What is Cognitive Therapy?
Robert Westermeyer, Ph.D.
The word "cognitive" or "cognition" means "to know" or "to think". Therefore, cognitive therapy is viewed as a "psychological treatment of thoughts." Simply, cognitive therapy operates under the assumption that thoughts, beliefs, attitudes and perceptual biases influence what emotions will be experienced and also the intensity of those emotions. Cognitive Therapy was pioneered by Aaron Beck, M.D. for the treatment of depression. Dr. Beck and other researchers have developed methods for applying cognitive therapy to other psychiatric problems, such as panic, anger control problems and substance abuse. This form of therapy has received considerable research support, especially with regard to depression.
The view that our thoughts influence our emotions and behavior is hardly new. In fact, the origins of this idea can be traced back to the Stoic philosophers, namely Epictetus, who wrote, "Men are disturbed not by things, but by the view which they take of them."
To illustrate this point, imagine you are asleep in bed and you are awakened by a loud crashing sound from downstairs. How will you feel if you believe that the crash was an intruder? Probably pretty frightened and anxious, right? Now imagine that you suddenly remember that you just acquired a new kitten that has been knocking over just about everything in sight. How might you be feeling then? Certainly not frightened or anxious; rather, you might be angry or even disappointed about the vase.
The nature of our feelings is largely determined by the way that we think. In the above example the feeling (frightened or angry) was solely dependent on how the event (crashing sound) was construed.
Depression is a mood state that can be brought upon by overly negative interpretations of events. For example, imagine two people experiencing the break up of a relationship. Imagine that both of them view themselves and the relationship in different ways. One person conceptualizes the relationship as evidence of his worth as a person and the break up, therefore, as evidence that he is worthless and unlovable. Further he views the break-up as being caused by his unlovable characteristics. The second person views the relationship as a very important part of his life. However, it does not represent his sum total worth. The second person views the break up as due to mutual incompatibility. Which of these two people would be more likely to experience depressed mood secondary to the break up? Probably the former, right? The break-up was construed in this as due to a flaw in his character, and since his worth was contingent on being in a relationship with that partner, the break up affirmed his belief in himself as a worthless failure.
Self-debasing beliefs like these lead to negative emotions like depression and anxiety. The second person didn't deny that the relationship was important. He may feel sad and frustrated after the break up, but probably will not sink into a clinical depression. This is because his construction of the break up was realistic and non-self-punitive.
Depression has many causes; biological changes can cause depression, rigid negative attitudes about oneself can cause depression, catastrophic events can cause depression. But one thing occurs after onset that is common to depression regardless of its etiology: negative thinking. Depressed people view the world in a negative manner; they view themselves in a debasing way; and they view their future as dismal. Cognitive therapy is a treatment designed to help people learn to identify and monitor negative ways of thinking, then to alter this tendency and think in a more realistic manner.
When depressed people learn to identify distorted automatic thinking and to replace them with more realistic ones, depression can be reduced. Moreover, when people become adept at altering negative thoughts and beliefs, their likelihood of experiencing episodes of depression in the future decreases.
To some this may sound overly simplistic. You might be thinking, "I've been depressed for years and you are trying to tell me that that all I need to do is think positively and it will all go away?"
This is a common response to some people when they first hear about cognitive therapy. First, though the notion of thoughts causing feelings is quite elementary, the actual information processing biases which occur in depression are really quite complex. Volumes of research investigating biases in memory retrieval, attention and processing structures that are activated in depressive states suggest that what happens cognitively in depression is far from simplistic. One of the things that research has discovered is that just "thinking positively" is not going to decrease depression in a lasting way. Though depressed people do not engage in a great deal of positive thinking, it is the negative thoughts, beliefs and assumptions that perpetuate depressed mood. Negative thinking in depressed people largely occurs automatically and sometimes without awareness. For cognitive therapy to be effective, depressed individuals need to learn how to identify their negative automatic thoughts, processing biases as well as the beliefs they have about themselves and others. Depressed individuals also need to learn to dispute their negative thoughts after they have been identified. Therefore, as opposed to positive thinking, cognitive therapy helps people think non-negatively. For many this requires the learning of new skills: monitoring ones stream of thoughts, identifying beliefs and attitudes and subjecting them to the laws of reason. With enough practice, these skills become second nature, and the risk of severe depression decreases.
Therefore, cognitive therapy is more educational than other non-directive forms of therapy. Cognitive therapy is not a "magic bullet." In order for one to benefit from it, effort must be placed on using the skills outside of therapy. Some find the initial sessions of cognitive therapy difficult, because the skills do not result in complete elimination of symptoms. I liken cognitive therapy to learning a foreign language. At first the tasks of self-monitoring, activity scheduling and thought disputation feel awkward and the outcome doesn't seem to be worth the effort. Like learning a foreign language, the more practice put into using cognitive therapy skills, the more effective they will become, the more automatic they will become and the more lasting will relief be.
In many ways cognitive therapy may sound like school; much of the therapy entails didactic presentation, and homework is assigned. However, it is more accurate to view cognitive therapy as an interactive workshop. A very good self-help book on using cognitive therapy for depression is "Feeling Good" by David Burns, M.D. In my opinion, this book is the best "self help" manual for cognitive therapy of depression. It can also serve as a good adjunct to actual cognitive therapy. It is available in paperback and widely available at most bookstores.