attitudes, and automatic thoughts related to themes of personal loss, deprivation, and failure (Beck et al., 1979). In contrast, individuals with clinically signifi cant anxiety tend to overestimate the probability of risk while simultaneously underestimating their resources for coping with potential threats. Th eir thoughts focus on themes of the self as vulnerable, the world as dangerous, and the future as potentially catastrophic (Beck et al., 1985). A per- son with paranoid personality disorder believes that others are malevolent, untrustworthy, abusive, and deceitful (Beck, Freeman, Davis, and Associates, 2004). On the other hand, an individual who experiences problems with substance abuse may have a set of core be- liefs that emphasize the self as inept, weak, trapped, or helpless. Such individuals may also engage in permission-giving beliefs (e.g., “I will just use one more time, then I will stop”) and hold particular beliefs about strategies for coping (e.g., “If I use, I can handle things better”) and about the inability to resist urges (e.g., “Even if I stop using, the craving will continue indefi nitely;” Ball, 2003).
3. Cognitive restructuring strategies 4. Modifi cation of core beliefs and schemas
5. Prevention of relapse/recurrence
A detailed discussion of these change strategies is beyond the scope of this chapter, and interested readers may consult DeRubeis et al. (2010) and Dobson & Dobson (2009). An overview of these strategies is provided below.
Th e therapeutic relationship is a key component of all psychotherapies, including cognitive therapy. Many of the basic interpersonal variables advocated by Carl Rogers (1951), including warmth, accurate empathy, unconditional positive regard, and genuine- ness and trust, serve as an important foundation for cognitive and symptomatic change.
As Beck et al. (1979) noted, however, we “believe that these characteristics in themselves are necessary but not suffi cient to produce an optimum therapeutic eff ect” (p. 45).
Dobson and Dobson (2009) summarize well the debate about nonspecifi c factors in psychotherapy by stating: “It is like a debate about whether it is the skeletal system, the nervous system, or the muscular system that permits humans to walk. Each of these factors is necessary but not suffi cient. So it is in psychotherapy” (p. 225). Although the relative emphasis in the writings on cognitive therapy has been on the effi cacy of various therapeutic strategies, this does not mean that relationship factors assume a secondary role. For instance, the Cognitive Th erapy Scale (Young & Beck, 1980), which is used to assess competency in cognitive therapy, has numerous items that pertain directly to the establishment of the therapeutic alliance (Dobson & Dobson, 2009).
Behavioral strategies serve an important function in cognitive therapy. Although these methods may serve to alter one’s reinforcement schedule (thereby increasing plea- sure or mastery) or habituate to feared stimuli, the primary focus is on cognitive change.
DeRubeis et al. (2010), for instance, describe the shifts in one’s belief system that may take place with the use of self-monitoring. Th e thought that “I am always down; it never lets up” or “Th ere is no point in getting out of bed” can be tested as hypotheses and by collecting data on one’s activities and mood state. Similarly, behavioral exposure results in belief change (the reassignment of meaning) about the threatening nature of feared stimuli. Behavioral strategies are arguably the most powerful means to attain cognitive change in cognitive therapy (Wells, 1997).
Cognitive therapists also help patients to identify and test the validity of their cogni- tions. One important strategy for eliciting and evaluating negative automatic thoughts is the Daily Record of Dysfunctional Th oughts (DRDT), of which there are a number of variants (e.g., Beck et al., 1979; DeRubeis et al., 2010; Greenberger & Padesky, 1995). By requiring one to write down an activating event, the mediating thoughts, and the ensuing emotional response, the DRDT fosters more objectivity about and distance from one’s thoughts. Th e evidence pertaining to a particular belief is then examined, using guided discovery and collaborative empiricism. Specifi cally, patients are asked a number of ques- tions, including: “What is the evidence for or against this belief ?” “What are the alterna- tive ways to think about this situation?” “If my best friend or loved one knew that I had
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this thought, what would he or she say to me?” “What would it mean about me even if this particular thought was true?” (D. Dobson & Dobson, 2009; Greenberger & Padesky, 1995). From this analysis of the evidence, patients are then taught to generate alternative thoughts that incorporate the evidence and lead to a shift in their emotional experience.
If a given thought is inconsistent with the weight of factual evidence that bears on the subject matter (e.g., “I am a failure”), the therapist helps the patient to alter and realign the thought so that it is evidence-based and, consequently, more adaptive and helpful.
Th ere are a number of common cognitive “errors” or processing biases (see Table 2.1) that all of us experience at diff erent times, particularly when aff ective arousal is high.
Instructing patients about the types of processing biases that are typical for them may be benefi cial, as it provides a convenient reminder about how their thinking may be unhelp- ful while promoting distance and objectivity. Th ere may be times when a patient’s thinking is not “distorted,” but rather refl ects the realities of given circumstances and hardships. In such instances, the emphasis is not on modifying cognition but on problem-solving, skill acquisition, and working out how best to approach the negative event or situation.
Table 2.1 Common Cognitive Errors Title Description
All-or-nothing thinking Also called black-and-white or dichotomous thinking.
Viewing a situation as having only two possible outcomes.
Catastrophization Predicting future calamity; ignoring a possible positive future.
Fortune-telling Predicting the future with limited evidence.
Mind-reading Predicting or believing you know what other people think.
Disqualifying the Not attending to, or giving due weight to, positive positive information. Similar to a negative “tunnel vision.”
Magnifi cation/ Magnifying negative information; minimizing positive
minimization information.
Selective abstraction Also called mental fi lter. Focusing on one detail rather than on the large picture.
Overgeneralization Drawing overstated conclusions based on one instance, or on a limited number of instances.
Misattribution Making errors in the attribution of causes of various events.
Personalization Th inking that you cause negative things, rather than examining other causes.
Emotional reasoning Arguing that because something feels bad, it must be bad.
Labeling Putting a general label on someone or something, rather than describing the behaviors or aspects of the thing.
Source: All EAs. From Evidence-Based Practice of Cognitive-Behavioral Th erapy (p. 129), by D. Dobson and K. S. Dobson. Copyright © 2009. Reprinted with permission from Guilford Press.
Th e next phase of therapy is predicated on the assumption that an individual’s auto- matic thoughts and cognitive distortions are functionally related to deeper core beliefs and schemas. Often, it is the modifi cation of these schemas that is believed to result in the most generalizable change and the greatest prevention of relapse (Dozois et al., 2009). With the use of the DRDT and other strategies (e.g., the downward arrow—
this approach begins with an automatic thought; rather than testing the thought with evidence, a patient is encouraged to deepen his or her level of aff ect and explore the thought with questions such as “what it would it mean if this thought was true?”, which typically helps to reveal deeper rules, beliefs, and assumptions), a number of themes emerge in therapy that provide clues as to the core beliefs that a given patient may hold.
In therapy, the patient and therapist chip away at these “deeper” beliefs, using Socratic dialogue and guided discovery, role plays, behavioral experiments, and other change strategies (DeRubeis et al., 2010; D. Dobson & Dobson, 2009).
Finally, at the end of treatment, cognitive therapists focus on the prevention of relapse/recurrence. Th is includes, among other things, a gradual titration of sessions and spreading apart of their timing; reviewing the treatment strategies that were used and were most helpful; creating a plan for the future; discussing feelings about the termina- tion of therapy; preparing for setbacks; identifying possible triggers of relapse (from the literature and the patient’s unique background); and ensuring that the patient makes internal attributions for treatment change.