14.4 Cognitive Therapies

You Are What You Think: Cognitive Therapy

Dr. Foster has identified his client’s maladaptive thoughts and is beginning to help her change the way she views her world and her relationships. This is the basic goal of cognitive therapy, an approach advanced by psychiatrist Aaron Beck (b. 1921).

Beck was trained in psychoanalysis, but he opted to develop his own approach after trying (without luck) to produce scientific evidence showing that Freud’s methods worked (Beck & Weishaar, 2014). Beck believes that patterns of automatic thoughts are at the root of psychological disturbances. These distortions in thinking cause individuals to misinterpret events in their lives (TABLE 14.2).

Beck identified a collection of common cognitive distortions or errors associated with psychological problems, such as depression (Beck, Rush, Shaw, & Emory, 1979). One such distortion is overgeneralization, or thinking that self-contained events will have major repercussions in life (Prochaska & Norcross, 2014). For example, a person may assume that just because something is true under one set of circumstances, it will be true in all others (I have had difficulty working for a male boss, so I will never be able to work effectively under a male supervisor). Another common cognitive distortion is dichotomous thinking, or seeing things in extremes (I can either be a good student, or I can have a social life).

One goal of cognitive therapy then is to help clients recognize and challenge cognitive errors such as overgeneralization. Beck suggests that cognitive schemas underlie these patterns of automatic thoughts, directing the way we interpret events. The goal is to restructure these schemas into more rational frameworks, a process that can be facilitated by client homework. For example, the therapist may challenge a client to test a “hypothesis” related to her dysfunctional thinking. (If you are truly the worst student in the world, then do you think you would have made it to college?) Client homework is an important component of cognitive therapy. So, too, is psychoeducation, which might include providing resources or links to resources that help clients understand their disorders and thus adopt more realistic attitudes and expectations.

Beck’s cognitive therapy aims to dismantle or take apart the mental frameworks harboring cognitive errors and replace them with beliefs that nurture more positive, realistic thoughts. Dr. Foster calls these mental frameworks “paradigms,” and he also tries to create a more holistic change in thinking. “I tell people that thoughts, behaviors, and words come from beliefs, and when a belief is not working for you, let’s change it,” he says. “To modify a belief doesn’t mean all or none,” he adds, “but when we outgrow a belief, that’s a wonderful time for transformation.”

The other major figure in cognitive therapy is psychologist Albert Ellis (1913–2007). Like Beck, Ellis was trained in psychoanalysis but was disappointed by its results, so he created his own treatment approach: rational-emotive behavior therapy (REBT). The goal of REBT is to help people identify their irrational or illogical thoughts and convert them into rational ones. An REBT therapist uses the ABC model to understand a client’s problems. Point A represents an Activating event in the client’s life (“My boss fired me”); point B stands for the irrational Beliefs that follow (“I will never be able to hold a steady job”); and point C represents the emotional Consequences (“I feel hopeless and depressed”). Therapy focuses on addressing point B, the irrational beliefs causing distress. If all goes well, the client successfully reaches point D: Disputing flawed beliefs (“Losing one job does not spell the end of my career”), and that leads to point E: an Effective new philosophy (“I can apply for another job”), a mature and realistic perspective on life (Ellis & Dryden, 1997; Figure 14.2).

According to Ellis, people tend to have unrealistic beliefs, often perfectionist in nature, about how they and others should think and act. This inevitably leads to disappointment, as no one is perfect. The ultimate goal of REBT is to arrive at self-acceptance, that is, to change these irrational thoughts to realistic ones. This often involves letting go of the “I shoulds” and “I musts,” what Ellis called “musturbatory thinking” (Prochaska & Norcross, 2014, p. 266). Through REBT, one develops a rational way of thinking that helps reduce suffering and amplify enjoyment: “The purpose of life,” as Ellis was known to say, “is to have a $&%#@ good time”.

As Ellis developed his therapy throughout the years, he realized it was important to focus on cognitive processing as well as behavior. Thus, REBT therapists focus on changing both cognitions and behaviors, and assigning homework to implement the insights clients gain during therapy. Ellis took a hardline with clients, forcefully challenging them to provide evidence for their irrational ideas (for instance, he might have asked: “Where is it written that you have to be beautiful in order to be happy?”). He often shocked people with his blunt style (Kaufman, 2007, July 25; Prochaska & Norcross, 2014).

Because Ellis and Beck incorporated both cognitive and behavior therapy methods, their approaches are commonly referred to as cognitive behavioral therapy. Both are action oriented, as they require clients to confront and resist their illogical thinking.

There is considerable overlap between the approaches of Ellis and Beck. Both are short-term (usually no more than about 20 one-hour sessions), action oriented, and homework-intensive. In some instances, cognitive therapy has been found to be more successful than relaxation and exposure therapy in treating certain disorders, such as social phobia and generalized anxiety disorder (Clark et al., 2006; Dugas et al., 2010). If you compare the effectiveness of Beck’s and Ellis’s approaches, you will find some studies showing greater support for Beck’s cognitive therapy. But this advantage is only apparent with certain client characteristics and problems, such as pathological gambling and chronic pain (Prochaska & Norcross, 2014).

In some cases, cognitive models that focus on flawed assumptions and attitudes present a chicken-and-egg problem. People experiencing depression often have distorted beliefs, but are distorted beliefs causing their depression or is depression causing their distorted beliefs? Perhaps it is a combination of both.

Thus far, our discussion has focused on interactions between one therapist and one client. But therapy needn’t be limited to therapist–client pairs.