Lecture
The foundations of cognitive counseling, or cognitive therapy, were developed by Dr. Aaron Beck in the early 1960s. Cognitive counseling places the greatest importance on the process of information processing. Cognitive counselors proceed from the premise that the way people interpret their experience determines how they feel and how they act. In the course of cognitive development, clients acquire faulty skills for processing and interpreting information. Cognitive counselors seek to correct harmful, deeply ingrained patterns of thinking and try to identify distortions in clients, helping them master the skills of more realistic information processing.
Cognitive psychotherapy, or cognitive therapy (English: cognitive therapy), is a widespread form of psychotherapy based on the assumption that errors in thinking underlie psychological problems, and at times mental disorders, and is aimed at changing a person's illogical or inexpedient thoughts and beliefs, as well as dysfunctional patterns of their thinking and perception. In the course of cognitive psychotherapy, the patient learns to solve problems and find ways out of situations that had previously seemed insurmountable, while rethinking and correcting their thinking. The cognitive therapist helps the patient learn to think and act more realistically and adaptively, thereby eliminating the symptoms that trouble them.
Cognitive therapy is a directive, structured, target-oriented approach based on a cognitive model of particular mental disorders or dysfunctional behavior, combining a range of techniques — both its own and borrowed from other psychotherapeutic approaches: Gestalt therapy, psychodrama, behavioral therapy, and client-centered therapy. Cognitive therapy is characterized by rigorous experimental testing of all the theoretical constructs on which its therapeutic principles are based, and careful evaluation of its effectiveness.
What distinguishes cognitive therapy from psychoanalytic therapy, in particular, is that its content is determined by «here and now» problems. Cognitive therapists, unlike psychoanalysts, do not attach great importance to the patient's childhood memories (unless they help clarify current observations); what matters most to the cognitive therapist is exploring what the patient thinks and feels during the therapy session and between sessions. What distinguishes cognitive psychotherapy from behavioral psychotherapy is greater attention to the patient's inner (mental) experience — their thoughts, feelings, desires, fantasies, and attitudes.
Beck's main books include: «Cognitive Therapy and the Emotional Disorders» (Cognitive Therapy and the Emotional Disorders); «Cognitive Therapy of Depression» (Cognitive Therapy of Depression), co-authored with Rush, Shaw, and Emery; «Anxiety Disorders and Phobias» (Anxiety Disorders and Phobias), co-authored with Emery with the assistance of Greenberg, and many others.
Tests and scales developed by Beck together with colleagues include the Beck Depression Inventory, the Beck Hopelessness Scale, the Suicide Intent Scale, the Suicide Ideation Scale, and the Beck Self-Concept Test.
Primary level of cognitive processing. Thinking based on primary cognitive processing tends to be «primitive» and interprets situations in global and relatively crude ways (Beck, Rush, in press).
Higher levels of cognitive processing. People are capable of higher-level cognitive processing that is more specific and effective. Higher levels of functioning perform reality testing and correct primary, global interpretations. However, in psychopathology these corrective functions are disrupted, and primary reactions can develop into full-blown psychiatric disorders.
Schemas. Beck notes that "schemas" are cognitive structures that organize experience and behavior. Schemas are relatively stable cognitive patterns that, through people's attitudes, influence how people sort and synthesize incoming data. Schemas can be adaptive or maladaptive. People classify and evaluate their experience using a matrix of schemas.
Schemas can be general or specific. Five main categories of schemas are distinguished according to their functions:
1) cognitive schemas, concerning actions such as abstracting, interpreting, recalling, and evaluating oneself and others;
2) emotional schemas, responsible for generating feelings;
3) motivational schemas, relating to aspirations and desires;
4) instrumental schemas, which prepare people for action;
5) control schemas, which include self-monitoring and inhibition, modification and regulation of actions.
Schemas can vary in breadth and flexibility. Core beliefs embedded in schemas determine information processing and can make people vulnerable due to their limitations.
Automatic thoughts reflect the content of schemas - deeper beliefs and assumptions. Most psychological disorders are characterized by specific biases in information processing (for example, depressive disorders are characterized by a negative view of oneself, one's experience, and the future, while anxiety disorders are characterized by fear of physical or psychological danger).
Automatic thoughts are part of people's inner monologue; they can take the form of words, images, or a combination of words and images. Such thoughts occur very rapidly and are usually on the edge of awareness. Automatic thoughts precede the emergence of emotions and the development of inhibition (for example, people's emotional reactions to each other's actions depend more on the interpretation of those actions than on the actions themselves). Automatic thoughts influence tone of voice, facial expression, and gestures. Although automatic thoughts are often difficult to identify, counselors can train clients to recognize these thoughts with great precision.
Cognitive errors – dysfunctional beliefs embedded in cognitive schemas. They are easily detected through the analysis of automatic thoughts, which characterize psychopathology and contribute to its persistence.
1. Arbitrary inference - drawing certain conclusions in the absence of evidence supporting the validity of the conclusions drawn, sometimes even when reality clearly contradicts the conclusions. An example of arbitrary inference is a working mother who, at the end of a hard day, concludes «I am a terrible mother».
2. Selective abstraction – selectively focusing attention on a detail taken out of context while ignoring other, more significant information (an example of selective abstraction - a boyfriend who becomes jealous upon seeing his girlfriend lean her head toward another person at a noisy party in order to hear him better).
3. Overgeneralization - deriving a general rule or conclusion from one or several isolated cases (an example of overgeneralization - a woman who, after a disappointing date, comes to the following conclusion: «All men are the same. I will always be rejected»).
4. Magnification and minimization – incorrect evaluation, viewing specific events as much more or much less important than they actually are (an example of magnification: a student who predicts catastrophe: «If I get even a little bit nervous, I will certainly fail»; an example of minimization: a person saying that his terminally ill mother has «a slight cold»).
5. Personalization – the tendency to relate external events to oneself in the absence of adequate evidence (for example, a person sees an acquaintance walking on the opposite side of a busy street who does not notice his friendly wave, and thinks: «I must have offended him somehow»).
6. Dichotomous thinking - «black-and-white», polarized thinking – characterized by all-or-nothing extremes (for example, a student thinks: «If I don't get an "excellent" on this exam, I'm a failure»).
8. Biased explanations. When relationships cause people pain, they tend to attribute negative feelings, thoughts, and actions to one another. People may be excessively willing to assume that a partner's "offensive" actions conceal malicious intentions or unworthy motives (for example, one partner may attribute the emergence of family problems to the other partner's bad character).
9. Attaching negative labels – assigning critical labels to partners and to oneself as if these labels were real things (examples of labels: «bully», «slob», «loser», etc.).
10. «Mind reading». Two errors can be identified here: «I can tell what my partner is thinking» and «My partner must be able to read my mind». As a result, partners may harm their relationship by making unfounded assumptions.
11. Subjective argumentation. Subjective argumentation is based on a mistaken belief (for example, the mistaken belief that if a person experiences some very intense emotion, that emotion is justified).
Cognitive theory of personality emphasizes the close connection between cognition and emotion. The fundamental emotions - sadness, joy, anxiety, and anger - are reflected in the basic cognitive themes. The four fundamental emotions are connected with the mobilization and preservation of basic cognitive structures and strategies, since they are related to the centers of pleasure and pain.
Sadness is associated with people's inability to achieve their positive goals. People experience sadness when they suffer a loss (for example, the loss of a loved one or of status) or when positive expectations are not confirmed. Typically, after experiencing sadness, people stop investing (including energy) in the source of disappointment.
People feel joy or delight when they receive some kind of gain (for example, when they achieve a goal or when others show their affection for them).
Anxiety and anger are reactions to perceived threats concerning either ourselves or people and things valuable to us. Anxiety serves to focus a person's attention on concerns related to physical and psychological vulnerability. Anxiety can lead to avoidance of the situation causing it or to calming down in the face of the threat. If, on the other hand, an individual experiences anger, they focus their attention on the aspects of the threat related to insult, which can lead to aggressive self-defense or counterattack.
Acquisition of vulnerability. The acquisition of the potential for mental disorder can be viewed as the result of the influence of many interacting factors: evolutionary, biological, as well as developmental and environmental ones. Among the ways of acquiring vulnerability, Beck includes childhood trauma, childhood maltreatment, and social learning. In the development of certain personality disorders, the main role is played by the reinforcement of corresponding strategies by parents and other significant figures.
Activation of vulnerability. Beck identifies three factors that activate the course of pathological processes: encountering increased demands, a sense of serious threat, stressful events, and radical changes.
Inability to test the reality of dysfunctional interpretations. Beck believes that people can temporarily lose the ability to test the reality of their interpretations. Information processing based on dysfunctional schemas and beliefs is permeated with automatic thoughts containing cognitive errors. Clients use rigid concepts, being unable to adequately distinguish between fact and inference. Instead of viewing their thoughts as hypotheses requiring testing, clients immediately jump to cognitive conclusions and then treat these conclusions as facts. They fail to sufficiently take into account any feedback that could change their thoughts and perceptions.
Resistance to change. People may resist change for various reasons. For example, they may fear having a negative effect on others. Many fear change as something unknown. Sometimes they fear the additional responsibility associated with change.
Beliefs about change. Illustrative beliefs: "My partner is not capable of changing," "Nothing can improve our relationship," "Everything will only get worse."
Justification of one's own beliefs. For example, "Behaving the way I behave is normal," "Thinking the way I think is right," "He/she hurt me. He/she deserves to be hurt."
Reciprocity arguments. For example, "I will not make any effort until my partner does," "It's not fair that I have to do all the work," "My partner caused me great pain in the past, so now he owes it to me to make up for it."
Belief that the problem lies with the partner. For example, "I had no problems in my life until we got married," "My partner is impossible," "My partner doesn't care about improving our relationship."
Beck views depression as a cognitive state. Depression entails the activation of three main cognitive patterns, which together make up what is known as the cognitive triad.
The first component concerns clients' negative views of themselves as unattractive, worthless, helpless, and incapable of being happy.
The second component concerns clients' negative views of their perception of the world in the past and present. Clients are extremely demanding of themselves, which hinders the achievement of goals.
The third component is a negative view of the future, which is seen as joyless and unchangingly bleak. This hopelessness can give rise to thoughts of suicide.
These cognitive patterns lead to the emergence of motivational, behavioral, and physical symptoms of depression. A telling motivational sign is the paralysis of will. Inertia and fatigue are, respectively, telling behavioral and physical symptoms.
Predisposing schemas. Depressive schemas can form from childhood. Situations resembling those that originally contributed to the instilling of a depressive schema can trigger depression. Absolute beliefs associated with the schemas of clients in a state of depression include attitudes such as "I am worthless," "I am unattractive," and "I can't do anything right."
Cognitive deficiencies and distortions. Depressive schemas and beliefs impair normal cognitive processing, perception, and inference-drawing, and worsen long-term memory. Clients lose the ability to test the validity of their interpretations of events and begin to cope less well with problems. The main characteristic features of depressive thinking are: a predominant focus on the negative aspects of life events; taking on responsibility for solving problems in all situations; self-devaluation in the event of failure; overgeneralization of specific shortcomings; and the presence of a "dead-end" viewpoint, according to which problems cannot be solved even partially.
Anxiety is a strategy used in response to threat. In anxiety disorders, the normal evolutionary survival mechanism associated with anxiety becomes exaggerated and starts to malfunction.
Primary appraisal is the first impression of a situation, one that suggests this situation is harmful.
Secondary appraisal involves a person assessing their resources for coping with the threat. At the same time as the secondary appraisal, an assessment of the nature of the threat is made.
As with depression, dysfunctional schemas and beliefs can predispose a person to anxiety. These dysfunctional attitudes can be activated by heightened demands, threats, and stresses, which can interact with problems that arose in the past. Cognitive errors reflecting a dysfunctional schema include overestimating the probability and severity of the threat, exaggerating the significance of negative consequences (catastrophizing), underestimating the resources needed to cope with the threat, and paying insufficient attention to supportive factors, such as the presence of other people who could offer help.
When disillusionment with a relationship begins, partners lose the ability to test the validity of their interpretations of thoughts, feelings, and actions, both their own and their loved one's. Instead, partners begin to react to their own perceptions, which are based on internal experiences, fears, and expectations rather than on what is actually happening. Dysfunctional schemas and beliefs are activated, resulting in the formation of negative cognitive attitudes toward the other person. The voluntary and automatic thinking of a distressed couple contains numerous cognitive errors. Partners tend to fixate more on what is wrong in their relationship than on what is right. They often stick negative labels on each other, engage in mind reading, and attribute undesirable and malicious motives to one another. In addition, partners send each other caustic messages that cause pain and provoke anger. Hostility is part of the primitive "fight-or-flight" survival mechanism. However, the primitive urge to attack often proves destructive to the relationship. It raises the level of threat within the relationship and, consequently, strengthens the partners' tendency to think rigidly and erroneously. Furthermore, hostility can increase the partners' resistance to working on their relationship.
The goal of cognitive counseling is to "prompt the reality-testing system back into action." Cognitive counselors teach patients to correct defects in cognitive processing themselves. When working with cognitions, counselors teach clients:
Cognitive counseling can be widely applied in addressing specific psychosocial problems, related, for example, to family discord or low self-esteem. It is also most effective when working with clients who are able to focus on automatic thoughts and take responsibility for helping themselves. Cognitive counseling is not recommended for clients with diminished reality-testing ability (as, for example, in hallucinations and sensory deception), or for clients with significantly impaired memory and logical reasoning ability (as, for example, in organic brain syndromes). For certain disorders, such as recurrent depression, a combination of cognitive counseling and medication is recommended.
Cognitive counseling is typically highly structured and conducted over a short period of time. The standard treatment protocol for depression using cognitive counseling involves 15-20 sessions over more than 12 weeks. Sessions usually last 45 minutes.
Cognitive counselors use the following cognitive techniques to help clients replace their distorted automatic thoughts and beliefs with more realistic ways of processing information.
Providing a rationale. Counselors can point out certain difficulties in testing the validity of clients' interpretations and give a logical explanation of the importance of exploring the connections between what clients think, feel, and do. Counselors can give examples of how underlying perceptions influence feelings.
Questioning. Questioning can be used to uncover the automatic thoughts that arise in clients when they lose their emotional equilibrium. Imagery or role-play can sometimes be useful for recalling automatic thoughts.
Focusing on imagery can be an important way of gaining access to automatic thoughts. Many people who imagine scenes react to them as if they were real events.
Self-monitoring of thoughts. Clients can be asked to keep a daily automatic thought record at home. It is helpful to structure the diary with the following columns:
1) date;
2) the situation in which the negative emotion arose;
3) the experience of the emotion(s) and a rating of its intensity on a scale of 0-100%;
4) the automatic thought(s) and the corresponding belief.
Testing and correcting automatic thoughts. The counselor's task is to teach clients to treat their thoughts as hypotheses requiring verification. If necessary, hypotheses should be rejected or modified. The following methods are used for this.
Socratic questioning – a method involving the counselor formulating a series of questions that prompt clients to question the validity of their thinking. This approach also makes it possible to select alternative interpretations that best fit the facts. A good question for activating a client's critical thinking is «How else could you look at this?».
Decatastrophizing. The probability of the event occurring and its severity are analyzed. The main question asked during decatastrophizing is: «So, what will happen if this occurs?». In addition, an analysis is made of the client's ability to cope with the situation, the presence of supporting factors, and the client's ability to accept the worst possible outcomes.
Reattribution involves testing automatic thoughts and the underlying beliefs, and considering alternative ways of assigning responsibility and establishing causes. Clients can be asked to rate on a scale of 0-100% the degree of responsibility they take on for the negative events they fear. The counselor tries to generate and evaluate alternative explanations.
Reframing problems involves making them more specific and changing their formulation. This takes into account the feasibility of the tasks set.
Decentering is helping clients change their belief that everyone is focused on them. Clients are encouraged to carefully observe the actions of other people. Clients can be asked to note how often they themselves pay attention to others. This helps them recognize the limitations of their own observations.
Rational responses. It is important to teach the client to respond rationally to automatic thoughts. Through questioning, counselors can help clients learn to use their inner monologue to their own benefit.
Once clients have learned to respond rationally to automatic thoughts, they can be asked to fill in the columns for describing rational responses and outcomes in the diary. In the «Outcomes» column, clients
1) re-evaluate their belief in the automatic thought(s) on a scale of 0-100%;
2) identify their subsequent emotions and rate them on a scale of 0-100%.
Imagery techniques. Discovering more realistic perspectives is possible by repeatedly mentally imagining fantasies, projecting oneself into the future, and looking back from there at the situations that exist at the present moment.
Identifying underlying beliefs. Three main groups of underlying beliefs can be distinguished: beliefs related to the acceptance of reality; beliefs related to one's own competence; and beliefs related to control. Clients' underlying beliefs can be inferred from the themes of their automatic thoughts, their strategies for coping with difficulties, and their personal histories. Counselors present clients with hypotheses about their underlying beliefs for verification and more precise formulation.
To change underlying beliefs, counselors may use Socratic questioning. Counselors can ask clients questions aimed at encouraging them to examine their beliefs. Examples of such questions include: «Does this belief seem reasonable?», «Can you review the evidence for this?», «What advantages and disadvantages are associated with holding this belief?».
Conducting cognitive experiments. Counselors can encourage clients to test the truth of their beliefs through experiments. Beck described the following case. A woman was afraid to make an emotional commitment to her husband because she feared discovering that she could not trust him. Her core belief was: «I must not, under any circumstances, allow myself to be vulnerable». As a result of this distorted thinking, distant behavior and a search for flaws in her husband introduced coldness into their relationship. Beck arranged a three-month experiment for his client to test the hypothesis: «If I fully devote myself to improving my relationship with my husband and look for the positive instead of the negative, I will feel more secure». As a result, the woman found that she became more confident and thought less about divorcing her husband.
Re-experiencing childhood memories. Beck believed that in chronic personality disorders, the use of childhood experience is of exceptionally great importance. Clients can be helped to review and freely express their core beliefs. By refreshing developmentally related «pathogenic» situations through role-play and role reversal, clients gain the opportunity to restructure or change beliefs formed during the period in question.
Reshaping beliefs. Counselors can help clients reshape their beliefs about themselves, other people, and the world so that they better correspond to reality.
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