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Unread November 11th, 2004, 06:12 PM
James Pretzer James Pretzer is offline
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Default Is CT defined by interventions designed to change cognitions? (Part 1)

Your idea of looking back to seminal works and also at subsequent ones is a good one (though my point isn't to prove you wrong). Certainly, trying to change the content of cognitions is a very important part of CT and one can build a good argument that it is a defining characteristic of CT. However, even in early publications, the emphasis was not solely on changing cognitions. In Cognitive Therapy and the Emotional Disorders, Beck (1976, pp. 214-215) wrote:
“In the broadest sense, cognitive therapy consists of all the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals. The emphasis on thinking, however, should not obscure the importance of the emotional reactions which are generally the immediate source of distress. It simply means that we get to the person’s emotions through his cognitions. By correcting erroneous beliefs, we can damp down or alter excessive, inappropriate emotional reactions.
-snip-
The ‘experiential’ approach exposes the patient to experiences that are in themselves powerful enough to change misconceptions. The interactions with other people –snip- may help a person to perceive others more realistically and consequently to modify his inappropriate maladaptive responses to them. –snip- Similarly, a patient, in response to his psychotherapist’s warmth and acceptance, often modifies his stereotyped conception of authority figures. –snip- Sometimes the effectiveness of psychotherapy is implemented by motivating a patient to enter situations he had previously avoided because of his misconceptions.
The ‘behavioral’ approach encourages the development of specific forms of behavior that lead to more general changes in the way the patient views himself and the real world. Practicing techniques for dealing with people who frighten him, as in ‘assertive training,’ not only enables him to regard other people more realistically but enhances his self-confidence.”
In Cognitive Therapy of Depression (Beck, Rush, Shaw & Emery, 1979, p. 117) the chapter on behavioral techniques preceeds the one on cognitive techniques and it clearly asserted that CT includes much more than the application of cognitive techniques:
“The cognitive therapy of depression is based on the cognitive theory of depression. By working within the framework of the cognitive model, the therapist formulates his therapeutic approach according to the specific needs of a given patient at a particular time. Thus the therapist may be conducting cognitive therapy even though he is utilizing predominantly behavioral or abreactive (emotion releasing) techniques.”
This also makes it clear that if the therapist is using interventions that don't make sense in terms of the cognitive model, they aren't doing good CT. This applies if one is using a "non-cognitive" technique in a way that doesn't make sense conceptually or if one is using a cognitive technique in a way that doesn't make sense conceptually. Using thought sheets inappropriately isn't good CT. Using mindfulness training or gestalt "empty chair" techniques can be good CT if it is done in a way that makes sense conceptually.

It is important to remember that the “seminal works” were written 25 or 30 years ago and that CT has evolved a bit since then. For a contemporary statement of CT’s view, consider the following excerpts from the chapter that Dr. Beck and I wrote of the second edition of Major Theories of Personality Disorder (Clarkin & Lenzenweger, 2004):
“Cognitive Therapy is based on the proposition that much psychopathology is the result of systematic errors, biases, and distortions in perceiving and interpreting events. These cognitive factors are seen as resulting in dysfunctional responses to events which, in turn, may have consequences which serve to perpetuate the dysfunctional cognitions. Theoretically, the focus is strongly on the interaction between the individual and his or her environment rather than emphasizing either individual or situational factors in isolation (for a detailed example see Pretzer, Beck, & Newman, 1990). Individuals' interpretations of events are seen as playing a central role in many forms of psychopathology, and these interpretations are seen as being the product of the interaction between the characteristics of the individual and the nature of the events the individual encounters. However, in discussing treatment, much more emphasis is placed on individual factors (such as dysfunctional beliefs) than on situational factors (such as negative life events) because therapist and client are more able to modify individual factors than situational ones.
-snip-
In considering the role of cognition in psychopathology, Cognitive Therapy uses the term "cognition" broadly to refer to much more than verbal thought of which the individual is self-consciously aware. "Cognition" is treated as synonymous with information processing and no a priori assumption is made that all important aspects of cognition are verbally mediated, are easily accessible to the individual's awareness, or are subject to the individual's volitional control. In fact, much cognition occurs outside of awareness simply because the individual is not paying attention to it. Many of the processes involved are automatic and occur without a need for awareness or volitional control. Cognition is not necessarily verbally-mediated. It can also be mediated by mental imagery or can involve more abstract modes of information processing
-snip-
Also, while the Cognitive model assumes that the individual's interpretation of events shapes his or her emotional response to the situation, we also argue that the individual's emotional state has important effects on cognition. A large body of research has demonstrated that affect tends to influence both cognition and behavior in mood-congruent ways (Isen, 1984). A number of studies have demonstrated that even a mild, experimentally induced depressed mood biases perception and recall in a depression-congruent way (see Watkins, Mathews, Williamson, & Fuller, 1992). This means that a depressed mood increases the likelihood that the individual will focus on negative aspects of the situation and preferentially recall negative experiences which occurred in the past. While this phenomenon has not been investigated extensively for most other moods, it appears that many moods tend to bias perception and recall in a mood-congruent way. Thus, as an individual's level of anxiety increases, attentional processes appear to be biased in favor of signs of threat (Watkins, et al., 1992). This phenomenon lays the foundation for a potentially self-perpetuating cycle where the individual's automatic thoughts elicit a particular mood, the mood biases perception and recall in a mood-congruent way, this increases the likelihood of additional mood-eliciting automatic thoughts, which elicit more of the mood in question, which further biases perception and recall, and so on until something happens to disrupt the cycle.
-snip
It is important to notice that the Cognitive model does not assert that cognition causes psychopathology. We view cognition as an important part of the cycle through which humans perceive and respond to events and thus as having an important role in pathological responses to events. However, we view it as a part of a cycle and as a promising point for intervention, not as the cause.
-snip-
The Cognitive model of psychopathology emphasizes the effects of dysfunctional automatic thoughts; dysfunctional schemas, beliefs and assumptions; and dysfunctional interpersonal behavior. Therefore, each of these are important targets for intervention in Cognitive Therapy. The initial goal of Cognitive Therapy is to break the cycle or cycles which perpetuate and amplify the client's problems (see Figure 3). This could potentially be done by modifying the client's automatic thoughts, by improving the client's mood, by working to counteract the biasing impact of mood on recall and perception, and/or by changing the client's behavior. In theory, these interventions could break the cycle or cycles which perpetuate the problems and thus could alleviate the client's immediate distress. However, if the therapist only does this, the client would be at risk for a relapse whenever he or she experienced events similar to the ones which precipitated the current problems. In order to achieve lasting results, it would also be important to modify the schemas, beliefs, and assumptions which predispose the client to his or her problems and to help him or her plan effective ways to handle situations which might precipitate a relapse.
Our view is that many dysfunctional cognitions persist because: a) many individuals are unaware of the role their thoughts play in their problems, b) the dysfunctional cognitions often seem so plausible that individuals fail to examine them critically, c) selective perception and cognitive biases often result in the individual's ignoring or discounting experiences which would otherwise conflict with the dysfunctional cognitions, d) cognitive distortions often lead to erroneous conclusions, e) the individual's dysfunctional interpersonal behavior often can produce experiences which seem to confirm dysfunctional cognitions, and f) individuals who are reluctant to tolerate aversive affect may consciously or non-consciously avoid memories, perceptions, and/or conclusions which would elicit strong emotional responses.
This view suggests that cognitive interventions should be directed towards identifying the specific dysfunctional beliefs which play a role in the individual's problems and examining them critically while correcting for the effects of selective perception, biased cognition, and cognitive distortions, and helping the individual to face and tolerate aversive affect. Logical or intellectual analysis of dysfunctional cognitions is usually not sufficient to accomplish substantive change. Individuals often find that within-session interventions can be intellectually convincing but that to be convinced "on the gut level", and to have the change in cognitions be manifested in their behavior, it is usually necessary to test the new cognitions in real-life situations. These "behavioral experiments" (see Beck, Rush, Shaw & Emery, 1979, p. 56 or Freeman, et al., 1990, pp. 76-77) are often much more convincing than any amount of intellectual insight. When dysfunctional cognitions are strongly supported by interpersonal experience, it may be necessary to accomplish changes in interpersonal behavior and/or in the individual's environment in order to challenge the cognitions effectively.
It is our view that many dysfunctional behaviors persist because: a) they are a product of persistent dysfunctional beliefs, b) expectations regarding the consequences of possible actions encourage behaviors which actually prove to be dysfunctional and/or discourage behaviors which would prove adaptive, c) the individual lacks the skills needed to engage in potentially adaptive behavior, or d) the environment reinforces dysfunctional behavior and/or punishes adaptive behavior. This view suggests that to change dysfunctional behavior it may be necessary to modify long-standing cognitions, to examine the individual's expectations regarding the consequences of his/her actions, to modify the individual's environment, or to help the individual master the cognitive or behavioral skills needed to successfully engage in more adaptive behavior.
It is interesting to note that when dysfunctional behavior is strongly maintained by dysfunctional cognitions, it may be necessary to modify the cognitions first, and that when dysfunctional cognitions are strongly maintained by the effects of dysfunctional behavior, it may be necessary to modify the dysfunctional behavior first. This suggests that if it is true that personality disorders are characterized by self-perpetuating cognitive-interpersonal cycles where dysfunctional cognitions strongly maintain dysfunctional behavior and dysfunctional behavior strongly maintains dysfunctional cognition, it may be difficult to find ways to intervene effectively. We argue that when a self-perpetuating cognitive-interpersonal cycle exists it may not be possible to effectively modify either cognitions or behavior in isolation and that a strategic intervention approach based on a clear conceptualization is likely to be necessary.”
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