In this article I will outline a critique of cognitive therapy (CT), a therapeutic approach most famously associated with the psychologist Aaron Beck (see Beck, 1967). Firstly, the philosophical underpinnings of the approach will be discussed such as the focus on conscious verses unconscious thought processes, as well as the mechanisms of dysfunctional thought such as the cognitive triad, negative self-schemas, and errors in logic. Next, typical features of how the approach is applied therapeutically are discussed as well as some important strengths and weaknesses outlined in the literature. Finally, I discuss how I utilize the cognitive approach in my own practice with clients.
Cognitive Therapy: Philosophical Principals
In the decades that followed Freud’s work (see Freud, 1915; Ellenberger, 2008), the rise of behaviourism and the subsequent ‘cognitive revolution’ eventually led to the development of cognitive therapy (Javel, 1999; Wedding, 1995). Beck, the founder of the approach, had indeed once applied Freudian principals in his earlier therapeutic work. However, while conducting Freudian free association techniques, Beck observed that thoughts were not as unconscious as described by Freud (Oatley, 2008). For Beck, it was largely the conscious negative thought patterns that were the root cause of psychological dysfunction.
According to Beck (1967) psychological dysfunction, and particularly depression, are caused by three main mechanisms. These are:
- The cognitive Triad (of negative automatic thinking).
- Negative self-schemas.
- Errors in Logic (i.e. faulty information processing).
The Cognitive triad: Generally, CT focuses directly on beliefs about helplessness and unloveability (Beck, 1995). According to beck, people who suffer from depression tend to generate negative thoughts about themselves, the world, and the future – a cognitive triad. These thoughts come seemingly spontaneously to the person and such spontaneous thoughts Beck felt were particularly important to therapeutic practice: “There is a whole level of mentation going on that isn't being tapped through our analytic methods” (Beck, 1997, p. 277). Spontaneous negative thoughts may arise in light of a specific stimulus and lead to a related emotional reaction. For instance, a person’s partner may forget about their anniversary. This may prompt a negative interpretation of the world (They really don’t care about me), themselves (Why would anyone love me), and feelings of helplessness (Nothing I ever do in relationships works). Each of these three negative assumptions may strengthen the others, leading to a downward spiral of negative thinking.
Negative self-schemas: Beck described the tendency for sufferers of depression to hold particularly negative or pessimistic views about themselves. These beliefs may have manifested as a result of traumatic childhood experiences (e.g., bullying, parental rejection/neglect). Often, the negative self-schema is upheld even in the face of abundant contradictory evidence. This highlights the illogical conclusions that can be drawn when an individual holds core beliefs that go unchallenged (Beck, 1967). However, by gradually uncovering the automatics thoughts of clients, underlying assumptions which influence how related events are perceived can be unearthed. The goal here is to challenge these core beliefs and change them if possible (Beck, 1976).
Errors in logic: An important feature of CT is that it identifies classifiable errors in reasoning typically found in clients seeking therapy (Beck, 1967). These include:
Arbitrary interference, whereby a largely irrelevant piece of information is assigned deeper implications (e.g., The weather in this country is awful and my life is depressing).
Selective abstraction, whereby a single piece of a story is illogically chosen as causal (e.g., I forgot to buy the right birthday cake and I’ve ruined my friends’ birthday).
Magnification, whereby the importance of a negative event is overblown (e.g., I only got a B in my term paper. I’m such a loser).
Minimization, whereby positive feedback is ignored without good reason (e.g., They told me I was an incredible singer but they’re just being nice. I’m not talented),
Overgeneralization, whereby broad conclusions are based on a single incident (e.g., My friend practically ignored me at the party. I feel our relationship is over), and...
Personalization, whereby an individual determines that they must be the cause of another person’s negativity (e.g., My lecturer never smiles. I think he hates me).
Identification and categorization of though, particularly dysfunctional thoughts, is a central aspect of CT (Brewin, 1996).
The Therapeutic Process
According to Beck (1995), the role of the therapist is to identify dysfunctional thought patterns and seek to guide the client through the process of cognitively reframing their interpretation of the stimulus.
In CT, there is little reliance on the therapists’ theories. Rather, CT is evidence based. A good illustration of this is in how Beck addressed the issue of clients’ defense mechanisms. For Beck, individuals often engage in various cognitive maneuvers in order to avoid facing undesirable thoughts, feelings or memories. CT suggests that the stance of the therapist is worth considering here. In psychoanalysis there is a tendency to presume that the analysts’ interpretations are accurate (Beck, 1995). Thus, if the client disagrees, they may be accused of being ‘in denial’. In CT however, the therapists’ interpretations should be regarded as hypotheses to be tested. Little to no assumption should be made.
In general, CT focuses on specific problems. In sessions, specific issues or problematic thinking are identified and addressed. Thus, CT is largely goal oriented. Clients working with their therapists are often asked to define specific goals for therapy. Long-term goals may take several sessions to address while some short-term goals may be addressed relatively quickly. During CT patients are expected to take an active role in sessions and even between sessions. They are often given homework assignments at the end of each session. During sessions, CT may involve multiple strategies such as Socratic questioning, role playing, imagery, guided discovery, and behavioural experiments (Gilbert & Procter, 2006).
Strengths and Limitations of Cognitive Therapy
Perhaps the most impressive aspect of CT is that it has been empirically proven to be effective. Butler and Beck (2000) examined the peer-reviewed empirical studies of therapeutic applications and concluded that approximately 80% of the sample benefited from the therapy. Their research also indicated that the therapy was more successful than drug therapy, with a significantly lower rate of relapse. This finding suggests strongly that there is indeed a cognitive basis for depression and that understand this mechanism can have a positive impact in improving people’s lives. CT has been very effective not only for treating depression (Hollon & Beck, 1994), but also for anxiety problems (Beck & Steer, 1993).
CT is founded in a cognitive theory of psychopathology. Moreover, cognitive theories lend themselves to testing. In a particularly illuminative study, Rimm and Litvak (1969) actually tried to control the independent variable (dysfunctional negative thinking). The hypothesis was that if there is in fact a cognitive basis for depression, participants should show signs of this psychopathology. This is exactly what the researchers found; participants encouraged to engage in dysfunctional thought patterns became more anxious and depressed.
While the Rimm and Litvak study indicates a clear role for cognition in psychopathology, not all researchers concur. The precise relationship between cognition and psychological dysfunction has not been fully determined. It may be the case that dysfunction thinking is merely a consequence of psychopathology and not its primary driver.
One study which suggest this is that of Lewinsohn (1981). Lewinson observed a group of people before any of them became depressed. Later, Lewinson observed that those who developed depression were no more likely to have engaged with dysfunctional thinking than those who remained psychologically well-adjusted. Thus, it may be that the ‘negative thinking leads to depression’ model is an oversimplification. In fact, the oversimplification argument has been a more general criticism of CT. Rossello and Bernal (1999) argue that thinking is just one part of human functioning, and that broader issues need to be addressed.
How I use Cognitive Therapy in my practice with clients
In this editorial section of the report, I will identify what I consider the most useful aspects of CBT; those that I use in my own practice. In my view, CBT should play a central part in the therapeutic process. This being said, I initally assess the clients’ readiness to engage with the process. Questioning the clients’ belief systems and potentially dysfunctional though processes can be a difficult undertaking. There may need to be a significant level of trust built in the client/therapist relationship before this process may begin. In general, using a person-centred approach may be a more appropriate way to initiate sessions. Over time, as the relationship grows stronger, the client may then feel prepared to engage with the challenging work of CBT.
CBT is a vital piece of the puzzle. I always maintain that it is a basic tool in our toolkit for mental health. In cases where trauma is an issue (PTSD, C-PTSD) more body-focused modalities are often more important. However, it's usually a matter of when CBT is used rather than if.