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Cognitive Therapy

Abstract and Keywords

Cognitive therapy is a perspective on social work intervention with individuals, families, and groups that focuses on conscious thought processes as the primary determinants of most emotions and behaviors. It has great appeal to social work practitioners because of its utility in working with many types of clients and problem situations, and its evidence-based support in the literature. Cognitive therapies include sets of strategies focused on education, a restructuring of thought processes, improved coping skills, and increased problem-solving skills for clients.

Keywords: cognitive theory, cognitive therapy, direct social work practice, evidence-based practice, automatic thoughts, causal attributions, cognition, cognitive deficits, cognitive distortions, cognitive coping, cognitive restructuring, problem-solving, schema, Socratic questioning

Definition and Description

Cognitive therapy is a direct practice modality that is focused on enhancing the rationality of clients' thinking patterns, or the degree to which conclusions about the self and the world are based on external evidence (Lantz, 1996). Cognitive therapy asserts that conscious thinking is the basis for most human behavior and emotional experience. Cognitions include a person's beliefs, assumptions, and expectations about the causes of events, attitudes, and perceptions. Cognitive theory postulates that people develop habits of thinking that form the basis for their screening and coding of environmental input, categorizing and evaluating experience, and judgments about how to behave. Emotions are defined within this theory as physiological responses that follow cognitive evaluation of input (Lazarus & Lazarus, 1994). The relationship between thoughts, feelings, and behaviors is such that an activating event produces a belief or thought that in turn produces an emotion or action (Beck, 1995).

A central concept in cognitive theory is that of the schema, defined as a person's internalized representation of the world, or patterns of thought, action, and problem solving (Granvold, 1994). Schemas include the ways people organize thought processes and process new information, and the products of those operations (knowledge). They develop through direct learning (personal experience) or social learning (watching and absorbing the experiences of others). When a person encounters a new situation he or she either assimilates it to “fit” the existing schema, or accommodates it, changing the schema. A flexible schema is desirable, but all schemas tend to be somewhat rigid by nature. Core beliefs (schemas) are not “correct” or “incorrect” as much as they are functional or nonfunctional for one's ability to achieve his or her goals. “Rational” thinking in cognitive theory can be understood as thinking that is based on external evidence, is life preserving, keeps one directed toward personal goals, and decreases internal conflicts (Ellis & McLaren, 1998).

Major Developers and Contributors

Cognitive therapy's influences include 20th-century developments in American philosophy, information processing theory, and social learning theory. American philosophers have always tended to evaluate ideas with reference to practical applications (Kurtz, 1972). One example is John Dewey (1938), who wrote that when a person experiences conflicts in understanding, the natural response is to initiate a process of “inquiry.” Dewey maintained that ideas are arrived at through plans of action evaluated for “truth” by their consequences. His work influenced the systematic procedures seen in the problem-solving model, described later in this entry. Logical positivism is another major philosophical movement that became prominent in the United States in the 1930s (Popper, 1968). The positivists perceived the task of philosophy to be the analysis and clarification of meaning, and they looked to logic and the sciences as their models for constructing formally perfect languages. They were critical of ideas that could not be empirically tested.

The advances in computer and information technology were particularly influential in the development of a “science of cognition” in the social sciences (Bara, 1995). Human service practitioners became interested in how people processed information and in correcting cognitive “errors.” Information processing theory established that people receive stimulation from the outside and code this with sensory receptors in the nervous system (Ingram, 1986). Information is integrated and stored for purposes of present and future adaptation to the environment. People develop increasingly sophisticated problem-solving processes through the evolution of cognitive patterns that enable them to attend to particular inputs as significant.

American psychologist George Kelly (1963) introduced a theory of personality in the late 1950s according to which a person's core tendency is to attempt to predict and control the events of experience. He described the essence of human nature as the scientific pursuit of truth—an engagement in the empirical procedure of formulating hypotheses and testing them in the tangible world. This “truth” represents a state in which perceptions are consistent with a person's internal construct system. Kelly's model of the “person as empirical scientist” influenced the ideas of cognitive theorists who followed him, including therapists Albert Ellis and Aaron Beck.

Ellis published Reason and Emotion in Psychotherapy in 1962. He believed that people can consciously adopt principles of reasoning, and he viewed the client's underlying assumptions about himself or herself and the world as targets for intervention. The major theme of Ellis's work is that behind most distressing emotions one can find irrational beliefs about how things should or must be. Ellis's therapy involved helping people become more “reasonable” about how they approached their problems. Cognitive therapy became more prominent with the publication of Beck's Cognitive Therapy and the Emotional Disorders in 1976. Beck was interested in the problem of depression, and his observations led him to conclude that depressed people maintain negative biases and memory structures featuring themes of personal ineffectiveness, personal degradation, and the world as an essentially unpleasant place. Cognitive therapy became an established modality in the social work profession through the writings of such scholars as Berlin (2002), Corcoran (2006), Granvold (1994), and Lantz (1978).

Demographics and Current Applications

Cognitive therapy is applicable to people aged 12 years and older because recipients must be able to engage in abstract thought. Some adults with cognitive limitations such as mental retardation, dementia, and some psychotic disorders may not be responsive to the approach. To benefit from cognitive interventions, clients must also be able to follow through with directions, not require an intensely emotional encounter with the social worker, demonstrate stability in some life activities, and not be in an active crisis (Lantz, 1996).

Current Change Philosophy and Techniques

According to cognitive theory, many problems in living result from misconceptions—conclusions that are based more on habits of thought rather than external evidence—that people have about themselves, other people, and their life situations. These misconceptions may develop for any of three reasons. The first is the simplest: the person has not acquired the information necessary to manage a new situation. This is often evident in the lives of children and adolescents, who face many situations at school, at play, and with their families that they have not experienced before. This lack of information is known as a cognitive deficit, and can be remedied with education.

Secondly, problems may be related to causal attributions, three kinds of assumptions that people hold about themselves in relation to the environment. A person might function from premises that life situations are more or less changeable (I'm unhappy with my job, and there is nothing that can be done about it), sources of power to make changes exist either within or outside the self, (Only my supervisor can do anything to make my job better), or the implications of his or her experiences are limited to the specific situation or are global. (My supervisor didn't like how I managed that client with a substance abuse problem. He doesn't think I can be a good practitioner.)

The final sources of misperceptions are cognitive distortions. Because of the tendency to develop thinking habits, people often interpret new situations in biased ways. These patterns are generally functional because many situations people face in life are similar to previous ones and can be managed with patterned responses. These habits become a source of difficulty, however, when they are too rigid to accommodate new information. For example, a low-income community resident may believe that he lacks the ability to advocate for certain medication benefits and, as a result, continues to live without them. This belief may be rooted in a distorted sense that other people will never respect him. The client may have had real difficulties over the years with failure and discrimination, but the belief that this will happen in all circumstances in the future may be arbitrary.

Cognitive theory interventions can help clients change in three ways. Clients can change their personal goals to become more consistent with their capabilities, adjust their cognitive assumptions (beliefs and expectations), or change their habits of thinking (which includes giving up cognitive distortions). The practitioner functions as a collaborator in determining change strategies with the client, and educates the client in the logic of cognitive theory. The social worker may further serve as a model of rational thinking and problem solving, or as a coach, leading the client through a process of guided reasoning. The social worker assesses the validity of a client's assumptions associated with a problem issue through focused questioning, known as Socratic questioning (Granvold, 1994). The social worker focuses on the following questions:

  • What are the client's core beliefs relative to the presenting problem?

  • What is the logic behind the client's beliefs regarding the significance of the problem situation?

  • What is the evidence to support the client's views?

  • What other explanations for the client's perceptions are possible?

  • How do particular beliefs influence the client's attachment of significance to specific events, emotions, and behaviors?

When a client's perceptions and beliefs seem valid, the practitioner intervenes by providing education about the presenting issue and implementing problem-solving or coping exercises. When the client exhibits significant cognitive distortions, the practitioner and client work to identify the situations that trigger the misconceptions, determine how they can be most efficiently adjusted or replaced with new thinking patterns, and then implement corrective tasks. Strategies for cognitive intervention fit into three general categories as described below.

Cognitive Restructuring

Cognitive restructuring is used when the client's thinking patterns are distorted and contribute to problem development and persistence (Emery, 1985). The social worker helps the client experiment with alternative ways of approaching challenges that will promote goal attainment. The ABC model is the basis of the cognitive restructuring approach. “A” represents an activating event; “B” is the client's belief about, or interpretation of, the event; and “C” is the emotional and behavioral consequence of B. For example, if A is an event (the hiring of a new colleague) and C, the consequence, is the person's feeling of depression, then the B (belief) might be: “He'll be a much better social worker than I am.” If the same activating event occurs, but the resulting emotion (consequence, or C) is contentment, the client's belief might be: “How nice to have someone to share the workload and learn from!”

In order to change a client's belief systems, three steps are necessary. The first is to help the person identify the thoughts preceding and accompanying the distressing emotions and nonproductive actions. The second step is to assess the client's willingness to consider alternative thoughts in response to the problem situation. One means of addressing this is the cost-benefit analysis, in which the social worker asks the client to consider the costs and benefits of maintaining his or her current beliefs pertaining to the problem (Leahy, 1996). The third step is to challenge the client's irrational beliefs by designing tasks that he or she can carry out in daily life. For instance, if a college student believes that if she speaks out in class everyone will laugh at her, she might be asked to volunteer one answer in class to see the reactions of others. By changing clients' actions, their cognitions and emotions may be indirectly modified, as the actions may provide new data to refute automatic beliefs about themselves and the world.

Cognitive Coping

A second category of interventions is cognitive coping. The practitioner helps the client learn and practice new or more effective ways of dealing with stress and negative moods. Cognitive coping involves education and skills training that target both covert and overt cognitive operations with the goal of helping clients become more effective at managing their challenges. Clients can modify their cognitive distortions when they experience positive results from practicing new coping skills.

Self-instruction skills development gives clients an internal cognitive framework for instructing themselves in how to cope more effectively with problem situations (Meichenbaum, 1999). It is based on the premise that many people, as a matter of course, engage in internal speech as a means of thinking. Some people have a lack of positive cues in their self-dialogue. Having a prepared internal (or written) script for problem situations can help a client recall and implement a coping strategy. When using this technique, the social worker assesses the client's behavior and its relationship to deficits in subvocal dialogue. The client and social worker develop a step-by-step self-instruction script, including overt self-directed speech, following their plan for confronting a problem. With practice the client gradually moves from overt self-dialogue to covert self-talk.

Communication skills development covers a wide spectrum of interventions that includes attention to clients' social, assertive, and negotiation skills. Positive communication builds relationships and closeness with others, which in turn help improve moods and feelings about oneself (Hargie, 1997). The components of communication skills training include using “I” messages, reflective and empathic listening, and making clear behavior change requests. “I” messages are those in which a person talks about his or her own position and feelings in a situation, rather than making accusatory comments about another person. Listening skills include both reflective listening and validation of the other person's intent. It decreases the tendency of people to draw premature conclusions about the meaning of another's statement (Brownell, 1986). Reflective listening involves paraphrasing back the content of the speaker's message. This conveys that, given the other person's perspectives and assumptions, his or her experiences are legitimate and understandable (“I can see that if you were thinking I had done that, you would feel that way”). A third component of communication skills training involves teaching people to make clear behavior requests of others. Such requests should always be specific, measurable, and stated in terms of positive behavior rather than the absence of negative behavior.

There are a variety of other social skills that can be taught in cognitive therapy. The process always involves teaching clients about the utility of such skills, breaking them down into discrete steps, practicing those steps, and encouraging the client's implementation of new behaviors in the social environment.

Problem-Solving Skills Development

The third category of cognitive intervention is problem solving. This is a structured, five-step method for helping clients who do not experience distortions but nevertheless struggle with how to manage their problems and challenges. Clients learn how to produce a variety of potentially effective responses to their problems through the following steps (McClam & Woodside, 1994):

  • Clearly defining the problem that the client wishes to overcome.

  • Brainstorming to generate as many possible solutions for a problem as the client can imagine. Spontaneity and creativity are encouraged. All possibilities are written down, even those that initially seem impossible or silly.

  • Evaluating the alternatives. Any patently irrelevant or impossible items are crossed out. Each viable alternative is then discussed as to its advantages and disadvantages.

  • Choosing and implementing an alternative by selecting a strategy that appears to maximize benefits over costs. Although the outcome of any alternative is always uncertain, the client is praised for exercising good judgment in the process.

  • Evaluate the implemented option. If successful, the process is complete. “Failures” must be examined closely for elements that may have gone well. If a strategy has not been successful, it can be attempted again with adjustments or the social worker and client can go back to the fourth step and select another option.

Evidence-Based Practice

Cognitive therapy is supported as effective in numerous literature reviews. Chambless (1998) compiled a list of validated cognitive interventions using the American Psychiatric Association's criteria for well-established or probably efficacious interventions. Chambless includes well-established cognitive interventions for depression and well-established cognitive-behavioral interventions for panic disorder, generalized anxiety disorder, bulimia, pain associated with rheumatic disease, and relapse prevention in smoking cessation. Probably efficacious cognitive interventions are described for obsessive-compulsive disorder, opiate dependence, geriatric depression, social problem solving, and couples' communication training as an adjunct to the treatment of agoraphobia, social phobia, relapse prevention in cocaine dependence, benzodiazepine withdrawal in persons with panic disorder, social skills training for persons with alcohol dependence, binge eating disorder, chronic pain, childhood anxiety, and social skills for persons with schizophrenia.

A number of meta-analyses of the professional literature produced between 2002 and 2007 provide further evidence of the effectiveness of cognitive interventions for a variety of psychological problems. These analyses support the effectiveness of cognitive interventions with families in the mental status improvement of a relative with schizophrenia (Pilling et al., 2002), and in group settings for general symptom alleviation (Petrocelli, 2002). The meta-analyses also support their effectiveness with recovery from social phobia (Gould & Johnson, 2002), eating disorders (Wilson & Fairburn, 2002), and insomnia (Bootzin, 2001). Cognitive-behavioral interventions also reduce the recidivism of legal offenders (Pearson, Lipton, Cleland, & Yee, 2002) and the severity of hallucinations and delusions in persons with psychotic disorders (Haddock et al., 1998). They consistently increase the social competence of children and adolescents in school settings (Topping, Holmes, & Bremmer, 2000).

Another recent literature review of 14 meta-analyses covering 325 studies provides a summary of the research on cognitive interventions (Butler & Beck, 2001). It was found that cognitive therapy was substantially superior to no treatment, waiting list, and placebo controls for adult and adolescent depression, generalized anxiety disorder, panic disorder (with or without agoraphobia), social phobia, and childhood depressive and anxiety disorders. Cognitive interventions were moderately superior in the treatment of marital distress, anger, childhood somatic disorders, and chronic pain. Cognitive therapies were somewhat superior to antidepressant medication in treating adult depression. A year after treatment discontinuation, depressed clients treated with cognitive therapy had half the relapse rate of depressed persons who had been treated with antidepressants. Cognitive therapy was equally effective as behavior interventions in the treatment of adult depression and obsessive compulsive disorder. In the small number of direct comparisons with supportive and nondirective therapy (two for adolescent depression and two for generalized anxiety disorder), cognitive therapies were superior. They were somewhat superior to miscellaneous psychosocial treatments for sexual offending.

Distinctiveness and Integration

Since the late 1960s, social workers have successfully integrated techniques from cognitive theory with strategies from other approaches. With its focus on practicality, precision in problem definition, and outcome measurement, it fits perhaps most obviously with behavioral therapy, as clients can integrate reinforcement systems as they experiment with new activities related to their adjusted thought processes (Thyer & Wodarski, 2007). With its recognition of the person's active construction of reality, it also fits well with postmodern approaches to therapy such as narrative therapy (Williams, 2006). It also fits well with solution-focused therapy, another therapy approach that is concerned with concrete, practical change strategies and respecting the client's personal perspectives on his or her reality (De Jong & Berg, 2002). Finally, cognitive therapy can be incorporated into the structural family intervention approach, as it considers communication skills and the rationality of the functions of family power, rules, roles, and boundaries.

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                                                                    Topping, K., Holmes, E. A., & Bremmer, W. (2000). The effectiveness of school-based programs for the promotion of social competence. In R. Bar-On & D. A. Parker (Eds.), The handbook of emotional intelligence: Theory, development, assessment, and applications at home, school, and in the workplace (pp. 411–432). San Francisco, CA: Jossey-Bass.Find this resource:

                                                                      Williams, N. R. (2006). Narrative family interventions. In A. C. Kilpatrick & T. C. Holland (Eds.), Working with families: An integrative model by level of need (4th ed., pp. 194–219). Boston: Allyn & Bacon.Find this resource:

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                                                                          Further Reading

                                                                          Aponte, H. J., & DiCesare, H. J. (2000). Structural theory. In F. M. Dattilio & L. J. Bevilacqua (Eds.), Comparative treatments for relationship dysfunction (pp. 45–57). New York: Springer.Find this resource:

                                                                            Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Hoeber.Find this resource:

                                                                              Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991). Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167–175.Find this resource:

                                                                                Ellis, P. M., Hickie, I. B., & Smith, D. A. R. (2003). Summary of guidelines for the treatment of depression. Australasian Psychiatry, 11(1), 34–38.Find this resource:

                                                                                  Kelley, P. (1996). Narrative theory and social work practice. In F. Turner (Ed.), Social work treatment (4th ed., pp. 461–479). New York: Free Press.Find this resource:

                                                                                    Walsh, J. (2006). Theories for direct social work practice. Pacific Grove, CA: Brooks/Cole.Find this resource:

                                                                                      The Academy of Cognitive Therapy. http://www.academyofct.org/Library/InfoManage/Guide.asp?FolderID=1001

                                                                                      The American Institute for Cognitive Therapy. http://www.cognitivetherapynyc.com/Information for Practice: Cognitive therapy http://google.nyu.edu/search?site=NYUWeb_Main&client=NYUWeb_Main&output=xml_no_dtd&proxyreload=1&poxystylesheet=gh_ipblog&sitesearch=www.nyu.edu%2Fsocialwork%2Fip&q=cognitive±therapy

                                                                                      The International Association for Cognitive Therapy. http://www.cognitivetherapyassociation.org/index.aspx