Cognitive Behavior Therapy
Theories Counsel & Psychotherapy
William A. Whitcraft
Developed by Aaron Temkin Beck (born July 18, 1921) (wikipedia.cm, 2014), Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT), is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. Therapists help clients to overcome their difficulties by changing their thinking, behavior, and emotional responses.
Cognitive behavioral therapy (CBT) is a form of treatment that focuses on examining the relationships between thoughts, feelings, and behaviors. By exploring patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts, people with mental illness can modify their patterns of thinking to improve coping. CBT is a type of psychotherapy that is different from traditional psychodynamic psychotherapy in that the therapist and the patient will actively work together to help the patient recover from their mental illness. People who seek CBT can expect their therapist to be problem-focused, and goal-directed in addressing the challenging symptoms of mental illnesses. Because CBT is an active intervention, one can also expect to do homework or practice outside of sessions.
A person who is depressed may have the belief, “I am worthless,” and a person with panic disorder may have the belief, “I am in danger.” While the person in distress likely believes these to be ultimate truths, with a therapist’s help, the individual is encouraged to challenge these irrational beliefs. Part of this process involves viewing such negative beliefs as hypotheses rather than facts and to test out such beliefs by “running experiments.” Furthermore, people who are participating in CBT are encouraged to monitor and write down the thoughts that pop into their minds (called “automatic thoughts”). This allows the patient and their therapist to search for patterns in their thinking that can cause them to have negative thoughts which can lead to negative feelings and self-destructive behaviors.
Scientific studies of CBT have demonstrated its usefulness for a wide variety of mental illnesses including mood disorders, anxiety disorders, personality disorders, eating disorders, substance abuse disorders, sleep disorders, and psychotic disorders. Studies have shown that CBT actually changes brain activity in people with mental illnesses who receive this treatment, suggesting that the brain is actually improving its functioning as a result of engaging in this form of therapy. (NAMI, 2012, Web)
The Basic Philosophies
Individuals tend to incorporate faulty thinking, which leads to emotional and behavioral disturbances. Cognitions are the major determinants of how we feel and act. Therapy is primarily oriented toward cognition and behavior, and it stresses the role of thinking, deciding, questioning, doing, and redeciding. This is a psychoeducational model, which emphasizes therapy as a learning process, including acquiring and practicing new skills, learning new ways of thinking, and acquiring more effective ways of coping with problems. (Corey, 15.1)
The philosophical traditions of examining how the individual constructs reality and how subjective experience is a valid subject of inquiry are the cornerstones of cognitive therapy. One could say that cognitive theory is derived from both the empiricism of the British associationists and the subjectivism of the phenomenological school. These traditions are integrated with what I would call “dynamic structuralism”—that is, the recognition that the structures of experience (schemas) are continuously modified by the individual’s interactions with reality. (Lehey
Although psychological problems may be rooted in childhood, they are reinforced by present ways of thinking. A person’s belief system is the primary cause of disorders. Internal dialogue plays a central role in one’s behavior. Clients focus on examining faulty assumptions and misconceptions and on replacing these with effective beliefs. (Corey, 15.2)
Goals of Therapy
The goals of cognitive therapy are to help individuals achieve a remission of their disorder and to prevent relapse. Much of the work in sessions involves aiding individuals in solving their real-life problems and teaching them to modify their distorted thinking, dysfunctional behavior, and distressing effect. Therapists plan treatment on the basis of a cognitive formulation of patients’ disorders and an ongoing individualized cognitive conceptualization of patients and their difficulties. A developmental framework is used to understand how life events and experiences led to the development of core beliefs, underlying assumptions, and coping strategies, particularly in patients with personality disorders.
A strong therapeutic alliance is a key feature of cognitive therapy. Therapists are collaborative and function as a team with patients. They provide rationales and seek patients’ agreement when undertaking interventions. They make mutual decisions about how time will be spent in a session, which problems will be discussed, and which homework assignments patients believe will be helpful. They engage patients in a process of collaborative empiricism to investigate the validity of the patient’s thoughts and beliefs.
Cognitive therapy is educative, and patients are taught cognitive, behavioral, and emotional-regulation skills so they can, in essence, become their own therapists. This allows cognitive therapy to be time-limited for many patients; those with straightforward cases of anxiety or unipolar depression often need only 6 to 12 sessions. Patients with personality disorders, comorbidity, or chronic or severe mental illness usually need longer courses of treatment (6 months to 1 year or more) with additional periodic booster sessions.
Cognitive therapists elicit patients’ goals at the beginning of treatment. They explain their treatment plan and interventions to help patients understand how they will be able to reach their goals and feel better. At every session, they elicit and help patients solve problems that are of greatest distress. They do so through a structure that seeks to maximize efficiency, learning, and therapeutic change. Important parts of each session include a mood check, a bridge between sessions, prioritizing an agenda, discussing specific problems and teaching skills in the context of solving these problems, setting of self-help assignments, summary, and feedback. (Beck Inst., 2014, web)
The Therapeutic Relationship
In REBT the therapist functions as a teacher and the client as a student. The therapist is highly directive and teaches clients an A-B-C model of changing their cognitions. In CT the focus is on a collaborative relationship. Using a Socratic dialogue, the therapist assists clients in identifying dysfunctional beliefs and discovering alternative rules for living. The therapist promotes corrective experiences that lead to learning new skills. Clients gain insight into their problems and then must actively practice changing self-defeating thinking and acting. (Corey, 15.4)
Techniques of Therapy
Therapists use a variety of cognitive, emotive, and behavioral techniques; diverse methods are tailored to suit individual clients. This is an active, directive, time-limited, present-centered, psycho-educational, structured therapy. Some techniques include engaging in Socratic dialogue, collaborative empiricism, debating irrational beliefs, carrying out homework assignments, gathering data on assumptions one has made, keeping a record of activities, forming alternative interpretations, learning new coping skills, changing one’s language and thinking patterns, role-playing, imagery, confronting faulty beliefs, self-instructional training, and stress inoculation training. (Corey, 15.5)
Applications of the Approaches
Applications of the Approaches have been widely applied to treatment of depression, anxiety, relationship problems, stress management, skill training, substance abuse, assertion training, eating disorders, panic attacks, performance anxiety, and social phobias. CBT is especially useful for assisting people in modifying their cognitions. Many self-help approaches utilize its principles. CBT can be applied to a wide range of client populations with a variety of specific problems. (Corey, 15.6) (Clark, D.A., & Beck, A.T. 2010).
Contributions to Multicultural Counseling
The focus is on a collaborative approach that offers clients opportunities to express their areas of concern. The psycho-educational dimensions are often useful in exploring cultural conflicts and teaching a new behavior. The emphasis on thinking (as opposed to identifying and expressing feelings) is likely to be acceptable to many clients. The focus on teaching and learning tends to avoid the stigma of mental illness. Clients may value the active and directive stance of the therapist. (Corey, 15.7)
Limitations in Multicultural Counseling
Before too quickly attempting to change the beliefs and actions of clients, it is essential for the therapist to understand and respect their world. Some clients may have serious reservations about questioning their basic cultural values and beliefs. Clients could become dependent on the therapist for deciding what are appropriate ways to solve problems. (Corey, 15.8)
Contributions of the Approaches
Major contributions include an emphasis on a comprehensive and eclectic therapeutic practice; numerous cognitive, emotive, and behavioral techniques; an openness to incorporating techniques from other approaches; and a methodology for challenging and changing faulty thinking. Most forms can be integrated into other mainstream therapies. REBT makes full use of action-oriented homework, various psycho-educational methods, and keeping records of progress. CT is a structured therapy that has a good track record for treating depression and anxiety in a short time. (Corey, 15.9)
Limitations of the Approaches
Tends to play down emotions, does not focus on exploring the unconscious or underlying conflicts, de-emphasizes the value of insight, and sometimes does not give enough weight to the client’s past. REBT, being a confrontational therapy, might lead to premature termination. CBT might be too structured for some clients. (Corey, 15.10)
It is this authors belief, that we will see an overwhelming increase in the need for the therapist to deal with the aging baby boomer population, for matters of depression, anxiety, and senile dementia. Many will present with multiple health concerns as well as Macular Degeneration, the leading cause of blindness in the elderly over the age of 65. Yet more will exhibit hearing impairments and incontinence issues.
One other issue will be Alzheimer’s Disease as well as other cognitive issues which will make treatment much more challenging and we will perhaps have to revisit patient flow, for the conveniences of the patient, family, nursing home, transportation companies.
Staff will need to be trained in Professional BLS (Basic Life Support in a Professional Setting)
Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults. (Journal of Psychiatric Practice 2009; 15:103–112).
Given the social changes and openness of both clients and therapists to religion and spirituality, it is a reasonable supposition that spirituality tailored therapies will increase to meet clients’ needs. There will also need to be continuing sensitivity to clients who do not want to attend religiously or spiritually tailored therapy. (p. 541) ( Hagedorn & Moorhead, 2011). Worthington (2011) (Corey, 15.2d)
The implementation of PsychoAudiitory Stimulation Therapy along with Music Therapy can be applied as a way of reconnecting with believers pasts and even bring a non-believer to Jesus through worship and the lyrics of the same. Worship, as described by David through the inspiration of the creator of the universe, says:
1 Let Everything Praise the Lord, Praise the Lord!
Praise God in his sanctuary; praise him in his mighty heavens!
2 Praise him for his mighty deeds; praise him according to his excellent greatness!
3 Praise him with trumpet sound; praise him with lute and harp!
4 Praise him with tambourine and dance; praise him with strings and pipe!
5 Praise him with sounding cymbals; praise him with loud clashing cymbals!
6 Let everything that has breath praise the Lord! Praise the Lord! (Psalm 150:1-6)
Implementing small group sessions, on location with mini-church therapy with friends, family and those serving the Lord will help provide confidence and comfort. We can provide this in the office or in the home. We will use the gifts given us to can help the cognitive deficient remember old memories as a child, a young man, husband, wife or servant of the Lord, and realize that frustrations are just a way of thinking and since long-term memory is usually not as severe as the near in some cases, we may afford someone another memory making smile and help them secure a bountiful legacy..
I have been witness to the miracle of regaining a voice and rejoicing in the Lord if even for a few minutes. I have seen the joy on the faces of those coming close to home. The feeling of despair versus the joyful acceptance of our fateful lives in our final days. We are given that choice to look forward to. We as Christian Counselors can revive and be the listening ear of confession which allows us to grow and become free with the knowledge that we are saved.
If we have extraordinary circumstances of severe concern we can be the intercessor and/or the one to pass on the legacy that they will leave behind, when they are called home.
I praise God every day for the opportunity that He has given me to be the friendly shoulder to cry on and help resolve habits, fears, functional difficulties and encourage copying, for the young and old as a disciple of Jesus Christ. Amen.
Beck Aaron T., Beck Institute Blog, retrieved 10/26/14 http://www.beckinstituteblog.org/cognitive-behavioral-therapy/
Clark, D.A., & Beck, A.T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York, NY: Guilford Press. ISBN 978-1-60623-434-1
Cloud H., & Townsend, J. (2001). How people grow: What the Bible reveals about personal growth. Peabody, MA: Zondervan Publishing House. [ISBN: 978-0310257370]
Corey, G. (2013). Theory and practice of counseling and psychotherapy (9th ed.). Belmont, CA: Brooks/Cole. [Book-w/Access Code ISBN: 978-1-133-39935-3
Course Mate for ‘Theory and practice of counseling and psychotherapy’ (9e) [student online access code]. (2013). Belmont, CA: Brooks/Cole. [Access-Only ISBN: 978-1133114529;
Hagedorn, W. B., & Moorhead, H.J.H. ( 2011). Counselor self-awareness: Exploring attitudes, beliefs, and values.
Journal of Psychiatric Practice, March 2009 – Volume 15 – Issue 2 – pp 103-112, doi: 10.1097/01.pra.0000348363.88676.4d
Leahy, R. L., & Aronson, J. (1996). Philosophical precursors. http://cognitivetherapynyc.com/docs/basicprinciples.pdf, accessed 10/26/2014
McBride, Carolina; Atkinson, Leslie; Quilty, Lena C.; Bagby, R. Michael Journal of Consulting and Clinical Psychology, Vol 74(6), Dec 2006, 1041-1054. http://dx.doi.org/10.1037/0022-006X.74.6.1041 Special Section: Attachment Theory and Psychotherapy.
NAMI | Cognitive Behavioral Therapy http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/About_Treatments_and_Supports/Cognitive_Behavioral_Therapy1.htm
Worthington, E. L., Jr. ( 2011). Integration of spirituality and religion into psychotherapy. In G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy. ( 2nd ed., pp. 533-544) Washington, DC: American Psychological Association.