Psychotherapy: Cognitive and Cognitive-Behavioral Therapy

Cognitive therapy is a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress. They help a client see how they misinterpret a situation (cognitive distortion). For example, a client may overgeneralize. Because Ray failed one test in his Psychology 101 course, he feels he is stupid and worthless. These thoughts then cause his mood to worsen. Therapists also help clients recognize when they blow things out of proportion. Because Ray failed his Psychology 101 test, he has concluded that he’s going to fail the entire course and probably flunk out of college altogether. These errors in thinking have contributed to Ray’s feelings of distress. His therapist will help him challenge these irrational beliefs, focus on their illogical basis, and correct them with more logical and rational thoughts and beliefs.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979)(Figure 1). Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things (Beck, 2011).

One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). Behaviorists such as Joseph Wolpe also influenced Ellis’s therapeutic approach (National Association of Cognitive-Behavioral Therapists, 2009). During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the U.S. Over time, cognitive-behavioral therapy came to be known not only as a therapy, but as an umbrella category for all cognitive-based psychotherapies.

Cognitive-behavioral therapy (CBT) helps clients examine how their thoughts affect their behavior. It aims to change cognitive distortions and self-defeating behaviors. For example, if it’s your first time meeting new people, you may have the automatic thought, “These people won’t like me because I have nothing interesting to share.” That thought itself is not what’s troublesome; the appraisal (or evaluation) that it might have merit is what’s troublesome. The goal of CBT is to help people make adaptive, instead of maladaptive, appraisals (e.g., “I do know interesting things!”). This technique of reappraisal, or cognitive restructuring, is a fundamental aspect of CBT. With cognitive restructuring, it is the therapist’s job to help point out when a person has an inaccurate or maladaptive thought, so that the patient can either eliminate it or modify it to be more adaptive. In essence, this approach is designed to change the way people think as well as how they act.

In total, hundreds of studies have shown the effectiveness of cognitive-behavioral therapy in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse (Beck Institute for Cognitive Behavior Therapy, n.d.). For example, CBT has been found to be effective in decreasing levels of hopelessness and suicidal thoughts in previously suicidal teenagers (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). Cognitive-behavioral therapy has also been effective in reducing PTSD in specific populations, such as transit workers (Lowinger & Rombom, 2012).

Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors using techniques like the ABC model. With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief. Let’s say, Jon and Joe both go to a party. Jon and Joe each have met a young woman at the party: Jon is talking with Megan most of the party, and Joe is talking with Amanda. At the end of the party, Jon asks Megan for her phone number and Joe asks Amanda. Megan tells Jon she would rather not give him her number, and Amanda tells Joe the same thing. Both Jon and Joe are surprised, as they thought things were going well. What can Jon and Joe tell themselves about why the women were not interested? Let’s say Jon tells himself he is a loser, or is ugly, or “has no game.” Jon then gets depressed and decides not to go to another party, which starts a cycle that keeps him depressed. Joe tells himself that he had bad breath, goes out and buys a new toothbrush, goes to another party, and meets someone new.

Jon’s belief about what happened results in a consequence of further depression, whereas Joe’s belief does not. Jon is internalizing the attribution or reason for the rebuffs, which triggers his depression. On the other hand, Joe is externalizing the cause, so his thinking does not contribute to feelings of depression. Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions. In overgeneralization, someone takes a small situation and makes it huge—for example, instead of saying, “This particular woman was not interested in me,” the man says, “I am ugly, a loser, and no one is ever going to be interested in me.”

All or nothing thinking, which is a common type of cognitive distortion for people suffering from depression, reflects extremes. In other words, everything is black or white. After being turned down for a date, Jon begins to think, “No woman will ever go out with me. I’m going to be alone forever.” He begins to feel anxious and sad as he contemplates his future.

The third kind of distortion involves jumping to conclusions—assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence. Consider the example of Savannah and Hillaire, who recently met at a party. They have a lot in common, and Savannah thinks they could become friends. She calls Hillaire to invite her for coffee. Since Hillaire doesn’t answer, Savannah leaves her a message. Several days go by and Savannah never hears back from her potential new friend. Maybe Hillaire never received the message because she lost her phone or she is too busy to return the phone call. But if Savannah believes that Hillaire didn’t like Savannah or didn’t want to be her friend, she is demonstrating the cognitive distortion of jumping to conclusions.

How effective is CBT? One client said this about his cognitive-behavioral therapy:

I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counseling, have helped [me] to cope with the symptoms and to get some insights into the roots of my problems. CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis. (Martin, 2007, n.p.)