Cognitive Therapy

Cognitive therapy rests upon the assumption that problematic behaviors result from the core schemas (beliefs) that developed in response to prior life experiences. Therapy participants are taught that these core schemas are not necessarily "The Truth" but merely reflect beliefs that were developed over time; typically through childhood experiences and parental influence. The goal of treatment is to identify, challenge, and replace these automatic thoughts and dysfunctional thinking patterns; and ultimately, to change the core schema that is at the root of dysfunctional thoughts.

These automatic, dysfunctional thinking patterns are often called cognitive distortions and can result in anxious feelings. Examples of cognitive distortions include:

(1) All or nothing thinking: anxiety can result when things are seen in terms of extremes and absolutes because most things have shades of grey. The thought, "If I am not perfect, then I am worthless," can create anxiety because it is impossible to be perfectly perfect.

(2) Fortune telling: anxiety can result when attempting to predict the future without adequate information by assuming a negative outcome is certain to occur, such as "I'll never find a boyfriend." A rather extreme version of fortune-telling is often called "catastrophizing," when the predicted future event is expected to result in some catastrophe.

(3) Emotional reasoning: anxiety may develop when feelings are considered an accurate and factual reflection of a situation. For instance, the thought "My feelings are hurt, therefore you must have done something unkind to me," could easily provoke an argument full of false accusations. Clearly, there are many reasons someone's feelings may get hurt that may have nothing to do with actions of another person. Afterwards, when logic is applied (feelings do not depict facts), the person may feel guilty and anxious about their unfounded accusations and hostile behavior.

4) Should statements: anxiety is often created when evaluating and judging oneself based upon what one "should" be doing, or should be feeling. For example, "I should be clean and tidy at all times" can result in a standard that is impossible to achieve.

In addition to examining and evaluating cognitive distortions, cognitive therapy also assists participants to examine and challenge their appraisal of an anxiety-provoking event. This emphasis evolves from cognitive appraisal theory which posits that our emotions are determined, in part, by our cognitive appraisal (subjective evaluation) of a particular circumstance. Thus, in any given situation a person must judge whether the situation poses any danger or not; then the person evaluates whether their resources for coping with the situation are adequate. For more information about cognitive appraisal theory, refer to the Biopsychosocial Model.

Our cognitive appraisals are strongly influenced by our core beliefs. For instance, suppose Jamal grew up in an environment where his parents did not adequately protect him. He may develop a core belief, "The world is an unsafe place." Such a belief will likely cause Jamal to over-estimate the threat of a particular situation. In addition, if Jamal's parents angrily and impatiently corrected his mistakes, Jamal might develop another core schema, "I am inadequate and incompetent." This core belief might lead Jamal to under-estimate his ability to cope with challenging situations. Indeed, the over-estimation of threat, and under-estimation of coping resources are commonly associated with anxiety disorders. For instance, when someone is having a panic attack, they may think, "Oh my gosh, I'm having a heart attack. I'm going to die!" Such an appraisal is likely to increase anxiety. Next, the person may become aware there is no one available to help them; thus, they appraise their resources for coping with this circumstance to be inadequate. This appraisal will further increase anxiety. Cognitive therapy would assist such a person to more accurately appraise their symptoms and to improve their coping skills, in order to reduce the escalation of anxious symptoms. Specific applications of this approach are discussed in the Treatment of Anxiety Disorders Section.

Cognitive therapy is collaboration between the therapist and therapy participant that systematically examines and challenges the dysfunctional thoughts and beliefs contributing to anxiety symptoms. Different anxiety disorders are associated with certain characteristic types of dysfunctional thoughts. For example, people with Obsessive-Compulsive Disorder might believe that their thoughts must be controlled at all times, and that the world is a dangerous place. Individuals with Social Phobia might believe that they are inadequate and inferior to others.

There are numerous specific techniques to challenge dysfunctional thinking patterns, but the first step is to assist the therapy participant identify their internal mental dialogue which will reveal these dysfunctional patterns. This is accomplished by asking therapy participants to record their internal dialog on homework sheets. Many people are unaware that their mind is constantly evaluating and judging their surrounding environment, and themselves. Next, the therapist guides the participant to challenge their dysfunctional thoughts by questioning their validity, and to form statements that are more accurate. When these dysfunctional thoughts occur again, the therapy participant consciously replaces the dysfunctional thought with a more accurate statement or belief. For example, Jamal might learn to replace the belief, "I am a failure" with the thought, "I may have failed in the past, but when I try my best, I often succeed." Cognitive therapy research has demonstrated that when these dysfunctional thoughts are corrected, people feel better and their behavior improves as well.

Cognitive therapy emphasizes the element of choice and this emphasis extends to the therapy itself. This emphasis is particularly important for anxiety disorder treatment. You may recall that one of the psychological variables that increase anxiety is the lack of perceived control. INSERT LINKp.17 Therefore, a therapy participant would be asked to reframe the thought, "I must do these therapy exercises because my therapist says I should" to "I choose to recover from this disorder; therefore, I choose to do these exercises." This slight shift in perspective is very important as it empowers therapy participants to develop the willingness to participate in some of the more uncomfortable behavioral exercises such as exposure and response prevention.

Cognitive therapy has wide ranging applications, and many people are able to benefit from this approach in less than 10 sessions. Cognitive therapy is an evidenced-based treatment, meaning there are numerous studies to support its effectiveness. Studies have even demonstrated that cognitive therapy can be as effective as anti-depressant medications for treating depression (Derubeis et al., 2005). In fact, cognitive therapy significantly reduces relapse rates when added to medication treatment (Bockting, et al., 2005). Cognitive therapy for anxiety disorders is similarly effective (Abramowitz, Franklin, & Foa, 2002; Franklin, Foa, & Kozak, 1998), although medication can be a valuable and necessary adjunct to treatment. For more information about medications please refer to the Adjunct Therapy section on pharmacologic treatments.

Authors Statement: Established in 1979, the Bio Behavioral Institute is a psychological and psychiatric clinic dedicated to the treatment and research of anxiety and mood disorders. Based in Long Island, NY, USA, the institute serves both a local and international clientele. Our staff have over 40 years of experience treating anxiety and mood disorders and have been at the forefront of scientifically supported treatments for anxiety disorders for many years. We offer a variety of programs provided by a multidisciplinary team of professionals. For more information, please visit us online at www.biobehavioralinstitute.com or view Bio Behavioral Institute and author biographical information on this website.