Exploration of a Psycho-Therapeutic Approach: Cognitive Therapy - Thesis Example

Cognitive Therapy Introduction Cognitive therapy is a form of psychotherapeutic intervention that involves identification and change of dysfunctional thinking, emotional responses and behavior. It is known to be effective in many psychological conditions like mood disorders, anxiety-related disorders, eating disorders, substance abuse, personality disorders and also various psychotic disorders. However it is commonly used as a first line of treatment in depression. Cognitive therapists help the individual to point out alternative ways of looking at a situation or event or view of life. The change in thoughts improves the mood of the individual. Aims and objectives The aim of this study is to explore cognitive therapy in detail. The objectives are to study the history, roots, theories, concepts and clinical application of this therapy through review of literature. I chose to study cognitive therapy because this therapy marks the transition from traditional psychiatric treatments to modern ones. History of Cognitive therapy The cognitive revolution occurred in the 1970s during the time when the cognitive model was described. Cognitive therapy was developed by Aaron. T. Beck, a famous psychiatrist in 1960s. The theory of cognitive therapy came after Beck noticed that his patients in analytical sessions had an internal dialogue in their minds and they were almost talking to themselves. Beck called these thoughts automatic thoughts. Beck realized that most people who suffered from anxiety or depression did not know about these thoughts. Hence Beck taught his patients identify these thoughts and report them. Beck considered identification of these thoughts as the key to overcoming of difficulties of the patient (Herkov, 2006). The Cognitive therapy Cognitive therapy is scientifically tested in over four hundred clinical trials which have proved its efficacy (Beck, 2008). The therapy is time- limited and problem-solving in nature. It is primarily focused on the present and hence, solution to current problems is aimed at (Beck, 2008). Patients acquire certain skills which they are able to use through out their lives. The skills which are taught to the patients are modification of beliefs, identification of distorted thinking, changing behaviors and relating to others in different ways (Beck, 2008). According to cognitive therapy, it is not situation that decides the emotional well being of an individual (Wedding and Corsini, 2008). Rather, it is the way the individual perceives situation. How an individual feels is based on his thoughts. In times of distress, thoughts of people are distorted and clear thinking is not possible. Cognitive therapy helps individuals identify these thoughts and change the way they view situations (Beck, 2008). Cognition means thought process. It reflects what we think, believe and perceive. Cognition therapy focuses on perception of thoughts (Kaplan, et al, 1998). This is because distorted and unrealistic thoughts result in misinterpretations which lead to symptomatology in anxiety and depression. Stressful states like depression, anxiety and anger are exacerbated by biased or exaggerated ways of thinking (Leahy, 2006). Figure-1: Process of emotion (Mulhauser, 2008) The main objective of the treatment is to identify thoughts, beliefs, assumptions and behaviors that are related to debilitating, dysfunctional, inaccurate and unhelpful negative emotions and then monitor them. The result expected out of such forms of therapy is to replace or transcend these emotions with more realistic and useful emotions. It is important to know that emotional dysfunction is maintained by metacognitive beliefs, inflexible self-focused attention, and perseverative thinking (Beck, 2008). Cognitive therapy helps a person to understand and step out of automatic thoughts (Herkov, 2006). The role of a cognitive therapist is to help the patient in understanding and recognizing the idiosyncratic thinking and help modification of this thought process through application of logic and evidence (Leahy, 2006). The therapist helps the patient challenge his or her thinking errors (Wedding and Corsini, 2008). Some of the errors which are targeted are (Herkov, 2006): 1. Magnification- Minimization: These thoughts distract the importance of particular events or situations. 2. Dichotomous thinking: This type of thinking arises when a person is able to generate only two choices in any given situation or event. The individual sees things as black or white or both. 3. Selective Abstraction: The individual mainly focuses on the negative aspects of a situation, and becomes sad. 4. Personalization: This thought process makes an individual relate all negative things to himself with no basis for such an assumption. Therapeutic approach of Cognitive therapy There are two ancillary assumptions which guide the cognitive therapist. They are: 1. An individual is capable of identifying his or her own thoughts and change them. 2. Thoughts which have been elicited by stimuli may not reflect reality accurately. The aim of cognitive therapy is to correct only those distortions that are root causes of distress. While examining the client, the therapist must try and understand the clients point of view. Both the client and therapist must work collaboratively exploring the thoughts, interferences and assumptions of the client. Once these thoughts and assumptions are identified, the therapist must teach the client to test these against reality and other assumptions. The process of checking will need to continue even outside the therapeutic session. Take for example a client who has fear of heights. This issue can be addressed by asking the client to write down on a piece of paper the estimate of odds of falling from a height as he gets up in the morning and begins his daily routine. A change in odds as the routine happens will enlighten the client that his assumptions are baseless (Mulhauser, 2008). Cognitive therapy for depression Various studies have demonstrated the efficacy of cognitive therapy in treating depression. The effectiveness of this form of treatment is comparable to anti-depressants. Cognitive therapy should be considered as a first line treatment for mild to moderate depression. In severe or chronic depression a combination of cognitive therapy and antidepressants has been shown to be effective. Cognitive therapy is also effective in treating depression that is only partially responsive to anti-depressants (Rupke, Blecke and Renfrow, 2006). It is useful in treating depression in adolescents. Cognitive therapy helps correct false self-beliefs. It is not yet clear as to what type of patients benefit the most in cognitive therapy. It is presumed that those who are motivated, who have the capacity to introspect and have an internal locus of control are benefited the most (Rupke, Blecke and Renfrow, 2006). In many cases of depression, behavior therapy is also incorporated into the treatment program. This form of psychotherapeutic intervention is known as cognitive- behavioral therapy. Cognitive therapy also reduces the chances of relapse in depression. It is effective in those who have residual symptoms after adequate antidepressants. Some studies have shown that those treated with cognitive therapy have fewer residual symptoms (Rupke, Blecke and Renfrow, 2006). In cognitive therapy, the patient is guided through a number of structured learning experiences (Rupke, Blecke and Renfrow, 2006). The first step is making the patient understand that some of her or his beliefs or thoughts or perceptions may be false and these self- beliefs are the ones which lead to certain behaviors and moods and not situations or events. The next step is to help the patient recognize negative or automatic thoughts. The patient is asked to maintain a diary and write down negative thoughts and mental images and then associate these with behavior, feelings and physiology. After these are identified, alternative thoughts that are more close to reality must be discovered and mentioned to the patient. The patient must be encouraged to pip in alternate thoughts. The patient must then be asked to decide internally whether automatic thoughts or alternate thoughts are realistic. In the beginning sessions, the patient will obviously choose automatic thoughts as realistic. However, as the treatment sessions go by and evidence is provided against unreality of automatic thoughts, the patient improves. During the progression of therapy, the therapist will focus more on core beliefs (Rupke, Blecke and Renfrow, 2006). For treating depression by cognitive therapy, the full course includes 14- 16 sessions. During the initial sessions, evaluation and modification of dysfunctional thoughts occurs. After that, the remaining sessions are used to modify these beliefs and enhance relapse prevention skills. In most patients remission occurs in 8- 12 sessions. Occasional booster sessions during the first year maintain treatment gains (Butler and Beck, 1995). Cognitive therapy in anxiety Cognitive therapy is very useful in the treatment of various anxiety disorders. It is now considered the first line therapy in any anxiety disorder. Infact, it is the most effective treatment for phobic disorders. It is often combined with behavioral therapy in the treatment of anxiety. Cognitive- behavioral therapy (CBT) is a symptom oriented therapy approach combining psycho education and specific treatment intervention. The basic concept is in vivo exposure where in the person is gradually exposed to the actual, feared stimulus. Normally when a person is exposed to a fearful stimulus, a fear response is evoked and then maintained due to classical conditioning. In CBT, repeated exposure is provided and this conditioning is unlearned. This process of unlearning is known as extinction and habituation. When anxiety is not associated with severe co-morbid conditions like personality disorders, the therapy can be time limited. It can be done in 12 to 15 settings. Fear of spiders, a type of phobia or phobia to any such insects can be treated with in vivo exposure in one session itself (Ost, 1989). The optimal range of duration for anxiety therapy is usually 7 to 14 hours. Most people would require weekly sessions of 1-2 hours for about 4 months. Briefer CBT should be atleast 7 hours and should be supplemented with proper information and tasks (NICE guidelines, 2007). The nature of process should be determined on a case-to- case basis. Sessions in CBT for anxiety are: 1. Psycho education: This is the first part of CBT treatment. During this session, the psychiatrist will explain to the patient about normal reactions of the body and also symptoms related to anxiety. The therapist will focus on real life experiences related to anxiety and phobia. Various forms of treatment including exposure therapy will be discussed in this session. Identification of early signs of relapse of anxiety symptoms and self- help options that help cope with these situations is done during this phase. 2. Panic monitoring. This is also known as self- monitoring. This is done by maintaining a symptom diary by the patient. The diary will consist of details of occurrence of symptoms, consequences of changed behavior and anxious cognitions. Thus symptoms are monitored. The frequency and nature of panic attacks can be assessed by this diary. The relationship of anxiety symptoms to various internal stimuli like images and emotion, and to external stimuli like behavior, substance and situation can be studied. Outcome can be measured by short, self -complete questionnaires such as panic subscale of agoraphobic motility. 3. Relaxation: This is an anxiety management technique wherein breathing exercises are used for relaxation and control of symptoms. The exercises control physiologic activity. The most commonly used breathing technique is abdominal breathing. Progressive muscle reaction is also a useful technique for relaxation. The patient is advised to practice these exercises daily. 4. Cognitive restructuring: The purpose of the techniques used in cognitive restructuring is to identify and counter fear of bodily sensations. It involves overestimation of the probability catastrophic thinking and negative consequence. Patients are taught to think of alternative possible outcomes once they experience bodily cues. Most important is to identify the likely origin of the feared sensations and any misinformation about the meaning of the sensations. 5. Exposure therapy: Here the patient is exposed to fear cues really. The cues may be interceptive or environmental. In panic attacks, the cues are interceptive while in agoraphobia, the cues are either interceptive or environmental. Prior to starting exposure therapy, the psychiatrist evaluates the patient and identifies a hierarchy of fear-evoking situations. In each of these situations, the degree of anxiety is elicited and is graded on a 0- 10 scale. The patient is then exposed to the fearful situations. Initially, situations at the low end of the hierarchy are exposed to. The exposure is done on a regular basis until the fear is attenuated. Once this is done, situation at the next level of anxiety is targeted. Sometimes psychiatrist may use a technique called flooding for exposure. In flooding, the person is exposed to fearful situations suddenly and not proceeding in a graduated manner. Some of the examples of exposures to anxiety cues are having patients run in place, spin in a desk chair, and breathe through a straw. While interceptive exposures are conducted in the psychiatrists room or at home in naturalistic situations, environmental exposures are conducted in actual situations. Obsessive compulsive disorder can be treated with exposure with response prevention. Most of the times, social phobia responses well to exposure coupled with some form of cognitive restructuring such as Heimbergs group therapy. Conclusion Cognitive therapy is one of the most useful psychotherapeutic interventions and was developed in the 1960s. It is mainly used for the treatment of depression and anxiety. The concept behind this therapy is that distorted thoughts and beliefs are the main causes of emotional distress and behavior and not situations. Hence helping the patient identify these thoughts and convert them to alternate realistic thoughts relieves symptoms in patients. Most of the times, cognitive therapy is given along with behavioral therapy, the combination of which is known as cognitive- behavioral therapy. References Beck, J.S. (2008). Questions and Answers about Cognitive Therapy. The Beck Institute for Cognitive Therapy and Research. Retrieved Feb 23, 2009 from http://beckinstitute.org/Library/InfoManage/Zoom.asp?InfoID=220&RedirectPath=Add1&FolderID=237&SessionID={30B583AB-3266-48ED-BC20-09A7829F5FA0}&InfoGroup=Main&InfoType=Article&SP=2 Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-5. Herkov, M. (2006). About Cognitive Psychotherapy. PsychCentral. Retrieved Feb 23, 2009 from http://psychcentral.com/lib/2006/about-cognitive-psychotherapy/ Kaplan, M.D, Harold, I. and Sadock, M.D, Benjamin, J. (1998). Synopsis of Psychiatry (8th Edition). Baltimore: Williams & Wilkins. Leahy, R.L. (2006). Cognitive Therapy Techniques. Lonon:Guilford Press: Mulhauser, G. (2008). An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches. Counselling resource. Retrieved Feb 23, 2009 from http://counsellingresource.com/types/cognitive-therapy/index.html Ost, L G (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27 (1): 1–7. Rupke, S.J., Blecke, D., and Renfrow, M. (2006). Cognitive Therapy for Depression. American Family Physician. Retrieved Feb 23, 2009 from http://www.aafp.org/afp/20060101/83.html NICE Guidelines. (2007). Anxiety. Retrieved Feb 23, 2009 from http://www.nice.org.uk/Guidance/CG22/NiceGuidance/pdf/English Rachman, S. (2008). Psychological Treatment of Anxiety: The Evolution of Behavior Therapy and Cognitive-Behavior Therapy. Annu Rev Clin Psychol. Retrieved 15 Dec, 2008 from http://www.ncbi.nlm.nih.gov/pubmed/19086834?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Wedding, D and Corsini, R.J. (2008). Current Psychotherapies. London: Peacock publishers. Read More