prepared. I’m so nervous I’ll forget everything.” Psychologists call this sort of relentless, overgeneralized, self-blaming behavior catastrophizing.

To change such negative self-talk, therapists teach people to restructure their thinking in stressful situations (Meichenbaum, 1977, 1985). Sometimes it may be enough simply to say more positive things to yourself: “Relax. The exam may be hard, but it will be hard for everyone else, too. I studied harder than most people. Besides, I don’t need a perfect score to get a good grade.” After learning to “talk back” to negative thoughts, depression-prone children, teens, and college students have shown a greatly reduced rate of future depression (Reivich et al., 2013; Seligman et al., 2009). To a large extent, it is the thought that counts. TABLE 44.1 provides a sampling of techniques commonly used in cognitive therapy.

It’s not just depressed people who can benefit from positive self-talk. We all talk to ourselves (thinking “I wish I hadn’t said that” can protect us from repeating the blunder). The findings of nearly three dozen sport psychology studies show that self-talk interventions can enhance the learning of athletic skills (Hatzigeorgiadis et al., 2011). For example, novice basketball players may be trained to think “focus” and “follow through,” swimmers to think “high elbow,” and tennis players to think “look at the ball.”

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“The trouble with most therapy,” said therapist Albert Ellis (1913–2007), “is that it helps you to feel better. But you don’t get better. You have to back it up with action, action, action.” Cognitive-behavioral therapy (CBT), today’s most widely practiced psychotherapy, aims not only to alter the way people think but also to alter the way they act. Like other cognitive therapies, this integrative therapy seeks to make people aware of their irrational negative thinking and to replace it with new ways of thinking. Like other behavior therapies, it trains people to practice the more positive approach in everyday settings.

Anxiety, depressive disorders, and bipolar disorder share a common problem: emotion regulation (Aldao & Nolen-Hoeksema, 2010). An effective CBT program for these emotional disorders trains people both to replace their catastrophizing thinking with more realistic appraisals and, as homework, to practice behaviors that are incompatible with their problem (Kazantzis & Dattilio, 2010; Kazantzis et al., 2010; Moses & Barlow, 2006). A person might, for example, keep a log of daily situations associated with negative and positive emotions and attempt to engage more in activities that lead to feeling good. Those who fear social situations might learn to restrain the negative thoughts surrounding their social anxiety and practice approaching people.

CBT may also be useful with obsessive-compulsive disorder. In one study, people learned to prevent their compulsive behaviors by relabeling their obsessive thoughts (Schwartz et al., 1996). Feeling the urge to wash their hands again, they would tell themselves, “I’m having a compulsive urge.” They would explain to themselves that the hand-washing urge was a result of their brain’s abnormal activity, which they had previously viewed in PET scans. Then, instead of giving in, they would spend 15 minutes in an enjoyable, alternative behavior, such as practicing an instrument, taking a walk, or gardening. This helped “unstick” the brain by shifting attention and engaging other brain areas. For two or three months, the weekly therapy sessions continued, with relabeling and refocusing practice at home. By the study’s end, most participants’ symptoms had diminished, and their PET scans revealed normalized brain activity. Many other studies confirm CBT’s effectiveness for treating anxiety, depression, and eating disorders (Covin et al., 2008; Milrod et al., 2015; Zalta, 2011).

A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful and even suicidal behavior patterns (Linehan et al., 2015; Valentine et al., 2015). DBT combines cognitive tactics for tolerating distress and regulating emotions with social skills training and mindfulness meditation. Individual therapy aims to teach both acceptance and change—the dialectical, or opposing, forces from which this therapy derives its name. Patients may also participate in a training group that teaches skills, provides a social context for skills practice, and assigns further practice as homework.