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NilsHolmberg
SeppoKähkönen

Cognitive Psychotherapy

Essentials

  • Cognitive psychotherapy is a form of therapy that attempts to understand and conceptualise a patient's problems in accordance with a cognitive model.
  • Therapy is based on an exploratory, collaborative relationship between the patient and therapist. The underlying principal factors of the therapy are explained to the patient, including the interrelationships between various cognitions (beliefs, conceptions, thoughts, feelings and behaviour).
  • An attempt is also made during the therapy process to identify such events from the patient's developmental history that will assist in understanding the causes of strong emotional reactions and cognitions during current problem situations.
  • The therapy is also influenced by the view of a learning theory that states that behaviour is guided by activating factors and consequences.
  • Cognitive psychotherapy has divided into many branches which retain many common features: a focused therapeutic approach and goal-orientated working, the use of homework assignments, a collaborative therapeutic relationship with a shared exploratory approach, an attempt to understand the person's experiences through investigating the inner processes of the mind and introducing the concept of alternative experiences.
  • Cognitive psychotherapy has been shown to be an effective therapy form particularly in monopolar depression, generalised anxiety disorder, panic disorder, social phobia, post-traumatic stress disorder as well as in childhood depression and anxiety.
  • After a fairly short training, a general physician will be able to use cognitive and behavioural methods when treating psychiatric disorders.

Salient points

  • At the beginning of cognitive therapy, the therapist will aim to make the patient identify what happens to him/her in a specific situation: what he/she is thinking, what conceptions he/she is experiencing and what kind of feelings and behaviour are associated with the situation.
  • Self-monitoring, i.e. monitoring one's own behaviour usually progresses with the aid of various recording tasks that are carried out in between the therapy sessions (home assignments).
  • The scrutiny of problem situations, previous attempts to solve the problems and the chain of events (what factors activate the behaviour, what maintains the behaviour and what are the consequences of the behaviour) is combined with the exploration of associated emotions, behaviour and cognitions. Functional analysis, i.e. chain analysis, is a useful tool when examining the chain of events.
  • During the therapy process the therapist will attempt to identify such events from the patient's developmental history that assist in understanding the causes of emotional reactions and cognitions during problem situations.
  • Understanding the significance of these events is the cornerstone of empathic listening and is also a prerequisite to deeper validation of emotions.
  • Restoring an interrupted therapeutic relationship is emotionally important to the patient because his/her distorted beliefs in human relationships and himself/herself will first be questioned and then restored.

The significance of conceptualisation

  • Cognitive case conceptualisation is a method used to present problems in such a way that they become comprehensible and thus suitable for modification.
  • Conceptualisation should be seen as a series of interacting working hypotheses that are to be tested. The more problems the patient has, e.g. personality disorders, the more important conceptualisation will become.
  • Without the common thread offered by conceptualisation the therapist may end up using varying approaches to treat isolated symptoms. These approaches may be effective as such but will not address the beliefs that reoccur unchanged from one situation to another and prevent change taking place.
  • The evaluation and modification of beliefs is important in cognitive psychotherapy - not because they are the underlying cause of problems but because they act as strong maintaining factors of various problems.
  • Conceptualisation should be seen as the basis of various acceptance and adaptation strategies because it acts as the guiding force in treatment strategies.

Specific intervention strategies

  • In short-term cognitive therapy (e.g. treatment of depression, panic disorders or a specific phobia; 15-20 sessions), each session usually has a specific designated agenda.
  • Conventional methods (table T1) are still in use, including behavioural methods (applied relaxation, behavioural experiments and activation, gradual exposure etc.) as well as cognitive methods (observation and recording of thoughts, recognition and questioning of cognitive distortions of thought, searching for alternatives, reattribution, risk-benefit analysis, metaphors etc.).
  • In the treatment of depression, phobia and anxiety, behavioural work models are useful in encouraging the feelings of coping and capability. In cognitive psychotherapy, they are often seen as the means to test negative cognitions.
  • Exposure hierarchy may be used to alter the patient's belief that a certain stimulus (e.g. a crowd of people, the metro etc.) is too hazardous and cannot be approached. Imaginal exposure may be used to alter the belief that even thinking of a certain issue is too distressing.
  • Socratic dialogue is a special therapy technique, which uses questions to encourage the patient to reflect on his/her own thinking processes and associated problem areas and inconsistencies.

Therapeutic approach in cognitive psychotherapy

TechniqueUse
Self-monitoringThe patient is asked to observe himself/herself, e.g. a harmful feeling or repeated problem behaviour. The patient writes down his/her observations which will be discussed at the beginning of the next therapy session.
Socratic methodThe patient learns to reassess and modify conclusions and thinking processes that occur in certain problem situations (e.g. ”I am no good at anything”). The Socratic method will assist the patient to recognise and question distortions of thought (such as black and white thinking or false generalisations), which hinder effective behaviour and emotional regulation. Questions often asked by the therapist include ”What were your thoughts at that moment?”, ”What other way could you think about this matter?”, ”What does this mean to you?” or ”How do you know that the matter is like that?”
Functional analysis or chain analysisAn attempt is made to identify the external and internal factors that have both activated the problem behaviour, either directly or indirectly, and maintained it, including vulnerability factors (e.g. lack of sleep), activating factors, intermediate factors (thoughts, feelings, acts) and both short-term and long-term consequences. During the analysis, it is important to intersperse skills teaching and problem solving with each other in order to equip the patient with the knowledge of how to manage a similar situation in the future.
Forming and testing working hypothesesThe patient decides to act the opposite to his/her belief, e.g. he/she attends a party and initiates conversation with another guest even though he/she believes strongly that ”everyone will laugh at me if I blush”.
Applied relaxationGuided self-dialogue, which is used to treat emotional and stress-related problems mediated by the nervous system, particularly the autonomic nervous system (e.g. tension headache, difficulties falling asleep)
Response preventionIn obsessive-compulsive disorders, exposure therapy often includes response prevention whereby the patient aims, with the aid of the therapist, to avoid avoidance behaviour in anxiety- or fear-provoking situations. The method allows the patient to experience the removal of anxiety without the need of avoidance behaviour.
Gradual exposure (interoceptive exposure, in vivo situational exposure, imaginal exposure)If, for example, panic reactions are associated with avoidance behaviour, gradual exposure to fear-provoking situations is important. In addition to cognitive methods, breathing and relaxation techniques are also useful for the optimum management of physical symptoms during a panic attack. Moreover, the life situation at the start of panic symptoms will also be addressed as well as the significance of the patient's developmental history as regards the emergence of symptoms.
Modelling techniques and role play, communication trainingWith the aid of these techniques, the patient will learn social coping strategies and skills, including standing up for oneself and asking for things. Behavioural experiments are one of the most powerful interventions to change harmful beliefs. By experimenting with a new way of behaviour, followed by observation of its consequences, the patient will receive immediate, direct and concrete evidence against harmful beliefs and may obtain support for a new, more positive belief.
Stimulus control techniquesControl of the surroundings: the antecedents (events and situations) of behaviour as well as circumstances where non-desired behaviour is reinforced are altered in order to elicit desired behaviour, i.e. the surroundings are changed so that desired behaviour is reinforced and non-desired behaviour rendered less likely.
Sensitisation trainingLearning observation and awareness skills, mindfulness training
Behavioural activation and activity schedulingThe patient is helped to identify poorly functioning aspects of his/her life, and the possibility of their elimination via behavioural activation is explored. The therapist both coaches and encourages the patient towards activity and modifies cognitions that hinder the process, such as ”There is no point in this”. The therapy also includes both the mapping of positive events and balancing of the weekly schedule between obligations and pleasurable events.
Recognising consequences and contingency managementAddressing the consequences may be used to encourage the patient's wish to engage in more appropriate behaviour; both desired and non-desired behaviour are taken into account (e.g. wrong behaviour is not rewarded or reinforced with empathetic crisis discussion and constructive behaviour is not ignored).

Long-term cognitive therapy Psychological Therapies for Borderline Personality Disorder

  • Because the clinical target groups have become larger, therapy intervention of longer duration (e.g. for 2-3 years) has become necessary, for example in the treatment of long-term disturbances. In such a case, the therapy will target in the long run the patient's schemas and underlying beliefs rather than the more superficial immediate automatic thoughts and beliefs.
  • In order to gain a deeper understanding of the patient, it is important to explore how the underlying beliefs were initially formed and how they have been maintained over the years. This task is usually not approached until the beliefs that exist in the present have been addressed and their modification, with the aid of cognitive methods, has commenced.
  • The process usually progresses in parallel, i.e. early and present experiences that either explain or are inconsistent with underlying beliefs are examined alternately.

Cognitive methods and the general physician

  • After a fairly short training, a general physician will be able to use cognitive and behavioural methods when treating psychiatric disorders.
  • A general physician may use various cognitive-behavioural methods, such as behaviour monitoring and activation, various psychoeducational mini-interventions, exposure, cognitive adaptation, improving problem solving skills and increasing contingency management in everyday life.
  • In the recent years, also internet-based cognitive-behavioural self-help programmes have become available for the treatment of anxiety disorders and depression.

Efficacy of treatment Cognitive-Behavioral Treatment (Cbt) for Antisocial Behavior in Youth in Residential Treatment, Cognitive Behavioural Therapy for Anxiety Disorders in Children and Adolescents, Combined Psychotherapy Plus Benzodiazepines for Panic Disorder, Cognitive Behaviour Therapies in the Depression in Children and Adolescents, Cognitive Stimulation to Improve Cognitive Functioning in People with Dementia, Psychological Therapies for Borderline Personality Disorder

  • Cognitive psychotherapy has been shown to be an effective therapy form particularly in monopolar depression, generalised anxiety disorder, panic disorder, social phobia, post-traumatic stress disorder as well as in childhood and adolescence depression and anxiety.
  • Good results have also been achieved in the treatment of chronic fatigue syndrome Cognitive Behaviour Therapy for Chronic Fatigue Syndrome (Cfs) in Adults and chronic pain.
  • The results of cognitive therapy are poor in the treatment of dementia and domestic violence Cognitive Behavioural Therapy (Cbt) for Intimate Partner Physical Abuse.
  • Dialectical behavioural therapy and schema therapy are adaptations of cognitive psychotherapy that have been shown to be effective treatment approaches for borderline personality disorder. Self-destructive behaviour, attempted suicides, depression, hopelessness, thoughts of self-destruction as well as bulimic behaviour have been significantly reduced in these patients. The results have been sustained over a follow-up period of 2 years.
  • Cognitive psychotherapy has reduced psychotic and negative symptoms in patients with schizophrenia.

References

  • Linehan MM, Comtois KA, Murray AM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006;63(7):757-66. [PubMed]
  • Grant PM, Huh GA, Perivoliotis D et al. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry 2012;69(2):121-7. [PubMed]
  • Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis 2012;200(10):832-9. [PubMed]

Evidence Summaries