Intro to CBT

INTRODUCTION TO COGNITIVE THERAPY

William C. Sanderson, PhD

Cognitive Therapy Center of Long Island, Great Neck NY

www.ctcli.com


The Simple Version

WHAT IS COGNITIVE THERAPY?

Cognitive Therapy is a problem-focused psychological treatment approach in which the therapist collaborates with the patient to improve one's emotional well-being and overall functioning. The focus of cognitive therapy is on "cognitions", or thoughts. Cognitive Therapy was originally developed by Dr. Aaron Beck at the University of Pennsylvania as a treatment for depression. Since then research has demonstrated that cognitive therapy is an effective treatment for a wide range of problems, including depression, anxiety, panic attacks, phobias, relationship & marital problems, and stress-related disorders.


The way you feel is related to your thinking.

The basic premise of cognitive therapy is that thoughts and beliefs have the greatest impact on your emotions and behavior. Emotional disturbance (e.g., anxiety, depression) is seen as a result of distorted thought patterns that determine the way that a person interprets the events in their life. These negative thought processes are usually "learned" during childhood. Since thought patterns become habitual and ingrained they are experienced as automatic, and therefore, go unnoticed by the individual. Nevertheless, they have a profound effect on the way one is feeling and behaving.

You can feel better by changing the way you think.

The overall aim of Cognitive Therapy is to help clients restructure their thinking. It is important to realize that Cognitive Therapy is not "positive thinking." Instead, the point of cognitive therapy is to view your life and your problems in a realistic perspective -- that is, to encourage accurate, logical thinking.




THE LONG VERSION
For those interested in a more technical explanation based on psychological theories of cognition and emotion read explanation below excerpted from some of my professional writings.

The Relationship Between Cognition and Emotion
Before we can discuss cognitive therapy for working with emotional disorders, an essential first step is to describe a model of psychopathology, which explains the role of cognition in the development and maintenance of psychopathology. Myconceptualization of emotional disorders is heavily influenced by the writings of the pioneers in specifying the importance of cognition in the psychotherapeutic treatment of emotional disorders: Aaron T. Beck (1976) and Albert Ellis (1962). In addition, we have relied extensively on the work of Richard S. Lazarus (1991), who devoted much of his career to elaborating the relationship between cognition and emotion, and whose work adds a richness to cognitive theories of emotional disorders that is often overlooked.

Central to these theories is the notion that cognitive appraisal is necessary for the generation of emotion. Emotions are conceptualized as biologically adaptive mechanisms that result from one's evaluation (appraisal) of his relationship with the environment (i.e., adaptational relationship). Negative emotional states arise from the appraisal of harmful/threatening person-environment relationships. Positive emotional states result from appraisal of beneficial person-environment relationships. For either a positive or negative emotion to be generated, the transaction or event must be perceived as personally relevant (Lazarus, 1991).

From a functional perspective, both positive and negative emotions facilitate goal directed behavior that will enhance the organism. In fact, the components of emotions (affect, cognitions, behavioral inclinations, physiology) become activated in very specific ways that facilitate the person's ability to meet the demands of the situation. For example, if a person is confronted by a vicious dog, all of his attention will be focused on the dog and thoughts of danger/harm will pervade his consciousness (cognitive), he will feel an urgent desire to flee from the situation (behavioral, action impulse), and he will experience an increase in autonomic nervous system activity increasing his ability to escape (physiological).

Cognitive Activation of Emotion.
As noted above, whether or not an emotion is activated depends upon a cognitive appraisal that a transaction is/has/may occur that is relevant to the individual's well-being.One's determination that a transaction is relevant, and of its significance, depends upon one's expectations, beliefs, and values. R.S. Lazarus (1991) has defined this schema as anEgo-identity. One's ego identity is based upon six broad components: (1) self- and social esteem, (2) moral values, (3) ego-ideals, (4) essential meanings and ideas, (5) other persons and their well-being, (6) life goals. The ego-identity is the schema, a core cognitive process, that serves as a filter for environmental stimuli, and precursor to emotion activation. To understand when emotions will be triggered in a particular person, one must understand the nature of the various aspects of his ego-identity. For example, one cannot understand a person’s judgment about her academic success without knowing her expectation, which may be a reflection of life goals. Consequently, a grade of a "B" may be excellent for one person, terrible for another. The nature of the ego-identity explains how each of us perceives the same environmental stimulus (such as a grade, interpersonal rejection, failure) differently.

It is important to keep in mind that appraisal is not necessarily deliberate or conscious -- instead it is automatic. As a result, individuals are typically unaware of the way they are viewing situations, although they are aware of how they feel. In cognitive therapy patients are taught to uncover the thought process activating the feeling.

It is also important to note that to a large degree individuals construct their own reality.People are not objective information processors. Instead, they select certain information from the environment, depending upon one’s preexisting schema determining what is personally relevant. For example, if you bought a new car today, say a silver Honda Accord, you are much more likely to notice the same car on the road than were you previously. This stimulus (i.e., the car) now has personal relevance to you. As a result, it may seem that there are more of them than now than there were before, because of your increased attention.

EMOTIONAL DISORDERS
In general, to determine whether or not an emotion is "pathological" two factors are considered. First, how well does the emotional reaction fit the provoking situation or context in which it occurs? Second, what are the adaptational consequences of the emotional reaction? If the emotional reaction is out of proportion to the provoking situation (e.g., the end of a relationship results in months of severe depression, having a panic attack on an elevator because of fear of crashing) and/or the adaptational consequences of the emotional reaction are negative (e.g., yelling at your boss who hasassaulted your ego may get you fired, cutting someone off in your automobile after they have done the same to you may result in a fatal accident, avoiding speaking in public because of fear of making a mistake and as a result losing your job), then the emotion may be considered pathological.

The generation of a negative emotional response depends upon the recognition that a transaction is/has/may occur that is not is not beneficial to the well-being of the person (appraisal). The generation and intensity of the emotion will also be affected by the person's perceived ability to cope with the threat. Appraisal and coping processes may be largely subjective, and thus, emotional disturbances (i.e., chronic negative emotional states) may be a result of distorted appraisal and coping processes. As a result, it becomes of paramount importance to understand each patient's idiosyncratic way of viewing themselves and the world, and the way in which they appraise situations and their perceived ability to cope.

Since many of the situations that are encountered are somewhat ambiguous, different individuals may attend to different components of any situation, leading to a range of different interpretations. As a result, individuals may experience different emotions, or degrees of emotion, depending upon their appraisal or evaluation of the situation. Thus, the process of emotion generation depends to a large degree on the nature of the person evaluating the situation. His/her expectations and beliefs (ones sense of "self" or schema) will greatly determine what gets processed, how it is appraised, and the nature and degree of emotional activation.

Consider this simple example. Michael Jordan, a remarkable basketball player who routinely averaged scoring 30 points per game, is likely to feel disappointed when he scored 15 points in a game ("I did not live up to an important life role"). However, a lesser player who averages 4 points per game is likely to feel elated when he scores 15 points in a game ("I played above my life role."). Both players score 15 points but are likely to feel different because of their prior expectations and sense of their basketball "selves."

Thus, this model of emotional disorders posits that the presence of relatively chronic, negative emotional states (i.e., emotional disorders) is an expression of the individual’s pervasive negative appraisal of their current life circumstances. More specifically, individuals suffering from emotional disorders evaluate their environment as not facilitative -- or harmful -- to their ability to survive and flourish. Environmental threats can range from threats to ones bodily integrity (e.g., the phobic patient afraid of flying on an airplane worries about being killed in a crash) to threats to ones ego or sense of self (e.g., the socially anxious patient fears speaking in front of a group because others may evaluate him/her negatively). For emotion to be generated a personal goal must be at stake, whether it be staying alive, gaining others esteem, or acquiring resources (R.S. Lazarus, 1991).

Emotional disorders can best be conceptualized as specific clusters of affect, cognitions, behaviors. For example, a patient with depression feels sad (affect), thinks he is worthless and his problems are insurmountable (cognitions), and withdraws from social relationships and activities (behaviors). Along the same line, a person afraid to use elevators will report being scared (affect), state that elevators are dangerous because one can get stuck (thought), experience increased heart rate when anticipating using elevators (physiological activation) and avoid using them (behavior).

The specific emotion generated depends upon the nature of the threat -- or more importantly the nature of the perceived threat. For example, being passed over for a promotion may be seen as a loss and lead to sadness (blames self for the loss). However, if the person believes that they were unfairly passed over, this may cause anger (blame of the loss is on someone else).

APPRAISAL PATTERNS ASSOCIATED WITH NEGATIVE EMOTIONS
The ranges of negative emotions that are often addressed in treatment have relatively specific appraisal patterns associated with them. Below, I will briefly detail the appraisal patterns for each.

ANXIETY. The cognitive appraisal pattern associated with anxiety (i.e., fear, worry, nervousness) is future threat (i.e., danger) to one's physical integrity, goal attainment, or self-esteem. This typically results in a focus on the "danger" associated with the threatening stimulus, with behavioral inclinations to escape from or avoid the stimulus.Patients suffering from various anxiety disorders (e.g., social phobia, panic disorder, obsessive compulsive disorder) have a cognitive appraisal patterns specific to the nature of each disorder. For example, the appraisal patterns of patients with social phobia focus on the risk of negative evaluation by others, that of obsessive compulsive disorder focus on the risk of being exposed to germs, and patients with panic disorder focus on his/her perceived risk of having a heart attack during a panic attack.

ANGER. Anger is the result of an appraisal that one's physical integrity, goal attainment, or self-esteem is being threatened, and someone or something is responsible. Typical appraisal patterns associated with anger contain frustrated goal attainment with a personal slight or a demeaning offense. In the generation of anger, a judgment must be made about who, if anyone, should be blamed for the frustration. If someone is accountable for the threat, then anger is directed at him/her. If the person feels personally responsible, then the anger is directed at his/her self. For many, especially those who tend to be in a relatively chronic state of anger, there is a bias towards looking for someone or something to blame for frustrated goal attainment in order to preserve one's ego and avoid anger at one's self. However, a certain level of control must be imputed to whomever is blamed for the frustration. For example, imagine being on an elevator and someone repeatedly steps on your foot. Most likely you will start to get angry, following an appraisal of something like "This person does not have any consideration for me!" (threat to self-esteem). Clearly, feeling angry seems like an appropriate response in this situation.Now, imagine turning towards the person and noticing he/she is blind -- much of the anger is likely to dissipate because less control is assigned to the person thus, his/her behavior does not appear to be because of a lack of respect.

Whether or not -- or how -- anger is expressed depends to a large degree upon one's perceived coping potential. Specifically, if an individual evaluates his/her potential for mounting a favorable attack, then retaliation (action potential) is likely. Criticism is a common form of active retaliation (attack). Otherwise, one is likely to inhibit his/her retaliatory response. However, there are other strategies that allow for the indirect expression of anger when the direct expression may be dangerous. For example, if someone else has not met one's needs, but one is unable to retaliate, pouting may occur in order to obtain succor from the other person and have one's needs met. Pouting is an attempt to get others to pay attention and give one what they want.
Pathological anger includes unrestrained and recurrent violence toward others, including verbal and physical abusiveness toward children and spouses, perpetual bitterness and unrelenting disillusionment, chronically over interpreting others actions as demeaning, and the inability to inhibit the expression of anger. Anger can often be self-defeating as the tendency to blame others rather than accepting responsibility and modifying ones behavior accordingly results in less adaptive functioning.

SADNESS. Anxiety and anger are emotions of adaptational struggle: essentially, in their nonpathological form, they facilitate avoiding (anxiety) or preventing/restoring (anger) harm, loss, or frustration of goal attainment. Sadness, on the other hand, is a reaction to loss when one perceives that efforts to restore it will fail. The loss is seen as irrevocable.Sadness is resignation rather than struggle. Common factors leading to sadness include loss of a loved one, failure of a central life value or role, or loss of the positive regard of another. Sadness, in its nonpathological form, is functional in that it moves the person toward acceptance of and disengagement from the loss. If the loss is irrevocable, no action is necessary since nothing can be done to restore the loss. For example, in the case of grief, nothing can be done to restore the deceased. Continuing to attempt ot restore the loss can ultimately be hazardous to the individual. Thus, disengagement to assist in coming to accept the loss, and moving on, is functional..

However, in its pathological form (i.e., depression), loss, or perceived loss, has been generalized to one's entire life. It is common for depressed individuals to see themselves as inadequate or defective, and they focus on their shortcomings and failures. They often believe that their lives will be filled with continuous failure -- the future offers no hope.Consequently, they do nothing to try to change circumstances that may be problematic and capable of being changed. The person sees no purpose for continuing to be engaged in living. The resulting action tendency is inaction, withdrawal.

GUILT. The emotion of guilt is generated when one believes he/she has violated a moral value that he/she wants to uphold. Guilt can be activated by wanting to, or acting in, a morally reprehensible way. The associated action tendency is to seek punishment and receive atonement.

SHAME. Shame is activated when one believes he/she has failed to live up to his/her own ideal, or that of a significant other (e.g., parent, spouse). Associated action tendency is to hide (avoid) so that others will not reject or disapprove.




THE PROCESS OF COGNITIVE THERAPY.
There are three broad phases of Cognitive Therapy. Gaining awareness of your thoughts is the first phase. You must become aware of exactly what you are "telling yourself" before you can change it. Once you have identified the thought pattern that is making you feel bad, the second phase is to examine the validity of this pattern (that is, scrutinize the accuracy of the thoughts). Typically, negative thoughts are incorrect or are an exaggeration of the truth. The third phase is to challenge" your negative thoughts by answering them back with a more accurate way of thinking that fits reality. Clients are taught to utilize this process outside of therapy sessions.

MAJOR ADVANTAGE OF COGNITIVE THERAPY
Proven Effective. There are hundreds of research studies demonstrating that Cognitive Therapy is an effective treatment. For many disorders, Cognitive Therapy is a more effective treatment than other forms of psychotherapy and equivalent to medication. In a recent review of Empirically Supported Treatments by the American Psychological Association's Division of Clinical Psychology, Task Force on Psychological Interventions, cognitive behavioral interventions were by far the most commonl to qualify as empirically supported.



PROBLEMS THAT CAN BE TREATED


DEPRESSION. The most common sign of depression is a sad mood. Other common symptoms include feelings of worthlessness, low self-esteem, hopelessness about the future, suicidal thoughts, fatigue, loss of energy, sleep difficulties, weight changes.


TREATMENT OF DEPRESSION

Research has demonstrated that an important factor in depression is that the depressed person interprets many situations incorrectly. Depressed people have continuous, unpleasant thoughts and with each negative thought the depressed feeling increases. Patients are often unaware of the thoughts they are having. These thoughts are generally not based on real facts yet make a person feel sad when there is no objective reason to feel that way. The negative thoughts may keep the depressed patient from engaging in activities that will make him feel better. The overall aim of cognitive therapy is uncover this faulty thinking pattern and change these thoughts.


ANXIETY DISORDERS

The characteristic features of anxiety disorders are feelings of fearfulness, apprehension, and nervousness in anticipation that something bad or dangerous is going to happen. Very often patients avoid situations that provoke the fear (phobic situations). There are several different anxiety disorders:

Panic Disorder (Agoraphobia): Patients with this disorder often experience panic attacks. Panic attacks are episodes of intense fear accompanied by physical symptoms such as dizziness, rapid heartbeat, chest pain, faintness, shortness of breath. Patients often believe they are dying, going crazy, or will lose control during the attack. Patients with panic disorder typically develop agoraphobia: fear and/or avoidance of certain situations (e.g., elevators, trains, stores) because they bring on panic attacks and anxiety.

Generalized Anxiety Disorder: Patients with this disorder experience persistent worry. Other common symptoms include muscle aches, restlessness, fatigue, insomnia, abdominal upset, concentration problems, edginess, and irritability.

Simple Phobia: Patients with this disorder experience irrational fear of a particular object or situation and avoid it. The most common phobias are of animals, flying, heights, and closed places.

Social Phobia: Patients with this disorder experience excessive, unreasonable fear in social situations that he or she may do something or act in a way that will be humiliating or embarrassing. The patient often avoids such situations whenever possible.

Post-Traumatic Stress Disorder: Patients with this disorder experience intense anxiety and emotional distress following a traumatic event, such as rape, assault, or wartime combat duty. Physical symptoms such as restlessness, jumpiness, insomnia are common.

Obsessive-Compulsive Disorder: Patients with this disorder experience recurrent obsessions (thoughts, ideas, images that are intrusive and senseless) and/or compulsions (repetitive behaviors performed in response to an obsession).


TREATMENT OF ANXIETY DISORDERS

Cognitive Therapy uses various cognitive and behavioral techniques to treat anxiety disorders. Cognitive restructuring attempts to alter the way a person thinks about certain circumstances that trigger his/her fear or anxiety. Cognitive restructuring is intended to change the thought patterns that cause anxiety. Relaxation Training and Breathing Exercises are often used to provide anxious patients with a strategy to decrease their symptoms, especially in stressful situations. During Exposure Therapy, patients follow a gradual, systematic plan to learn to use anxiety management strategies to cope with phobic situations.


LONGER-TERM PROBLEMS:

Schema Focused Therapy, a form of Cognitive Therapy, was developed by Dr. Jeffrey Young to deal more effectively with lifelong personality problems. Such problems include chronic low self-esteem and feelings of inadequacy, loneliness, dependence on others, mistrust, an undeveloped sense of self, constricted emotions, problems choosing appropriate partners, and failure ot fulfill one's potential in school or career. Compared to standard Cognitive Therapy, Schema Focused Therapy looks more deeply into childhood origins and problems, uses more imagery and emotive techniques, and is longer-term. However, Schema Focused Therapy uses all the techniques of standard Cognitive Therapy, and keeps the practical, focused, problem-solving approach.


Other Problems That Are Effectively Treated With Cognitive Therapy:Eating Disorders, Anger Problems, Procrastination, Bereavement, Assertiveness, Stress-Disorders, Hypochondriasis, Sexual Problems, Psychosomatic Disorders, Marital & Relationship Problems.

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