Cognitive Therapy in a Nutshell

Michael Neenan, Windy Dryden

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9780857023384, 9780857023377
• eBook ISBN: 9781446259795
• Edition: 2
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Cognitive Behavioural Therapy in a Nutshell - Second Edition is a concise introduction to one of the most widely-practised approaches to counselling and psychotherapy.

Leading authors, Michael Neenan and Windy Dryden, explain the model and the core techniques used during the therapeutic process to:

- elicit and examine negative automatic thoughts

- uncover and explore underlying assumptions, rules and core beliefs (schemas); and

- maintain gains from therapy.

For newcomers to the subject, this revised and updated edition of Cognitive Therapy in a Nutshell provides the ideal place to start and a springboard to further study.

ONE

An Overview of Cognitive Therapy

Introduction

Three people working for the same company at the same level and salary are all made redundant at the same time. The first person is angry because she believes she should have been promoted, not sacked; the second person is anxious because he thinks about the financial difficulties that lie ahead; the third person is hopeful because she thinks about the good opportunities that redundancy may lead to. These three different emotional reactions to the same event underscore a key idea in cognitive therapy (CT): namely, that our reactions to events are powerfully influenced by the way we view these events. By ‘tapping the internal communications’ (Beck, 1976), you can discover the thoughts and beliefs that largely determine your emotional responses to events. Clients are often surprised to learn that they are, in general, responding to their interpretation of the event rather than the event itself, e.g. ‘I always thought that being criticized made me angry but, on reflection, what really triggers the anger is my belief that I’ve been exposed as stupid and incompetent’. To summarize: the way you think affects the way you feel. As Clark and Beck observe (2010: 31), ‘This simple statement is the cornerstone of cognitive theory and therapy of emotional disorders.’

Some clients (and therapists) might say that events do directly cause our emotional reactions and, for example, point to everyone being anxious if they were in a burning building. While everyone may well be anxious, some people might be in a wild panic, creating additional dangers for themselves and others; some are frozen in terror; while others are struggling to stay in control in order to find a way out. When outside, some will calm down and recover more quickly than others from the ordeal, while one or two individuals may go on to develop full-blown post-traumatic stress disorder (PTSD). All have experienced the same event but only by examining each person’s viewpoint can you truly understand why they reacted in the way that they did (and, in some cases, continue to suffer from their experiences). CT teaches clients that there is always more than one way of seeing events and, therefore, their viewpoint is largely a matter of choice (Butler and Hope, 1996).¹ Helping clients to develop and maintain more helpful viewpoints in tackling their problems is the focus of therapy.

CT was developed by Aaron T. Beck at the University of Pennsylvania in the early 1960s. Beck’s approach initially focused on research into, and the treatment of, depression (Beck et al., 1979). Since then, CT has been applied to an ever-increasing number of clinical problems such as anxiety and phobias (Beck et al., 1985), substance abuse (Beck et al., 1993), schizophrenia (Kingdon and Turkington, 2004), obsessive-compulsive disorder (Clark, 2004), post-traumatic stress disorder (Taylor, 2006), health anxiety (Taylor and Asmundson, 2004), chronic pain (Winterowd et al., 2003), bipolar disorder (Basco and Rush, 2005), chronic fatigue syndrome (Kinsella, 2007), eating disorders (Fairburn, 2008), and working with couples and families (Dattilio, 2010), groups (Bieling et al., 2006), psychiatric inpatients (Wright et al., 1993), personality disorders (Davidson, 2008), children and young people (Stallard, 2002) and older people (Laidlaw et al., 2003).

CT has a strong commitment to scientific empiricism, i.e. testing its cognitive conceptualizations of various disorders (e.g. panic, health anxiety, obsessive-compulsive disorder) and their accompanying treatment protocols (see Clark, 1996, for the steps to follow in the Beckian approach to psychotherapy research). Scientific empiricism is not only a method but also a mindset – the willingness to abandon key CT tenets if not supported by research evidence: ‘This is the gold standard to which we hold an “empirically based psychotherapy”: a commitment to empirically examine every tenet of the therapy and follow the data, wherever they may lead’ (Padesky and Beck, 2005: 188). Therapists are encouraged to adopt the stance of a scientist-practitioner by drawing on research evidence to inform their clinical practice as well as evaluating the effectiveness of their own practice (see Westbrook et al., 2007); clients are also encouraged to take an empirical stance in testing their problematic thoughts and beliefs and collecting information from experiments in order to develop alternative and more helpful viewpoints. The Beckian view of psychotherapy, which is speaking only from research studies, is challenged by therapists from other orientations who point out that knowledge of human behaviour and change comes from many sources (e.g. philosophy, literature, spiritual traditions) and science is only one of them; a scientific approach cannot answer all questions of importance about the human condition. In our experience, not every cognitive therapist would describe him- or herself as a ‘strict Beckian’ in the sense of being led only by research.

CT comes under the umbrella term cognitive behavioural therapy (CBT). CBT is not a single approach but made up of various ones such as rational emotive behaviour therapy (REBT; Ellis, 1994), problem-solving training (PST; Nezu et al., 2007), stress inoculation training (SIT; Meichenbaum, 1985), relapse prevention (RP; Marlatt and Donovan, 2005) and dialectical behaviour therapy (DBT; Linehan, 1993). Each approach differs in the varying emphasis it places on cognitive as compared to behavioural principles and interventions (Hollon and Beck, 2004; Craske, 2010). When the same intervention is used, different explanations for change are advanced (Craske, 2010), e.g. in exposure treatment, behaviour theory attributes change to clients’ staying long and often enough in feared situations until habituation (anxiety diminishes) occurs while a cognitive perspective attributes change to testing clients’ fearful thoughts (e.g. ‘I’ll go mad if I stay for too long in this shop’) in order to provide a direct disconfirmation of them – she did not go mad in the shop – thereby leading to a reduction in anxiety.

Beck’s CT is the dominant CBT approach in the UK because of the substantial evidence base supporting its effectiveness and is recommended by the National Institute for Health and Clinical Excellence (NICE) as the first line treatment in the NHS for a wide range of psychological disorders (NICE, 2005). The wider dissemination of CT in the NHS is under way through the government funded Improving Access to Psychological Therapies (IAPT) programme (Department of Health, 2007).

Theory

In this section, we focus on some of Beck and colleagues’ conceptual contributions to increasing our understanding of psychopathology (disturbances in thought, feelings and behaviours) and its amelioration.

Information-processing model

The cognitive theory of psychopathology is based on an information-processing model ‘which posits that during psychological distress a person’s thinking becomes more rigid and distorted, judgements become overgeneralized and absolute, and the person’s basic beliefs about the self, [others] and the world become fixed’ (Weishaar, 1996: 188). In other words, when we become emotionally distressed our normal information-processing abilities tend to become faulty because we introduce a consistently negative bias into our thinking, thereby maintaining our problems. For example, a person who makes himself angry over not being invited to a party, denounces his friends as ‘bastards and backstabbers’ and declares he will ‘get them back for humiliating me’ fails to consider other reasons for not being invited (for example, he becomes aggressive when he has had too much to drink). Distorted thinking underlies all psychological disturbances (Ledley et al., 2005). These distortions usually stem from underlying dysfunctional beliefs that are activated during emotional distress, e.g. a person experiencing depression after the break-up of his relationship insists ‘I’ll always be alone’ (fortune-telling) because he believes he is unattractive (core belief).

Common information-processing distortions or biases include:

• All-or-nothing thinking: Situations are viewed in either/or terms (e.g. ‘Either you’re a success or failure in life. There is no in-between’).
• Mind-reading: You believe you can discern the thoughts of others without any accompanying evidence (e.g. ‘She doesn’t have to tell me – I know she thinks I’m an idiot’).
• Labelling: Instead of labelling only the behaviour, you attach the label to yourself (e.g. ‘I failed to get the job, so that makes me a failure’).
• Jumping to conclusions: Drawing conclusions on the basis of inadequate information (e.g. ‘My girlfriend didn’t phone when she was supposed to, so she must be going off me’).
• Emotional reasoning: Assuming that your feelings are facts (e.g. ‘I feel a phoney for not being able to answer the question, so I must be one’).

Teaching clients how to identify and change these cognitive distortions (or errors as they are sometimes called) facilitates the return of information-processing that is more flexible, accurate, evidence-based and relative (non-absolute) in its appraisal of events.²

Hierarchical organization of thinking

The cognitive model of emotional disorders advances three levels of thinking to be examined and modified.

1 Negative automatic thoughts (NATs)

These are thoughts that come rapidly, automatically and involuntarily to mind when a person is stressed or upset (Gilbert [2000] calls them ‘pop-up thoughts’) and seem plausible at the time. NATs can be triggered by external events (e.g. late for a meeting: ‘They’ll think badly of me. My opinion won’t count. I’ll lose their respect’) and/or internal events (e.g. pounding heart: ‘I’m having a heart attack. I’m going to die. Oh God!’). NATs are situation-specific and the easiest cognitions to gain access to by asking the ‘cardinal question of cognitive therapy: What was just going through my mind?’ (J. S. Beck, 1995: 10). NATs can also occur as images, such as a person seeing himself ‘dying of embarrassment’ if he makes a faux pas when he is the best man at his friend’s wedding. The clinical focus at this level is twofold: what we think (specific NATs in specific situations) and how we think, i.e. ways of processing information which result in some of the cognitive distortions listed above. Three general questions can be used in attempting to modify NATs (Dobson and Dobson, 2009):

1. What is the evidence for and against this thought?
2. What are the alternative ways to think in this situation?
3. What are the implications of thinking this way?

2 Underlying assumptions/rules

These are the often unarticulated assumptions that guide our everyday behaviour, set our standards and values, and establish our rules for living. A positive assumption might be ‘If I work hard then I will be a success in life’ and an accompanying negative assumption (the reverse side of the positive one) might be ‘If I slacken in any way then I will be a failure’. Underlying assumptions are often identified by their ‘if … then’ or ‘unless … then’ construction (for example, ‘Unless I’m respected by others I can never have self-respect’). Rules are often expressed in ‘should’ and ‘must’ statements (‘I must never show any weaknesses’; ‘I should always be there for my friends when they need me’). As long as the terms of these rules, standards and positive assumptions are met, individuals remain relatively stable and productive and thereby avoid activating the ‘bottom line’ (Fennell, 1997), i.e. negative core beliefs; however, these rules serve to maintain or reinforce negative core beliefs rather than change them. Underlying assumptions and rules apply across a range of situations. Assumptions and rules are also called intermediate beliefs (J. S. Beck, 1995) as they link NATs with core beliefs.

Beck et al. (1985) suggest that maladaptive assumptions often focus on three major issues: acceptance (e.g. ‘I’m nothing unless I’m loved’); competence (e.g. ‘I am what I accomplish’); and control (e.g. ‘I can’t ask for help’). As rules for living contain our values and standards, interventions here are based on discussing the usefulness of following rigidly certain rules and assumptions that do not reflect the complexities of life. For example, ‘I must give a hundred percent at all times’ does not allow for life’s vicissitudes and triggers self-condemnation when the person falls below this standard.

3 Core beliefs

These are the fundamental beliefs about ourselves (e.g. ‘I’m weak’), others (e.g. ‘People will walk all over me’) and the world (e.g. ‘It’s harsh and uncaring’) that help us to make sense of our life experiences. We usually have both positive (e.g. ‘I’m great’) and negative (e.g. ‘I’m useless’) core beliefs. Core beliefs are usually formed through early learning experiences and become instrumental in shaping our outlook. In emotional disturbance, absolute and global negative core beliefs are activated and then process information in a biased way that maintains the core belief and discredits or disconfirms any contradictory evidence. Core beliefs can also be recently acquired, such as by experiencing a traumatic incident, e.g. a person who has always seen herself as strong and resolute fails to ‘bounce back’ from a serious car accident and concludes that she is weak and pathetic. The terms ‘core beliefs’ and ‘schemas’ are sometimes seen as synonymous in CT but schemas are not just core beliefs.³

Once the disturbance has passed, negative core beliefs become deactivated or return to their latent state and a more positive outlook is re-established (clients with personality disorders may have their negative core beliefs activated most of the time, see Davidson, 2008). Judith Beck (2005) suggests that negative core beliefs about the self can be slotted into three broad categories of helplessness (e.g. ‘I’m no good on my own’), unlovability (e.g. ‘I’m undesirable’) and worthlessness (e.g. ‘I’m rubbish’). Once negative core beliefs are identified, alternative views of the self can be formulated that are balanced, realistic, flexible and compassionate, e.g. ‘I’m reasonably likeable but not to everyone. If I am disliked I can accept this as part of the experience of life rather than blame myself for being bad or defective in some way. I want to learn to be self-accepting, not self-condemning, when things don’t turn out in my favour.’

How do these three cognitive levels interact? For example, a negative core belief (‘I’m unattractive’) is activated when a client’s positive assumption (‘If a man is interested in me, then that proves I’m attractive’) is undermined by rejection (‘He’s not interested in me, so that proves I must be unattractive’). Her mind is flooded with negative automatic thoughts (NATs) such as ‘Why did he dump me? I can’t cope without him. I hate being on my own. He’s probably laughing at me now with his new woman.’ The usual treatment strategy in CT is to focus on tackling NATs to effect symptom-relief before moving on to modify underlying assumptions and core beliefs to achieve longer-term change and thereby reduce the chances of a relapse (a return to the original problem). It is important to poi...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Preface
• 1 An overview of cognitive therapy
• 2 Assessment and conceptualization
• 3 Identifying and examining negative automatic thoughts
• 4 Homework
• 5 Identifying and examining underlying assumptions, rules and core beliefs
• 6 Maintaining gains from therapy
• Resources
• References
• Index