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Cognitive-Behavioral Therapy

COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapy (CBT) is a combination of cognitive and behavior therapies that are directive, time-limited, structured, and place great emphasis on homework exercises. While cognitive therapy emphasizes the role of cognitive processes in the origin and maintenance of psychological disorders, behavior therapy focuses on principles of learning theory and the role of reduced reinforcement in the creation and maintenance of these disorders. In cognitive therapy, individuals learn to identify and monitor distorted, negative thinking, to become aware of the relationship between such thoughts and negative assumptions about oneselfand of the association between thoughts and feelings. Individuals also learn to apply techniques to challenge these thoughts. In behavior therapy, individuals are taught to track the frequency of targeted behaviors and to understand the relationship between these behaviors and their antecedents and consequences. Furthermore, individuals learn techniques to increase or decrease particular events, and are taught skills such as problem solving, relaxation, and assertiveness. Both cognitive therapy and behavior therapy assume that psychological problems can be alleviated by teaching individuals new skills to identify negative thoughts, form adaptive thoughts, and alter maladaptive behavior patterns.

CBT is effective in treating the psychological problems of older adults. In a review of empirically validated psychological treatments for older adults (Gatz et al., 1998) reported that behavioral and environmental interventions can help older adults with dementia, sleep disorders, and depression.

Potential sources of change in psychotherapy with older adults

Potential modifications to psychotherapeutic regimens may be necessary due to the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. It is important to keep in mind that these changes represent hypotheses in need of empirical investigation. Outcomes of psychological interventions with older adults indicate that maturational changes with aging have no negative impact upon the use of CBT with older adults.

Development. Slowing in cognitive processes and memory changes may require changes in cognitive-behavioral therapy. For instance, therapeutic conversation may need to be slower and simpler with older clients. Furthermore, it may be necessary for therapists to repeat new material, to ask the client to summarize the information to make sure that he or she understands it, and to ask the client to take notes on important points to increase recall of information and the effectiveness of the therapeutic intervention.

Changes in therapy may also arise as a result of the more positive aspects of maturation. Older adults have many useful strengths and existing skills as a result of the stability of crystallized intelligence and the development of expertise in several life domains. Rediscovering these skills, rather than teaching new ones, may frequently occur in therapy. It is also important to note that the normal decline in fluid intelligence suggests that the therapist may need to guide the older adult to certain conclusions, rather than giving suggestions and expecting the client to infer them.

Emotional changes that come with maturity may also affect the presentation of problems, requiring an adjustment of cognitive interventions. Research on emotion suggests that young adults experience pure and intense emotions, whereas older adults experience both sad and happy emotions in response to the same environmental or cognitive stimulus. Instead of replacing a negative, distorted thought with a more neutral or positive thought, it may be more strategic to have the older client focus on both the positive and negative emotions experienced.

A tendency for older adults to reminisce may make it difficult to focus on the present in CBT. Keeping an exclusively present-oriented focus when working with older adults who want and need to talk about the past is likely to be counterproductive. It is important to allow time for reminiscence, which may be perceived as reinforcement for other therapeutic work.

Cohort differences. In working with older adults, it is important to be aware of cohort differences that may influence the process of therapy. Cohort differences refer to an individual's membership in a birth-year group and the socialization process that shapes the abilities, beliefs, attitudes, and personality aspects of individuals born in a specific cohort. The attributes of a cohort are believed to be stable as the cohort ages, and thus differentiate it from those born earlier and later. For example, later-born cohorts (people who are now younger) have more years of formal education, are superior in reasoning ability and spatial orientation, and are more extroverted. Consequently, it may be necessary to change the wording of scales or assignments to adjust to different education levels of earlier cohorts and to adapt to cohort-specific values or examples in order to increase comfort with written assignments given in CBT. Thus, younger therapists working with older adults need to learn what it was like to grow up before the therapist was born because cohort differences in education level, intellectual skills, and personality may influence the process of therapy.

Social environment. Knowledge of the social context of older adults is crucial for appropriate interventions within both classic behavioral and social learning models of therapy because reinforcement contingencies that create or maintain maladaptive behavior or negative affect often arise from the environmental context. Staff in nursing homes, for example, may reward older adults for passively conforming to scheduled routines, a passivity that may result in reduced activity levels, lowered sense of control, and worsened mood. In order to improve the client's mood, the environment will need to be changed or staff will need to be consulted about possible environmental changes in the client's highly structured residential setting.

Cognitive-behavioral interventions for late-life problems

Many older adults who seek help in therapy deal with problems that threaten their well-being, including chronic illness, disability, and the death of loved ones. These problems are not unique to late life, but they are likely to occur more frequently at older ages. Furthermore, the usual difficulties of life, such as disappointments in love, arguments with family, and failure to achieve goals, can also take place in late life. Finally, many persons who struggle with depression, anxiety, substance abuse, or psychosis in their younger years continue to do so in their later years.

Chronic illness and disability. Conducting CBT with distressed older adults often means working with a population that is chronically ill, physically disabled, or both, and that struggles to adjust to these problems. In working with this population, it is important to learn about chronic illnesses and their psychological impact, control of chronic pain, adherence to medical treatment, rehabilitation strategies, and assessment of behavioral signs of medication reactions.

A frequent element of treating chronically ill or disabled elders is addressing concurrent depression, since up to 59 percent of this population experiences depression. Although there have been few studies examining the effectiveness of cognitive-behavioral therapy with medically ill older adults, results are encouraging for both outpatient and inpatient populations. Rybarczyk et al. (1992) have identified five important issues in applying CBT to chronically ill older adults: (1) solving practical barriers impeding participation, (2) acknowledging that depression is a separate and reversible problem, (3) limiting excess disability, (4) counteracting the loss of important social roles and autonomy, and (5) challenging the thought of being a "burden." For instance, in challenging the belief of being a burden on a family caregiver, the therapist may help the client to recall things he or she has done for the family caregiver in the past, thereby providing the client with a greater sense of equity in the relationship. Breaking down the issues facing the chronically ill older adult is helpful to the therapist in developing a strategy using both cognitive-behavioral techniques and practical considerations.

In addition to treating depression in medically ill or disabled elders, cognitive and behavioral techniques are also effective in managing pain associated with rheumatoid arthritis and delayed healing from injuries. Cognitive pain-management methods include distracting oneself from the pain, reinterpreting pain sensations, using pleasant imagery, using calming self-statements, and increasing daily pleasurable activities.

Depression. As mentioned previously, depression is prevalent in older adults who are chronically ill, disabled, or grieving; although the prevalence of depression in older adults is less than in young adults. Cognitive and behavioral approaches are effective in relieving depression in older adults. In treating depression, CBT focuses on teaching new coping strategies to deal with problems and on challenging those thoughts that interfere with effective coping. The client's participation in daily events that affect mood may also be addressed in therapy. By using a chart to monitor the frequency of these events, the therapist enables the client to see the relationship between pleasant events and moods, so that the frequency of pleasant events can be increased while the frequency of unpleasant events is reduced during the course of therapy. The therapist may also use the dysfunctional-thought record, a technique showing self-talk and negative interpretation of events, to enable the client to recognize distorted thoughts and replace negative and irrational thoughts with more adaptive ones.

Anxiety. Anxiety is fairly common in late life, but it is an understudied problem. Results from various studies indicate that brief courses (less than twenty sessions) of cognitive-behavioral therapy may be effective in treating late-life anxiety. In cognitive therapy, distorted thoughts that may exacerbate anxiety, such as "My heart is beating faster, which means I am about to have a heart attack" are challenged (Wetherell, 1998). Other cognitive restructuring techniques consist of making more accurate risk estimates; "decatastrophizing" by determining ways to cope with the feared situation; stopping thoughts by noticing and eliminating anxiety-provoking thoughts; and replacing automatic, anxious thoughts with positive thoughts. Relaxation training is often combined with diaphragmatic breathing and cognitive restructuring. For a review of treatment of anxiety in older adults, see Wetherell (1998).

Alcohol abuse. Even though alcoholism rates are lower for older adults than for younger adults, older problem drinkers often drink in response to loneliness, depression, and poor social-support networks. Consequently, CBT for the treatment of alcoholism in older adults focuses on improving the client's life in various ways in addition to just abstaining from drinking. Studies indicate that CBT models are effective in treating alcoholism in older adults, although further research is needed because not all studies have included a control group.

Stopping drinking completely, or at least achieving a period of abstinence followed by very limited and controlled drinking is a mandatory goal in treatment. Analysis of the drinking behavior itself also takes place to figure out the maladaptive purpose underlying the drinking behavior. Coping skills and behavior alternatives are then developed and practiced in therapy to handle situations in which the urge to drink arises. Irrational thoughts associated with the drinking are also challenged during therapy to increase the mood and self-esteem of the client, which in turn helps to control drinking behavior.

Conclusion

CBT may be effectively adapted for use with older adults by applying minor modifications to clinical techniques, since the principles of cognitive and behavioral theory are assumed to be similar for older and younger adults. Deciding which modifications to make, and how to conduct them, relies on a complete understanding of the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. Applying CBT to older clients entails several challenges, including learning about the social environment of older adults, working with clients whose experiences may be different from and prior to those of the therapist, and dealing with the interplay of physical and psychological problems on a frequent basis. Those who take on the challenge are likely to discover that their ideas about therapy and about aging will be transformed by working with older clients.

Bob G. Knight Gia S. Robinson

See also Alcoholism; Anxiety; Behavior Management, Bereavement, Depression; Geriatric Psychiatry; Intelligence; Psychotherapy.

BIBLIOGRAPHY

Arean, P., and Miranda, J. "The Treatment of Depression in Elderly Primary Care Patients: A Naturalistic Study." Journal of Clinical Geropsychology 2 (1996): 153160.

Baltes, M. M. "Dependency in Old Age: Gains and Losses." Current Directions in Psychological Science 4 (1995) 1418.

Carstensen, L. L.; Edelstein. B. A.; and Dornbrand, L., eds. The Practical Handbook of Clinical Gerontology. Thousand Oaks, Calif.: Sage Publications, 1996.

Cook, A. J. "Cognitive-Behavioral Pain Management for Elderly Nursing Home Residents." Journal of Gerontology: Psychological Sciences 53B (1998): P51P59.

Duffy, M. Handbook of Counseling and Psychotherapy with Older Adults. New York: John Wiley, 1999.

Finch, E.; Ramsay, R.; and Katona, C. "Depression and Physical Illness in the Elderly." Clinics in Geriatric Medicine 8 (1992): 275287.

Gallagher-Thompson, D., and Thompson, L. W. "Applying Cognitive-Behavioral Therapy to the Psychological Problems of Later Life." In A Guide to Psychotherapy and Aging. Edited by S. Zaret and B. G. Knight. Washington, D.C.: American Psychological Association, 1996: Pages 6182.

Gatz, M.; Fiske, A.; Fox, L. S.; Kaskie, B.; Kasl-Godley, J.; McCallum, T.; and Wetherell, J. "Empirically-Validated Psychological Treatments for Older Adults." Journal of Mental Health and Aging 4 (1998): 946.

Knight, B. G. Psychotherapy with Older Adults, 2d ed. Thousand Oaks, Calif.: Sage Publications, 1996.

Knight, B. G., and Satre, D. D. "Cognitive-Behavioral Psychotherapy with Older Adults." Clinical Psychology: Science and Practice 6 (1999): 188203.

Lichtenberg, P. A. A Guide to Psychological Practice in Geriatric Long-Term Care. New York: Haworth Press, 1994.

Lopez, M. A., and Mermelstein, R. J. "A Cognitive-Behavioral Program to Improve Geriatric Rehabilitation Outcome." The Gerontologist 35 (1995): 696700.

Rybarczyk, B.; Gallagher-Thompson, D.; Rodman, J.; Zeiss, A.; Gantz, F. E.; and Yesavage, J. "Applying Cognitive-Behavioral Psychotherapy to the Chronically Ill Elderly: Treatment Issues and Case Illustration." International Psychogeriatrics 4 (1992): 127140.

Schonfeld, L., and Dupree, L. W. "Treatment Approaches for Older Problem Drinkers." The International Journal of the Addictions 30 (1995): 18191842.

Teri, L.; Curtis, J.; Gallagher-Thompson, D.; and Thompson, L. W. "Cognitive-Behavior Therapy with Depressed Older Adults." In Diagnosis and Treatment of Depression in Late Life. Edited by L. S. Schneider, C. F. Reynolds, B. Liebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Press, 1994. Pages 279292.

Wetherell, J. L. "Treatment of Anxiety in Older Adults." Psychotherapy 35 (1998): 444458.

Widner, S., and Zeichner, A. "Psychological Interventions for the Elderly Chronic Pain Patient." Clinical Gerontologist 13 (1993): 318.

Zarit, S. H., and Knight, B. G., eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, D.C.: American Psychological Association, 1996.

Zeiss, A. M., and Steffen, A. "Behavioral and Cognitive-Behavioral Treatments: An Overview of Social Learning." In A Guide to Psychotherapy and Aging. Edited by S. Zarit and B. G. Knight. Washington, D.C.: American Psychological Association, 1996. Pages 3560.

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Knight, Bob G.; Robinson, Gia S.. "Cognitive-Behavioral Therapy." Encyclopedia of Aging. 2002. Encyclopedia.com. 23 Jul. 2016 <http://www.encyclopedia.com>.

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Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy

Definition

Cognitive-behavioral therapy is an action-oriented form of psychosocial therapy that assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and "negative" emotions. (Maladaptive behavior is behavior that is counter-productive or interferes with everyday living.) The treatment focuses on changing an individual's thoughts (cognitive patterns) in order to change his or her behavior and emotional state.

Purpose

Theoretically, cognitive-behavioral therapy can be employed in any situation in which there is a pattern of unwanted behavior accompanied by distress and impairment. It is a recommended treatment option for a number of mental disorders, including affective (mood) disorders, personality disorders, social phobia, obsessive-compulsive disorder (OCD), eating disorders, substance abuse, anxiety or panic disorder, agoraphobia, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). It is also frequently used as a tool to deal with chronic pain for patients with illnesses such as rheumatoid arthritis, back problems, and cancer. Patients with sleep disorders may also find cognitive-behavioral therapy a useful treatment for insomnia.

Precautions

Cognitive-behavioral therapy may not be suitable for some patients. Those who do not have a specific behavioral issue they wish to address and whose goals for therapy are to gain insight into the past may be better served by psychodynamic therapy. Patients must also be willing to take a very active role in the treatment process.

Cognitive-behavioral intervention may be inappropriate for some severely psychotic patients and for cognitively impaired patients (for example, patients with organic brain disease or a traumatic brain injury), depending on their level of functioning.

Description

Cognitive-behavioral therapy combines the individual goals of cognitive therapy and behavioral therapy.

Pioneered by psychologists Aaron Beck and Albert Ellis in the 1960s, cognitive therapy assumes that maladaptive behaviors and disturbed mood or emotions are the result of inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual reacts to his or her own distorted viewpoint of the situation. For example, a person may conclude that he is "worthless" simply because he failed an exam or did not get a date. Cognitive therapists attempt to make their patients aware of these distorted thinking patterns, or cognitive distortions, and change them (a process termed cognitive restructuring).

Behavioral therapy, or behavior modification, trains individuals to replace undesirable behaviors with healthier behavioral patterns. Unlike psychodynamic therapies, it does not focus on uncovering or understanding the unconscious motivations that may be behind the maladaptive behavior. In other words, strictly behavioral therapists do not try to find out why their patients behave the way they do, they just teach them to change the behavior.

Cognitive-behavioral therapy integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. The therapist works with the patient to identify both the thoughts and the behaviors that are causing distress, and to change those thoughts in order to readjust the behavior. In some cases, the patient may have certain fundamental core beliefs, called schemas, which are flawed and require modification. For example, a patient suffering from depression may be avoiding social contact with others, and suffering considerable emotional distress because of his isolation. When questioned why, the patient reveals to his therapist that he is afraid of rejection, of what others may do or say to him. Upon further exploration with his therapist, they discover that his real fear is not rejection, but the belief that he is hopelessly uninteresting and unlovable. His therapist then tests the reality of that assertion by having the patient name friends and family who love him and enjoy his company. By showing the patient that others value him, the therapist both exposes the irrationality of the patient's belief and provides him with a new model of thought to change his old behavior pattern. In this case, the person learns to think, "I am an interesting and lovable person; therefore I should not have difficulty making new friends in social situations." If enough "irrational cognitions" are changed, this patient may experience considerable relief from his depression.

A number of different techniques may be employed in cognitive-behavioral therapy to help patients uncover and examine their thoughts and change their behaviors. They include:

  • Behavioral homework assignments. Cognitive-behavioral therapists frequently request that their patients complete homework assignments between therapy sessions. These may consist of real-life "behavioral experiments" where patients are encouraged to try out new responses to situations discussed in therapy sessions.
  • Cognitive rehearsal. The patient imagines a difficult situation and the therapist guides him through the step-by-step process of facing and successfully dealing with it. The patient then works on practicing, or rehearsing, these steps mentally. Ideally, when the situation arises in real life, the patient will draw on the rehearsed behavior to address it.
  • Journal. Patients are asked to keep a detailed diary recounting their thoughts, feelings, and actions when specific situations arise. The journal helps to make the patient aware of his or her maladaptive thoughts and to show their consequences on behavior. In later stages of therapy, it may serve to demonstrate and reinforce positive behaviors.
  • Modeling. The therapist and patient engage in role-playing exercises in which the therapist acts out appropriate behaviors or responses to situations.
  • Conditioning. The therapist uses reinforcement to encourage a particular behavior. For example, a child with ADHD gets a gold star every time he stays focused on tasks and accomplishes certain daily chores. The gold star reinforces and increases the desired behavior by identifying it with something positive. Reinforcement can also be used to extinguish unwanted behaviors by imposing negative consequences.
  • Systematic desensitization. Patients imagine a situation they fear, while the therapist employs techniques to help the patient relax, helping the person cope with their fear reaction and eventually eliminate the anxiety altogether. For example, a patient in treatment for agoraphobia, or fear of open or public places, will relax and then picture herself on the sidewalk outside of her house. In her next session, she may relax herself and then imagine a visit to a crowded shopping mall. The imagery of the anxiety-producing situations gets progressively more intense until, eventually, the therapist and patient approach the anxiety-causing situation in real-life (a "graded exposure"), perhaps by visiting a mall. Exposure may be increased to the point of "flooding," providing maximum exposure to the real situation. By repeatedly pairing a desired response (relaxation) with a fear-producing situation (open, public spaces), the patient gradually becomes desensitized to the old response of fear and learns to react with feelings of relaxation.
  • Validity testing. Patients are asked to test the validity of the automatic thoughts and schemas they encounter. The therapist may ask the patient to defend or produce evidence that a schema is true. If the patient is unable to meet the challenge, the faulty nature of the schema is exposed.

Initial treatment sessions are typically spent explaining the basic tenets of cognitive-behavioral therapy to the patient and establishing a positive working relationship between therapist and patient. Cognitive-behavioral therapy is a collaborative, action-oriented therapy effort. As such, it empowers the patient by giving him an active role in the therapy process and discourages any overdependence on the therapist that may occur in other therapeutic relationships. Therapy is typically administered in an outpatient setting in either an individual or group session. Therapists include psychologists (Ph.D., Psy.D., Ed.D. or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. with specialization in psychiatry) and should be trained in cognitive-behavioral techniques, although some brief cognitive-behavioral interventions may be suggested by a primary physician/caregiver. Treatment is relatively short in comparison to some other forms of psychotherapy, usually lasting no longer than 16 weeks. Many insurance plans provide reimbursement for cognitive-behavioral therapy services. Because coverage is dependent on the disorder or illness the therapy is treating, patients should check with their individual plans.

Rational-emotive behavior therapy

Rational-emotive behavior therapy (REBT) is a popular variation of cognitive-behavioral therapy developed in 1955 by psychologist Albert Ellis. REBT is based on the belief that a person's past experiences shape their belief system and thinking patterns. People form illogical, irrational thinking patterns that become the cause of both their negative emotions and of further irrational ideas. REBT focuses on helping patients discover these irrational beliefs that guide their behavior and replace them with rational beliefs and thoughts in order to relieve their emotional distress.

There are 10 basic irrational assumptions that trigger maladaptive emotions and behaviors:

  • It is a necessity for an adult to be loved and approved of by almost everyone for virtually everything.
  • A person must be thoroughly competent, adequate, and successful in all respects.
  • Certain people are bad, wicked, or villainous and should be punished for their sins.
  • It is catastrophic when things are not going the way one would like.
  • Human unhappiness is externally caused. People have little or no ability to control their sorrows or to rid themselves of negative feelings.
  • It is right to be terribly preoccupied with and upset about something that may be dangerous or fearsome.
  • It is easier to avoid facing many of life's difficulties and responsibilities than it is to undertake more rewarding forms of self-discipline.
  • The past is all-important. Because something once strongly affected someone's life, it should continue to do so indefinitely.
  • People and things should be different from the way they are. It is catastrophic if perfect solutions to the grim realities of life are not immediately found.
  • Maximal human happiness can be achieved by inertia and inaction or by living passively and without commitment.

Meichenbaum's self-instructional approach

Psychologist Donald Meichenbaum pioneered the self-instructional, or "self-talk," approach to cognitive-behavioral therapy in the 1970s. This approach focuses on changing what people say to themselves, both internally and out loud. It is based on the belief that an individual's actions follow directly from this self-talk. This type of therapy emphasizes teaching patients coping skills that they can use in a variety of situations to help themselves. The technique used to accomplish this is self-instructional inner dialogue, a method of talking through a problem or situation as it occurs.

Preparation

Patients may seek therapy independently, or be referred for treatment by a primary physician, psychologist, or psychiatrist. Because the patient and therapist work closely together to achieve specific therapeutic objectives, it is important that their working relationship is comfortable and their goals are compatible. Prior to beginning treatment, the patient and therapist should meet for a consultation session, or mutual interview. The consultation gives the therapist the opportunity to make an initial assessment of the patient and recommend a course of treatment and goals for therapy. It also gives the patient an opportunity to find out important details about the therapist's approach to treatment, professional credentials, and any other issues of interest.

In some managed-care clinical settings, an intake interview or evaluation is required before a patient begins therapy. The intake interview is used to evaluate the patient and assign him or her to a therapist. It may be conducted by a psychiatric nurse, counselor, or social worker.

KEY TERMS

Automatic thoughts Thoughts that automatically come to mind when a particular situation occurs. Cognitive-behavioral therapy seeks to challenge automatic thoughts.

Cognitive restructuring The process of replacing maladaptive thought patterns with constructive thoughts and beliefs.

Maladaptive Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Psychodynamic therapy A therapeutic approach that assumes dysfunctional or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.

Relaxation technique A technique used to relieve stress. Exercise, biofeedback, hypnosis, and meditation are all effective relaxation tools. Relaxation techniques are used in cognitive-behavioral therapy to teach patients new ways of coping with stressful situations.

Schemas Fundamental core beliefs or assumptions that are part of the perceptual filter people use to view the world. Cognitive-behavioral therapy seeks to change maladaptive schemas.

Normal results

Many patients who undergo cognitive-behavioral therapy successfully learn how to replace their maladaptive thoughts and behaviors with positive ones that facilitate individual growth and happiness. Cognitive-behavioral therapy may be used in conjunction with pharmaceutical and other treatment interventions, so overall success rates are difficult to gauge. However, success rates of 65% or more have been reported with cognitive-behavioral therapy alone as a treatment for panic attacks and agoraphobia. Relapse has been reported in some patient populations, perhaps due to the brief nature of the therapy, but follow-up sessions can put patients back on track.

Resources

ORGANIZATIONS

Albert Ellis Institute. 45 East 65th St., New York, NY 10021. (800) 323-4738. http://www.rebt.org.

Beck Institute. GSB Building, City Line and Belmont Avenues, Suite 700, Bala Cynwyd, PA 19004-1610. (610) 664-3020. http://www.beckinstitute.org.

National Association of Cognitive-Behavioral Therapists. P.O. Box 2195, Weirton, WV 26062. (800) 853-1135. http://www.nacbt.org.

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Ford-Martin, Paula. "Cognitive-Behavioral Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 23 Jul. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula. "Cognitive-Behavioral Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (July 23, 2016). http://www.encyclopedia.com/doc/1G2-3451600401.html

Ford-Martin, Paula. "Cognitive-Behavioral Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved July 23, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600401.html

Cognitive-behavioral therapy

Cognitive-behavioral therapy

Definition

Cognitive therapy is a psychosocial (both psychological and social) therapy that assumes that faulty thought patterns (called cognitive patterns) cause maladaptive behavior and emotional responses. The treatment focuses on changing thoughts in order to solve psychological and personality problems. Behavior therapy is also a goal-oriented, therapeutic approach, and it treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training. Cognitive-behavioral therapy (CBT) integrates features of behavior modification into the traditional cognitive restructuring approach.

Purpose

Cognitive-behavioral therapy attempts to change clients' unhealthy behavior through cognitive restructuring (examining assumptions behind the thought patterns) and through the use of behavior therapy techniques.

Cognitive-behavioral therapy is a treatment option for a number of mental disorders, including depression, dissociative identity disorder , eating disorders, generalized anxiety disorder , hypochondriasis , insomnia , obsessive-compulsive disorder , and panic disorder without agoraphobia .

Precautions

Cognitive-behavioral therapy may not be appropriate for all patients. Patients with significant cognitive impairments (patients with traumatic brain injury or organic brain disease, for example) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.

Description

Origins of the two approaches

Psychologist Aaron Beck developed cognitive therapy in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted view of the situation. Cognitive therapy strives to change these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.

Behavior therapy focuses on observable behavior and its modification in the present, in sharp contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past. Behavior therapy was developed during the 1950s by researchers and therapists who were critical of the prevailing psychodynamic treatment methods. The therapy drew on a variety of theories and research, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), the work of American B. F. Skinner (1904-1990), and the work of psychiatrist Joesph Wolpe (1915-1997). Pavlov became famous for experiments in which dogs were trained to salivate at the sound of a bell, and Skinner pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. Wolpe is probably best known for his work in the areas of desensitization and assertiveness training . By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Since the 1980s, many therapists have begun to use cognitive-behavioral therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.

The combined approach

In cognitive-behavioral therapy, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, that are flawed and are having a negative impact on the patient's behavior and functioning.

For example, a patient suffering from depression may develop a social phobia because he is convinced that he is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends who care for him and enjoy his company. By showing the patient that others value him, the therapist exposes the irrationality of the patient's assumption and also provides a new model of thought for the patient to change his previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations in order to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.

Cognitive-behavioral therapy is usually administered in an outpatient setting (clinic or doctor's office) by a specially trained therapist. Therapy may be in either individual or group sessions. Therapists are psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. trained in psychiatry).

Techniques

Therapists use several different techniques in the course of cognitive-behavioral therapy to help patients examine and change thoughts and behaviors. These include:

  • Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
  • Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to cope successfully with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to manage it.
  • Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
  • Writing in a journal. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behaviors that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
  • Homework. In order to encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling, review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
  • Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.
  • Systematic positive reinforcement. Human behavior is routinely motivated and rewarded by positive reinforcement , and a more specialized version of this phenomenon (systematic positive reinforcement) is used by behavior-oriented therapists. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of tokens that may be accumulated and later exchanged for certain privileges. Just as providing reinforcement strengthens behaviors, withholding it weakens them. Eradicating undesirable behavior by deliberately withholding reinforcement is another popular treatment method called extinction. For example, a child who habitually shouts to attract attention may be ignored unless he or she speaks in a conversational tone.
  • Aversive conditioning. This technique employs the principles of classical conditioning to lessen the appeal of a behavior that is difficult to change because it is either very habitual or temporarily rewarding. The client is exposed to an unpleasant stimulus while engaged in or thinking about the behavior in question. Eventually the behavior itself becomes associated with unpleasant rather than pleasant feelings. One treatment method used with alcoholics is the administration of a nausea-inducing drug together with an alcoholic beverage to produce an aversion to the taste and smell of alcohol by having it become associated with nausea. In counterconditioning, a maladaptive response is weakened by the strengthening of a response that is incompatible with it. A well-known type of counterconditioning is systematic desensitization , which counteracts the anxiety connected with a particular behavior or situation by inducing a relaxed response to it instead. This method is often used in the treatment of people who are afraid of flying.

Preparation

Because cognitive-behavioral therapy is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in CBT should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist's professional credentials, his/her approach to treatment, and other relevant issues.

In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.

Results

Because cognitive-behavioral therapy is employed for such a broad spectrum of illnesses, and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. However, several studies have indicated that CBT:

  • may reduce the rate of rehospitalization and improve social and occupational functioning for bipolar disorder patients, when combined with pharmacotherapy (treatment with medication)
  • is an effective treatment for patients with bulimia nervosa
  • can help generalized anxiety patients manage their worry, when combined with relaxation exercises
  • is helpful in treating hypochondriasis
  • may be effective for treating depression, especially when combined with pharmacotherapy, and may also prevent depression in at-risk children
  • is one of the first-line treatments for obsessive-compulsive disorder
  • that focuses on education and provides some exposure and coping skills is effective for treating panic disorder without agoraphobia
  • is effective for helping to treat insomnia, and its effects may be sustained longer than the effects of medications alone

See also Aversion therapy; Behavior modification; Cognitive problem-solving skills training; Cognitive retraining techniques; Covert sensitization; Exposure treatment; Rational emotive therapy

Resources

BOOKS

Alford, B. A., and A. T. Beck. The integrative power of cognitive therapy. New York: Guilford, 1997.

Beck, A. T. Prisoners of hate: the cognitive basis of anger, hostility, and violence. New York: HarperCollins Publishers, 1999.

Craighead, Linda W. Cognitive and Behavioral Interventions: An Empirical Approach to Mental Health Problems. Boston: Allyn and Bacon, 1994.

Nathan, Peter E., and Jack M. Gorman. A Guide to Treatments that Work. 2nd edition. New York: Oxford University Press, 2002.

Weishaar, Marjorie. "Cognitive Therapy." In Encyclopedia of Mental Health, edited by Howard S. Friedman. San Diego, CA: Academic Press, 1998.

Wolpe, Joseph. The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, 1996.

Paula Ford-Martin, M.A.

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Cognitive retraining

Cognitive retraining

Definition

Cognitive retraining is a therapeutic strategy that seeks to improve or restore a person's skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem-solving, decision making, and higher level cognitive abilities. These skills are all interrelated. Cognitive retraining is one aspect of cognitive rehabilitation, a comprehensive approach to restoring such skills after brain injury or other disability.

Purpose

The purpose of cognitive retraining is the reduction of cognitive problems associated with brain injury, other disabilities or disorders, and/or aging. The overall purpose of the therapy is to decrease the everyday problems faced by individuals with cognitive difficulties, thereby improving the quality of their lives.

Precautions

The extent to which a person with a brain injury can recover from or compensate for cognitive problems related to the injury requires more information about the person and about their injury. Therapy must be tailored to each individual's needs and abilities. Some cognitive retraining techniques require higher levels of skill, and therefore would be more suitable for persons who have made some progress in their recovery. Moreover, a person's moods and emotions have an effect on their cognitive skills. Someone who is depressed, for example, may need psychotherapy and/or medication before he or she can engage in and benefit from cognitive retraining. Some persons with brain injuries may find it difficult to transfer a skill learned in one setting, such as a clinic, to another setting, such as their home. Although a specific individual may show some improvement on training tasks, his or her cognitive skills may not be considered improved or restored unless there is some evidence that the skills have been transferred to everyday settings and can be maintained over time.

Description

Professionals from a variety of fields, such as psychology, psychiatry, occupational therapy, and speech-language pathology , may be involved in cognitive retraining. The techniques of cognitive retraining are best known for their use with persons who have suffered a brain injury. Cognitive retraining has also been used to treat dementia , schizophrenia , attention-deficit disorder, learning disabilities, and cognitive changes associated with aging.

Cognitive retraining includes a considerable amount of repetitive practice that targets the skills of interest. In fact, repetition is essential for the newly retrained skills to become automatic. Regular feedback is another important element of cognitive retraining, as is the use of such rewards as money. Retraining usually begins with simpler skills and proceeds to more complicated skills. The therapist may address cognitive skills while the person is practicing real-life tasks, in an effort to improve their performance of these tasks. In fact, practicing skills in the ways and settings they will be used in real life is critical to the success of retraining efforts. The length of time for cognitive training varies according to the type and extent of the injury and the type of retraining skills used. For example, retraining memory may take months or years. In comparison, it may take only a few days or weeks to retrain someone to organize his or her home or workplace. The use of computers for cognitive retraining has become an increasingly common practice.

Types of cognitive retraining

  • Attention and concentration retraining. This type of cognitive retraining aims to improve several abilities, including focusing attention; dividing attention; maintaining attention while reducing the effects of boredom and fatigue ; and resisting distraction. Attention has been considered the foundation of other more complicated cognitive skills, and therefore an important skill for cognitive retraining. This area of cognitive retraining has been widely researched, and has been shown to improve patients' abilities in various tasks related to attention.
  • Memory retraining. Memory retraining involves teaching the patient several strategies that can be used to recall certain types of information. For example, rhymes may be used as a memory aid. A series of numbers, such as a phone number with an area code, may be broken down into smaller groups. A person may be taught to go through each letter of the alphabet until he or she remembers someone's name. Both memory and organization problems are common and disabling after head injury.
  • Organizational skills retraining. This approach is used when the person has difficulty keeping track of or finding items, doing tasks in a set order, and/or doing something in a timely manner. Strategies may include having one identified place for an item ("a place for everything and everything in its place"). In addition, the person can be taught to keep the items that are used most frequently closer to him or her (the front or the lower shelves of a cabinet, drawer, closet, or desk, for example). Items that are often used together (such as comb and brush, toothbrush and toothpaste) are placed beside each other. Items may be put into categories (Christmas decorations, Easter decorations, for example). These strategies help individuals function better in their home or work environment.
  • Reasoning. Reasoning refers to the ability to connect and organize information in a logical, rational way. Reasoning retraining techniques include: listing the facts or reality of a situation; excluding irrelevant facts or details; putting the steps to solve a problem in a logical order; and avoiding irrational thinking, such as jumping to conclusions based on incomplete information, or focusing on the negative aspects of the situation and ignoring the positive. When the person can connect relevant information in a logical way, they are better able to understand or comprehend it.
  • Problem solving. Problem-solving retraining aims to help people define a problem; come up with possible solutions to it; discuss the solution(s) with others and listen to their advice; review the various possible solutions from many perspectives; and evaluate whether the problem was solved after going through these steps. This sequence may be repeated several times until the problem is solved. This process is referred to as "SOLVE," from the first letter of the name of each step: Specify; Options; Listen; Vary; and Evaluate. The "SOLVE" technique is more appropriate for use with individuals at a higher level of functioning.
  • Decision making. Decision-making retraining is used when a person must choose among a number of options. The goal of this retraining is to help him or her consider the decision thoroughly before taking any action. The considerations may range from such practical matters as money, people, rules and policies, to personality issues.
  • Executive skills. Executive skills retraining refers to teaching individuals how to monitor themselves, control their thinking and actions, think in advance, set goals, manage time, act in socially acceptable ways, and transfer skills to new situations. These are higher-level cognitive skills. Charts and videotapes may be used to monitor behavior, and a variety of questions, tasks, and games may be used in retraining these skills.

Preparation

Cognitive retraining usually takes place in a quiet room without distractions. It is also important for the person to feel relaxed and calm while they are being retrained in cognitive skills. Engaging in cognitive retraining is not recommended when someone is emotional distressed; for example, if they have recently lost a loved one. The therapist usually evaluates the person's level of cognitive skills and the extent of their cognitive problems before retraining begins. This evaluation provides a way to monitor improvement by comparing the patient's skill levels during and after retraining to his or her skill levels before retraining. Cognitive retraining requires patience and persistence from everyone involved.

Aftercare

The therapist will try to promote the transfer of skills learned using cognitive retraining techniques to the patient's everyday life settings and demands. Training may be continued until the patient's skills are improved, transferred to, and maintained in real world activities.

Risks

It is important for the therapist, patient, and the patient's friends or family members not to assume that improvement on training exercises and tests automatically leads to transfer of the skills to real-life settings.

Normal results

Cognitive retraining may be considered successful if performance on a behavior related to a particular cognitive skill has improved. It is ultimately successful if it helps the injured person improve his or her functioning and meet his or her needs in real-life situations and settings.

See also Attention-deficit/hyperactivity disorder; Dementia; Learning disabilities; Schizophrenia

Resources

BOOKS

Mateer, Catherine A., and Sarah Raskin. "Cognitive Rehabilitation." In Rehabilitation of the Adult and Child with Traumatic Brain Injury, 3rd ed., edited by M. Rosenthal, E. R. Griffith, J. S. Kreutzer, and B. Pentland. Philadelphia: F. A. Davis, 1999.

Parente, Rick, and D. Herrmann. Retraining Cognition: Techniques and Applications. Gaithersburg, MD: Aspen, 1996.

Ylvisaker, Mark, and Timothy J. Feeney. Collaborative Brain Injury Intervention. San Diego: Singular, 1998.

Joneis Thomas, Ph.D.

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Cognitive problem-solving skills training

Cognitive problem-solving skills training

Definition

Cognitive problem-solving skills training (CPSST) attempts to decrease a child's inappropriate or disruptive behaviors by teaching the child new skills for approaching situations that previously provoked negative behavior. Using both cognitive and behavioral techniques and focusing on the child more than on the parents or the family unit, CPSST helps the child gain the ability to self-manage thoughts and feelings and interact appropriately with others by developing new perspectives and solutions. The basis of the treatment is the underlying principle that children lacking constructive ways to address the environment have problematic behaviors; teaching these children ways to positively problem-solve and challenge dysfunctional thoughts improves functioning.

Purpose

The goal of CPSST is to reduce or terminate inappropriate, dysfunctional behaviors by expanding the behavioral repertoire (including ways of cognitive processing). The behavioral repertoire is the range of ways of behaving that an individual possesses. In children with conduct disorder , intermittent explosive disorder , oppositional-defiant disorder , antisocial behaviors, aggressive acting-out, or attention-deficit/hyperactivity disorder with disruptive behavior, the number of ways of interpreting reality and responding to the world are limited and involve negative responses. Although CPSST originally focused on children with problem behaviors or poor relationships with others, it has generalized to a variety of different disorders in children and adults (this treatment has the most research supporting its use in children).

Description

The therapist conducts individual CPSST sessions with the child, once a week for 45 minutes to an hour, typically for several months to a year. The cognitive portion of the treatment involves changing faulty or narrow views of daily situations, confronting irrational interpretations of others' actions, challenging unhelpful assumptions that typically underlie the individual's problem behaviors, and generating alternative solutions to problems. For example, meeting with a child who has received a school suspension for becoming physically enraged at a teacher, the therapist starts by exploring the situation with the child, asking what thoughts and feelings were experienced. The child might state, "My teacher hates me. I'm always getting sent to the principal and she yells at me all the time." The therapist helps the child see some faulty ways of thinking by asking what the child has seen or experienced in the classroom previous to this incident, thus exploring the supporting evidence for the "my teacher hates me" notion. Questions would be ones that could confirm or disconfirm the assumptions, or that identify the precipitants of the teacher disciplining the child. The therapist tries to help the child shift his or her perceptions so that, instead of seeing the student-teacher negative interactions as something external to the self, the child comes to see his or her part in the problem. This discussion also helps the child to discern opportunities to influence the outcome of the interactions. When the child makes a global, stable, and negative attribution about why the interactions with the teacher are negativewhere the attitude of the teacher is the cause of the problemsthe child loses the sense of having any efficacy and is liable to show poorer behavior. By changing the child's perceptions and examining different options for the child's-responses in that situation, however, the child can identify ways that changing his or her own behavior could improve the outcome.

The behavioral aspect of CPSST involves modeling of more positive behaviors; role-playing challenging situations; and rewarding improvement in behavior, providing corrective feedback on alternative (and more appropriate) ways of handling situations when undesirable behavior occurs. In each session, the child is coached on problem-solving techniques including brainstorming a number of possible solutions to difficulties, evaluating solutions, and planning the steps involving in gaining a desired goal (also called means-end thinking ). For instance, if the child in the above example felt that the teacher's accusations were unfair, the therapist would help to come up with some options for the child to use in the event of a similar situation (such as visualizing a calming scene, using a mediator to work out the conflict, or avoiding the behaviors that precipitate a trip to the principal's office). The options generated would be discussed and evaluated as to how practical they are and how to implement them.

The child is given therapy homework of implementing these newer ways of thinking and behaving in specific types of problematic situations in school, with peers, or at home. The child might be asked to keep track of negative, externalizing thoughts by keeping a log of them for several days. The therapist would ask the child to conduct an experimenttry one of the new options and compare the results. Typically, the between-sessions work begins with the conditions that appear the easiest in which to successfully use the updated ways of thinking and behaving, gradually progressing to more complex or challenging circumstances. The child would get rewarded for trying the new techniques with praise, hugs, or earning points towards something desired.

Although the bulk of the sessions involve the individual child and the therapist, the parents are brought into the therapy for a portion of the work. The parents observe the therapist and the child as they practice the new skills and are educated on how to assist the child outside the sessions. Parents learn how to remind the child correctly to use the CPSST techniques for problem-solving in daily living and assist the child with the steps involved in applying these skills. Parents are also coached on how to promote the positive behaviors by rewarding their occurrence with praise, extra attention, points toward obtaining a reward desired by the child, stickers or other small indicators of positive behavior, additional privileges, or hugs (and other affectionate gestures). The scientific term for the rewarding of desired behavior is positive reinforcement, referring to consequences that cause the desired target behavior to increase.

In research studies of outcomes, CPSST has been found to be effective in changing children's behavior. Changes in behavior have been shown to persist long-term after completion of treatment. Success in altering undesirable behaviors is enhanced when CPSST is combined with parent management training . Parent management training is the in-depth education of parents or other primary caretakers in applying behavioral techniques such as positive reinforcement or time away from reinforcement opportunities in their parenting.

Risks

Inappropriate or inept application of cognitive-behavioral techniques such as those used in CPSST may intensify the problem. CPSST should be undertaken with a behavioral health professional (psychologist , psychiatrist , or clinical social worker) with experience in CPSST. Parents should seek therapists with good credentials, skills, and training.

Results

While individual results vary, problematic behaviors are reduced or eliminated in many children.

See also Behavior modification; Token economy system

Resources

BOOKS

D'Zurilla, T. J. and A. M. Nezu. Problem solving therapy: A social competence approach to clinical intervention. Second edition. New York: Springer Publishing Company, 1999.

Hendren, R. L. Disruptive behavior disorders in children and adolescents. Review of Psychiatry Series, vol. 18, no. 2. Washington, DC: American Psychiatric Press, 1999.

PERIODICALS

Gilbert, S. "Solution-focused treatment: A model for managed care success." The Counselor 15, no. 5 (1997): 23-25.

Kazdin, Alan E., T. Siegel and D. Bass. "Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children." Journal of Consulting and Clinical Psychology 60 (1992): 733-747.

Matthews, W. J. "Brief therapy: A problem solving model of change." The Counselor 17, number 4 (1999): 29-32.

ORGANIZATIONS

Association for the Advancement of Behavior Therapy. 305 Seventh Avenue, 16th Floor, New York, NY 10001-60008. (212) 647-1890.

Deborah Rosch Eifert, Ph.D.

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Cognitive Therapy

Cognitive therapy

Cognitive therapy is a psychosocial therapy that assumes that faulty cognitive, or thought, patterns cause maladaptive behavior and emotional responses. The treatment focuses on changing thoughts in order to adjust psychological and personality problems.

Purpose

Psychologist Aaron Beck developed the cognitive therapy concept in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted viewpoint of the situation. Cognitive therapy focuses on changing these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.

Cognitive therapy is a treatment option for a number of mental disorders, including agoraphobia, Alzheimer's disease , anxiety or panic disorder, attention deficit-hyperactivity disorder (ADHD), eating disorders , mood disorders, obsessive-compulsive disorder (OCD), personality disorders, post-traumatic stress disorder (PTSD) , psychotic disorders , schizophrenia , social phobia , and substance abuse disorders. It can be useful in helping individuals with anger management problems, and has been reported to be effective in treating insomnia. It is also frequently prescribed as an adjunct, or complementary, therapy for patients suffering from back pain , cancer, rheumatoid arthritis, and other chronic pain conditions.

Treatment techniques

Cognitive therapy is usually administered in an out-patient setting (clinic or doctor's office) by a therapist trained or certified in cognitive therapy techniques. Therapy may be in either individual or group sessions, and the course of treatment is short compared to traditional psychotherapy (often 12 sessions or less). Therapists are psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. trained in psychiatry).

Therapists use several different techniques in the course of cognitive therapy to help patients examine thoughts and behaviors. These include:

  • Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
  • Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to successfully cope with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to deal with it.
  • Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
  • Journaling. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behavior that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
  • Homework. In order to encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling (see above), review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
  • Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.

Cognitive-behavioral therapy (CBT) integrates features of behavioral modification into the traditional cognitive restructuring approach. In cognitive-behavioral therapy, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, which are flawed, and are having a negative impact on the patient's behavior and functioning. For example, a patient suffering from depression may develop a social phobia because he/she is convinced he/she is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends that care for him/her and enjoy his/her company. By showing the patient that others value him/her, the therapist exposes the irrationality of the patient's assumption and also provides a new model of thought for the patient to change his/her previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations in order to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.

Preparation

Cognitive therapy may not be appropriate for all patients. Patients with significant cognitive impairments (e.g., patients with traumatic brain injury or organic brain disease) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.

Because cognitive therapy is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in cognitive therapy should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist's professional credentials, his/her approach to treatment, and other relevant issues.

In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.

Typical results

Because cognitive therapy is employed for such a broad spectrum of illnesses, and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. Cognitive and cognitive behavior treatments have been among those therapies not likely to be evaluated, however, and efficacy is well-documented for some symptoms and problems.

Some studies have shown that cognitive therapy can reduce relapse rates in depression and in schizophrenia, particularly in those patients who respond only marginally to antidepressant medication. It has been suggested that this is because cognitive therapy focuses on changing the thoughts and associated behavior underlying these disorders rather than just relieving the distressing symptoms associated with them.

Paula Ford-Martin

Further Reading

Alford, B.A. and Beck, A.T. The integrative power of cognitive therapy. New York: Guilford, 1997.

Beck, A.T. Prisoners of hate: the cognitive basis of anger, hostility, and violence. New York: Harper Collins Publishers, 1999.

Greenberger, Dennis and Christine Padesky. Mind over mood: a cognitive therapy treatment manual for clients. New York: Guilford Press, 1995.

Further Information

Beck Institute For Cognitive Therapy And Research. GSB Building, City Line and Belmont Avenues, Suite 700, Bala Cynwyd, PA, USA. 19004-1610, fax: (610)664-4437, (610)664-3020. Email: beckinst@gim.net. http://www.beckinstitute.org.

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Cognitive Behavior Therapy

Cognitive behavior therapy

A therapeutic approach based on the principle that maladaptive moods and behavior can be changed by replacing distorted or inappropriate ways of thinking with thought patterns that are healthier and more realistic.

Cognitive therapy is an approach to psychotherapy that uses thought patterns to change moods and behaviors. Pioneers in the development of cognitive behavior therapy include Albert Ellis (1929-), who developed rational-emotive therapy (RET) in the 1950s, and Aaron Beck (1921-), whose cognitive therapy has been widely used for depression and anxiety. Cognitive behavior therapy has become increasingly popular since the 1970s. Growing numbers of therapists have come to believe that their patients' cognitive processes play an important role in determining the effectiveness of treatment. Currently, almost 70% of the members of the Association for the Advancement of Behavior Therapy identify themselves as cognitive behaviorists.

Like behavior therapy, cognitive behavior therapy tends to be short-term (often between 10 and 20 sessions), and it focuses on the client's present situation in contrast to the emphasis on past history that is a prominent feature of Freudian psychoanalysis and other psychodynamically oriented therapies. The therapeutic process begins with identification of distorted perceptions and thought patterns that are causing or contributing to the client's problems, often through detailed record keeping by the client. Some self-defeating ways of thinking identified by Aaron Beck include all-or-nothing thinking; magnifying or minimizing the importance of an event; overgeneralization (drawing extensive conclusions from a single event); personalization (taking things too personally); selective abstraction (giving disproportionate weight to negative events); arbitrary inference (drawing illogical conclusions from an event); and automatic thoughts (habitual negative, scolding thoughts such as "You can't do anything right").

Once negative ways of thinking have been identified, the therapist helps the client work on replacing them with more adaptive ones. This process involves a repertoire of techniques, including self-evaluation, positive self-talk, control of negative thoughts and feelings, and accurate assessment of both external situations and of the client's own emotional state. Clients practice these techniques alone, with the therapist, and also, wherever possible, in the actual settings in which stressful situations occur (in vivo ), gradually building up confidence in their ability to cope with difficult situations successfully by breaking out of dysfunctional patterns of response.

Today cognitive behavior therapy is widely used with children and adolescents, especially for disorders involving anxiety, depression, or problems with social skills. Like adult clients, children undergoing cognitive behavior therapy are made aware of distorted perceptions and errors in logic that are responsible for inaccurate or unrealistic views of the world around them. The therapist then works to change erroneous beliefs and perceptions by instruction, modeling , and giving the child a chance to rehearse new attitudes and responses and practice them in real-life situations. Cognitive behavior therapy has been effective in treating a variety of complaints, ranging from minor problems and developmental difficulties to severe disorders that are incurable but can be made somewhat more manageable. It is used either alone or together with other therapies and/or medication as part of an overall treatment plan.

Cognitive behavioral therapy has worked especially well, often in combination with medication, for children and adolescents suffering from depression. It can help free depressed children from the pervasive feelings of helplessness and hopelessness that are supported by self-defeating beliefs. Children in treatment are assigned to monitor their thoughts, and the therapist points out ways that these thoughts (such as "nothing is any fun" or "I never do anything right") misrepresent or distort reality. Other therapeutic techniques may include the completion of graded task assignments, and the deliberate scheduling of pleasurable activities.

Cognitive behavioral therapy is also used for children with conduct disorder , which is characterized by aggressive, antisocial actions, including hurting animals and other children, setting fires, lying, and theft. Through a cognitive behavioral approach (which generally works better with adolescents than with younger children because of the levels of thinking and control involved), young people with this disorder are taught ways to handle anger and resolve conflicts peacefully. Through instruction, modeling, role playing, and other techniques, they learn to react to events in socially appropriate, nonviolent ways. Other childhood conditions for which cognitive behavior therapy has been effective include generalized anxiety disorder and attention deficit/hyperactivity disorder . It can help children with ADHD become more controlled and less impulsive; often, they are taught to memorize and internalize the following set of behavior guidelines: "StopListen LookThinkAct."

Cognitive behavioral therapy has also been successful in the treatment of adolescents with eating disorders , who, unlike those with conduct disorders, hurt themselves rather than hurting (or attempting to hurt) others. The cognitive approach focuses on the distorted perceptions that young women with anorexia or bulimia have about food, eating, and their own bodies. Often administered in combination with medication, therapy for eating disorders needs to be continued for an extended period of timea year and a half or longer in the case of anorexia.

Cognitive therapy is generally not used for disorders, such as schizophrenia or autism , in which thinking or communication are severely disturbed.

Further Reading

Beck, Aaron. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press, 1976.

Dryden, Windy, ed. The Essential Albert Ellis: Seminal Writings on Psychotherapy. New York: Springer, 1990.

Feindler, Eva L. Adolescent Anger Control: Cognitive-Behavioral Techniques. New York: Pergamon Press, 1986.

Fishman, Katharine Davis. Behind the One-Way Mirror: Psychotherapy and Children. New York: Bantam Books, 1995.

Mahoney, Michael J., ed. Cognition and Psychotherapy. New York: Plenum Press, 1985.

Martorano, Joseph T., and John P. Kildahl. Beyond Negative Thinking: Breaking the Cycle of Depressing and Anxious Thoughts. New York: Insight Books, 1989.

Wolpe, Joseph. Life Without Fear. Oakland, CA: Harbinger, 1988.

Further Information

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue NW, Washington, DC 20016, (202) 9667300.

American Society for Adolescent Psychiatry. 4330 East West Highway, Suite 1117, Bethesda, MD 20814, (301) 7186502.

Association for Advancement of Behavior Therapy. 15 West 36th St., New York, NY 10018, (212) 2797970.

Albert Ellis Institute (formerly the Institute for Rational-Emotive Behavior Therapy). 45 East 65th St., New York, NY 10021, (212) 5350822. http://www.rebt.org.

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Cognitive-Behavioral Therapy

COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral treatments represent a group of approaches, grounded in social learning theories of substance abuse, that hold that lack of effective coping skills may be one factor underlying the development or perpetuation of substance use disorders. Cognitive behavioral treatments have been among the most well defined and rigorously studied of the psychosocial treatments for substance abuse and dependence, and have a comparatively high level of empirical support across the addictions. For example, in their review of cost and effectiveness data for treatments for alcohol use disorders, Holder and colleagues (1991) included social skills training, self-control training, stress management training, and the Community Reinforcement Approach (Azrin et al., 1976), all broad-spectrum CBT approaches, as having good empirical evidence of effectiveness. Recent meta-analyses (Irvin et al., 1999) and reviews of the effectiveness of treatments for substance abuse (APA Workgroup on Substance Use Disorders, 1996; DeRubeis & Crits-Christoph 1998) have identified this group of approaches as having among the highest level of empirical support for the treatment of substance use disorders.

OVERVIEW AND STRUCTURE OF CBT

Cognitive-behavioral treatments are typically highly structured in comparison to other approaches for substance use disorders. That is, these treatment approaches are typically comparatively brief (12-24 weeks) and organized closely around well-specified treatment goals. There is typically an articulated agenda for each session and discussion remains focused around issues directly related to substance use. Progress toward treatment goals is monitored closely and frequently, and the therapist takes an active stance throughout treatment.

Cognitive-behavioral approaches typically include a range of skills to foster or maintain abstinence and to prevent relapse. These typically include strategies for:

  1. reducing availability and exposure to the substance and related cues,
  2. fostering resolution to stop substance use through exploring positive and negative consequences of continued use,
  3. self-monitoring to identify high risk situations and to conduct functional analyses of substance use,
  4. recognition of conditioned craving and development of strategies for coping with craving,
  5. identification of seemingly irrelevant decisions which can culminate in high risk situations,
  6. preparation for emergencies and coping with a relapse to substance use,
  7. substance refusal skills, and
  8. identifying and confronting thoughts about the substance.

The techniques of teaching these coping responses include a combination of direct verbal instruction, modeling of appropriate skills through role play, and rehearsal of the skills within the therapy session (Marlatt & Gordon, 1985). Material discussed during sessions is typically supplemented with extra-session tasks (i.e., homework) intended to foster practice and mastery of coping skills.

Broad-spectrum cognitive-behavioral approaches such as that described by Monti and colleagues (1989), and adapted for use in Project MATCH (Kadden et al., 1992), expand to include interventions directed to other problems in the individual's life that are seen as functionally related to substance use. These may include general problem-solving skills, assertiveness training, strategies for coping with negative affect, awareness of anger and anger management, coping with criticism, increasing pleasant activities, enhancing social support networks, job seeking skills, and so on.

There are a variety of manuals available (Monti et al., 1989; Kadden et al. 1992, Carroll, 1998) which describe key CBT strategies and techniques, as well as guidelines for its implementation with a variety of types of substance users. The classic resource in this area remains the Marlatt and Gordon's (1985) landmark book on relapse prevention.

The goals of cognitive-behavioral treatments tend to be somewhat broader than those of 'strict' behavioral approaches, and the choice of treatment goals will dictate the specific interventions implemented. For example, in broad spectrum cognitive-behavioral treatments (e.g., Azrin et al., 1976; Monti et al., 1989), the patient and therapist may select a wide range of target behaviors in addition to a treatment goal of abstinence, including improved social skills or social functioning, reduced psychiatric symptoms, and reduced social isolation, entry into the work force. Cognitive behavioral therapy also differs from cognitive therapy through greater emphasis on building specific behavioral skills (e.g., coping with craving, avoiding high risk situations, understanding behavioral patterns) and somewhat lesser emphasis on targeting and challenging maladaptive cognitions in the earlier stages of abstinence.

STRENGTHS AND WEAKNESSES

Strengths of cognitive-behavioral approaches have been summarized by Rotgers (1996) and include:

  1. flexibility in meeting individual needs,
  2. acceptability to a wide range of substance-abusing individuals seen in clinical settings,
  3. solid grounding in established principles of behavior theory and behavior change,
  4. an emphasis on linking science to treatment,
  5. well-specified treatment goals and clear guidelines for assessing treatment progress,
  6. emphasis on building self-efficacy, and
  7. a comparatively strong level of empirical support.

These approaches are highly flexible, and can be used in a number of treatment modalities and settings, can be applied across different types of substance use with minor modifications, and are compatible with a wide range of other treatment approaches, including family therapy and pharmacotherapy. Another advantage is that these approaches have emphasized clear specification of treatment and a variety of manuals are available, thus allowing a high level of technology transfer. Disadvantages of this group of approaches include:

  1. research evaluating these approaches have tended not to emphasize the importance of isolating and evaluating the specific 'active ingredients' associated with behavior change,
  2. comparative underutilization of these approaches outside of academic treatment settings (Rotgers, 1996), and
  3. lack of emphasis on patient motivation and specific procedures for addressing the patient's readiness for change.

SUMMARY

Cognitive behavioral treatments have emerged in the last decade as a leading approach to the treatment of substance use disorders. Solidly grounded in well-established principles of behavior change, with strong empirical support, and applicable to a wide range of individuals with substance use disorders, these well-defined approaches should be a part of any clinician's treatment repertoire.

BIBLIOGRAPHY

American Psychiatric Association, Work Group on Substance Use Disorders (1995). Practice guideline for the treatment of patients with substance use disorders: Alcohol, cocaine, opioids. American Journal of Psychiatry, 152 (sup), 2-59.

Azrin, N. H. (1976). Improvements in the community-reinforcement approach to alcoholism. Behavior Research and Therapy, 14, 339-348.

Carroll, K. M. (1998). A Cognitive-Behavioral Approach: Treating Cocaine Addiction. NIH Publication 98-4308. Rockville, MD: National Institute on Drug Abuse.

Carroll, K. M. (1999). Behavioral and cognitive behavioral treatments. In B. S. McCrady & E. E. Epstein (eds.), Addictions: A Comprehensive Guidebook (pp. 250-267). New York: Oxford University Press.

Chaney, E. F., O' Leary, M. R., & Marlatt, G.A. (1978) Skill training with problem drinkers. Journal of Consulting and Clinical Psychology, 46, 1092-1104.

DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.

Holder, H. D., Longabaugh, R., Miller, W. R., & Rubonis, A. V. (1991). The cost effectiveness of treatment for alcohol problems: A first approximation. Journal of Studies on Alcohol, 52, 517-540.

Irvin JE, Bowers CA, Dunn ME, Wong MC. Efficacy of relapse prevention: A meta-analytic review. J Consult Clin Psychology. 1999;67:563-570.

Kadden, R., Carroll, K. M., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., & Hester, R. (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series Volume 3, DHHS Publication No. (ADM) 92-1895. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Marlatt, G. A., & Gordon, J. R., (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford.

Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence: A coping skills training guide in the treatment of alcoholism. New York: Guilford.

Rotgers, F. (1996). Behavioral theory of substance abuse treatment: Bringing science to bear on practice. In F. Rotgers, D. Keller, & J. Morgenstern (eds.), Treating Substance Abusers: Theory and Technique (pp. 174-201). New York: Guilford.

Kathleen M. Carroll

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cognitive behavioural therapy

cognitive behavioural therapy (CBT) n. a cognitive therapy that is combined with behavioural elements (see behaviour therapy). The patient is encouraged to analyse his or her specific ways of thinking around a problem. The therapist then looks at the resulting behaviour and the consequences of that thinking and tries to encourage the patient to change his or her cognition in order to avoid adverse behaviour or its consequences.

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"cognitive behavioural therapy." A Dictionary of Nursing. 2008. Encyclopedia.com. 23 Jul. 2016 <http://www.encyclopedia.com>.

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cognitive therapy

cognitive therapy Form of psychotherapy that aims to treat psychological problems through changing patients' attitudes and beliefs. It is based on the theory that behaviour is learned, and beliefs and attitudes that lead to negative behaviour can be altered by relearning and conditioning. It is used in the treatment of various behavioural problems, phobias, and sometimes for children with learning problems.

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"cognitive therapy." World Encyclopedia. 2005. Encyclopedia.com. 23 Jul. 2016 <http://www.encyclopedia.com>.

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cognitive therapy

cognitive therapy n. a form of psychotherapy based on the belief that psychological problems are the products of faulty ways of thinking about the world. It may involve analysis and retraining of unhelpful behaviours (see cognitive behavioural therapy) or it may include an element of psychodynamic exploration of the problems (cognitive analytical therapy).

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