Cognitive counselling theories focus on mental processes and their influences on mental health and behaviour. A common premise of all cognitive approaches is that how people think largely determines how they feel and behave.
Aaron Beck (1921), a psychiatrist, is credited as the founder of cognitive therapy (CT). He initially worked with Freud and trained him to be psychoanalytic. Later he began to notice that rather than retroflected anger, as Freud theorized with depression, clients exhibited a negative bias in their interpretation or thinking towards any life situations. This is when he developed the concept of automatic thoughts (personalized notions that are triggered by particular stimuli that lead to emotional responses) which he theorized, can lead to depression. These automatic thoughts are often negative therefore he later used the term Negative Automatic Thoughts (NATs) which are unconscious and are often distressing, distorted(away from reality, rationality and logic) and dysfunctional (unhelpful and maladaptive).
Beck asserted these biases that people with emotional difficulties have, distort the way they make sense of the experiences that she/he has in the world, leading to cognitive errors which are also termed as cognitive distortions.
Principles of CBT
- CBT needs sound therapeutic alliance and active participation of the client as well as the therapist. Cognitive therapists are continuously active and deliberately interactive with clients. Therapists ensure clients’ active participation and collaboration throughout all phases of therapy, including deciding how often to meet, how long therapy should last, what problems to explore, making the client participate in designing homework and setting an agenda for each therapy session.
- It is a goal oriented and solution- focused therapy, increasing client’s capacity to deal with the problems. The goals of CT centre around examining and modifying negative thoughts. Cognitive therapy is highly collaborative and involves designing specific learning experiences to help clients monitor their automatic thoughts; examine the validity of their automatic thoughts; understand the relationship among thoughts, feelings, and behaviour; develop more accurate and realistic cognitions; and change underlying beliefs and assumptions.
- It is educative in nature where the teaching is the focus. Typically, a therapist will educate clients about the nature and course of their problem, about the process of cognitive therapy, and how thoughts influence their emotions and behaviours. The educative process includes providing clients with information about their presenting problems and about relapse prevention.
- The therapy focuses on the present rather than delving deeper into the past. Past is explored only to be aware of the situations that triggered the presenting thoughts which are having an impact on the person’s mental well being. Much work is done on altering the dysfunctional thought pattern, which then results in positive and adaptive reactions.
CBT uses an inductive method where homework is tailored to help clients cope with their specific problems. The purpose of homework is not merely to teach clients new skills and techniques but also to enable them to test their beliefs using these newly learnt techniques and experiment with different behaviours in daily-life situations.
Cognitive model of CBT:
Cognitive model of CBT states that specific situations trigger automatic thoughts and these negative automatic thoughts give rise to reactions. These resultant reactions can be manifested into 3 types i.e., emotional (sad, depressed, anxious, etc), behavioural (crying, drinking, etc) and physiological (anything related to physiology like sweating, heart beating faster, breathes getting shorter).
Example–
Situation– Miss X’s friend didn’t receive her call despite calling many times during the day.
Negative Automatic thoughts– “She is ignoring me, I might have done something wrong with her”, “I end up losing every friend this way”, “I’m a bad friend”, “I’m bound to stay alone all my life”.
Reactions- Emotional- Sad, annoyed.
Behavioural- crying, minimizing interaction with other friends.
Here it is also important to note that it is not necessary for all the 3 types of reactions to be shown by the client. The client might show any 1 or 2 or all the 3 types of reactions.
There are two more concepts introduced by Beck which needs to be understood along with the automatic thoughts in order to practice CT. Those are core beliefs and attitudes, rules and assumptions (ARA).
Core Beliefs (CBs)
- Core beliefs are ideas about self, others and the world.
- These are absolute truths for the person.
- They are fundamental, global, rigid and overgeneralized.
- Core beliefs influence people’s perceptions about situations and events they encounter in daily life.
- They start forming from childhood.
- These generally arise from ATs.
- ATs generally fall under 3 categories of CBs- unlovable, worthless and helpless.
- For example– during childhood there were times when my parents weren’t able to give me time because they were always busy working- AT: “nobody cares about me”. Later, I got into a relationship which eventually ended up with cheating- AT: “I’m unattractive and unlovable”. Next I got into another relationship which also didn’t work (at this point the core belief of unlovable has started to form). Next, I joined a job and my friends didn’t invite me for a party- AT- “my colleagues don’t like me” (the core belief of unlovable formed and got stronger).
- This way multiple situations lead to the forming of core beliefs.
Attitudes Rules and Assumptions (ARAs)
- Attitudes: These are viewpoints and are generalized. These generally occur in statement format. These are either good or bad.
- E.g., Mistakes are terrible (generalized statement not specific).
- Rules: Commands or demands that direct our behaviour.
- E.g., I must do everything perfectly.
- Assumptions: Conditional in nature. They are ‘if’ and ‘then’ statements.
- E.g., If I do everything perfectly then it is okay, if not then I’m a loser.
- These three things can help us identify the core beliefs.
ARAs and core beliefs are formed out of automatic thoughts and the development of core beliefs tend to produce negative thoughts in any life situation and this in turn reinforce the core beliefs. This way they are maintained by reinforcing each other in a cycle.
Techniques:
1. Cognitive Restructuring
3 aims of this technique are
i) clarifying,
ii) challenging (i.e., asking more and more questions and shattering their logical ground) and
iii) changing (change the thoughts from unhealthy to healthy ones).
Socratic questioning:
- Ask for evidence– “Give me some instances that support this thought”, “Give me some evidence of events/ instances that convinced you to believe in these thoughts”.
- Asking for evidence will help the client look for instances that support his/her interpretation or thinking but end up with none guided by logic. Then with the help of a therapist’s assistance, the client will understand that these biased interpretations tend to occur automatically and one tends to believe them without evidence.
- Is there any other way of looking at the situation?- Clients often have the tendency to view their problems as insurmountable. Their thought patterns are often rigid and consider no other way of looking at it, rather view them as absolute truths. Asking this question will help the client think of the situation from another perspective and put ideas which are more adaptive.
- Worst, Best, Realistic(this works best in decatastrophizing)
- Ø Asking what is the worst that can happen?
- Ø What is the best that can happen?
- Ø What is happening right now? Or what is the realistic situation? – The client with the help of the therapist must focus and work on the realistic situation.
- What happens when I believe in this Automatic Thought (AT)? What could be the effect of changed thinking?- Here, the therapist together with the client focuses on the reactions or emotional responses of the client when he or she engages in this AT. Then the therapist helps the client reframe or modify the AT in a positive way and examine the effects of changed thinking. The rationale behind this is to make the client understand that thoughts determine feelings i.e., negative thoughts lead to negative emotions and changing these thoughts can have a positive effect.
- What would you suggest to your friend, or close family member if they were in the same place as yours?-This gives the client a third-person perspective and proves that one is being too rigid with one’s own self.
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Thought Record Sheet
SITUATION AUTOMATIC THOUGHTS REACTIONS ALTERNATE THOUGHTS OUTCOME 1. What actual event of stream of thoughts, or daydreams, or recollection led to the unpleasant emotion? 1. What thought(s) and/or image(s) went through your mind? 1. What emotion(s) (sad, anxious, angry, etc) did you feel at the time? 1. (optional) What cognitive distortion did you make? 1. How much do you believe in each alternate thought? 2. What (if any) distressing physical sensations did you have? 2. How much did you believe each one at the time? 2. How intense (1- 100) was the emotion? 2. Use questions at above (like evidences) to counter and compose a response to the automatic thought(s) 2. What emotion(s) do you feel now? How intense (1-100) is the emotion? – – – 3. How much do you believe each response? 3. What will you do? (or did you do?)
This sheet can be used by therapists during the sessions to record the client’s progress and whatever has been examined during therapy. Then this sheet can be shown to the client towards the end of therapy to increase their awareness of their progress and gain more clarity over whatever happened during the past sessions. This sheet consists of the following:
- In the first column the situation or specific events that trigger automatic thoughts is recorded.
- In the second column, the automatic thoughts triggered by the situation are to be recorded. This should be followed by recording the client’s rate of how much he/she believes in the ATs on a scale of 1- 10 or 1-100.
- In the next column, reactions to the ATs and rating of how intensely the emotions have been felt by the client are to be recorded.
- In the next column of alternate thoughts, cognitive distortions committed by the client which were identified by the therapist in collaboration with the client are to be recorded and then the questions (or technique) used to counter and compose a response to the automatic thoughts and the resultant alternative thought(s) are to be recorded. This can be followed by recording of how much does the client believe in the response made to the ATs.
- In the last column of outcome, how much do the client believe in the alternate thought is to be recorded. Next the reactions or emotions elicited by the alternate thoughts and rating of those emotions are to be recorded. Lastly, what the client has decided to do or have already done with the alternate thoughts and the new emotions, basically the new healthy behaviour are to be recorded. For e.g., if the client says “I’m going to work hard and plan well for the next exam. It’s ok if I got less marks in one exam it is not the end of this world and I can change this outcome by doing things a bit differently from before”, then this new behaviour is to be recorded in the thought record sheet.
Thought record sheet can also be given to the clients as homework assignment where they can be asked to record any situation they encounter in future which evoke some kind of ATs, the succeeding reactions, techniques they have applied to counter those ATs, the resultant alternate thoughts and the outcome. Doing this homework assignment will help people monitor their own thoughts and emotions more closely and jotting those down will help them gain more clarity and control over them. Writing and observing one’s own positive outcome will reinforce and motivate them to work more towards their ATs by applying the skills and techniques learnt in therapy.
CT has been adapted to treat a wide range of disorders, including depression and anxiety. Now, however, this form of treatment is used for a broad range of conditions, including eating disorders and obesity, personality disorders, substance use, and even schizophrenia (Beck, 2005; Beck & Rector, 2005).
Limitations
- CT is not an appropriate therapy for people seeking a more unstructured, insight oriented approach that does not require their strong participation.
- CT is primarily cognitive in nature and not usually the best approach for people who are intellectually limited or who are unmotivated to change.
- CT doesn’t delve into the past issues or childhood traumas which might actually be the reason for presenting problems and not addressing those might be an obstacle for therapy to work.
- CT is demanding. Clinicians and clients must be active and innovative. The approach is more complex than it appears on the surface.
– Stuti Parasha Kashyap
