54-6 What are the goals and techniques of cognitive therapy and of cognitive-behavioral therapy?

We have seen how behavior therapists treat specific fears and problem behaviors. But how do they deal with depressive disorders? Or with generalized anxiety, in which anxiety has no focus? Behavior therapists treating these less clearly defined psychological problems have had help from the same cognitive revolution that has profoundly changed other areas of psychology during the last half-century.

667

The cognitive therapies assume that our thinking colors our feelings (FIGURE 54.2). Between an event and our response lies the mind. Self-blaming and overgeneralized explanations of bad events are often an integral part of the vicious cycle of depression. The depressed person interprets a suggestion as criticism, disagreement as dislike, praise as flattery, friendliness as pity. Ruminating on such thoughts sustains the negative thinking. If such thinking patterns can be learned, then surely they can be replaced. Cognitive therapies therefore teach people new, more constructive ways of thinking. If people are miserable, they can be helped to change their minds.

Cognitive therapist Aaron Beck believes that changing people’s thinking can change their functioning. When Beck analyzed depressed people’s dreams, he found recurring negative themes of loss, rejection, and abandonment that extended into their waking thoughts. Such negativity even extends into therapy, as clients recall and rehearse their failings and worst impulses (Kelly, 2000). With cognitive therapy, Beck and his colleagues (1979) sought to reverse clients’ catastrophizing beliefs about themselves, their situations, and their futures. 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.

668

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.”

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. Anyhow, I’m so nervous I’ll forget everything.” To change such negative self-talk, Donald Meichenbaum (1977, 1985) offered stress inoculation training: teaching people to restructure their thinking in stressful situations. Sometimes it may be enough simply to say more positive things to oneself: “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 being trained to dispute their negative thoughts, depression-prone children, teens, and college students exhibit 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 54.1 provides a sampling of techniques commonly used in cognitive therapy.

669

It’s not just depressed people who can benefit from positive self-talk. We all talk to ourselves (“Where did I leave the keys?” “I wish I hadn’t said that”). The findings of nearly three dozen sport psychology studies show that self-talk interventions can enhance the learning of athletic skills (Hatzigeorgiadas 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.”

Cognitive-behavioral therapy (CBT) today’s most widely practiced psychotherapy, aims not only to alter the way people think (cognitive therapy), but also to alter the way they act (behavior therapy). It seeks to make people aware of their irrational negative thinking, to replace it with new ways of thinking, and to practice the more positive approach in everyday settings. Behavioral change is typically addressed first, followed by sessions on cognitive change; the therapy concludes with a focus on maintaining both and preventing relapses.

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 et al., 2010a,b; Moses & Barlow, 2006). A person might, for example, keep a log of daily situations associated with negative and positive emotions, and engage more in activities that lead them to feeling good. Or those who fear social situations might be assigned to 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,” and attribute it to their brain’s abnormal activity, as previously viewed in their PET scans. Instead of giving in to the urge, they would then 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 anorexia or bulimia nervosa (Covin et al., 2008; Zalta, 2011).

670

Studies have also found that cognitive-behavioral skills can be taught and therapy can be effectively conducted over the Internet (Andersson et al., 2012; Stross, 2011). To make psychological treatment more accessible and affordable, some mental health experts advocate phone-based interventions, web-based skill training, work-setting treatment, and self-help efforts facilitated by groups, books, and even phone apps (Kazdin & Blase, 2011a,b; Merry et al., 2012; Teachman, 2014). Skype therapy may lack eye contact, but it means “the therapist can see you now”—anywhere and anytime.