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A BRIEF OVERVIEW OF COGNITIVE THERAPY
©2004 by Dr. Charles Stanford, CCBT
INTRODUCTION
The cognitive approach shows that the ideas or beliefs we hold about certain issues are the key to change and/or self-improvement. It is only when the person can make these beliefs conscious that they can be examined and help up to scrutiny.
From a conceptual standpoint, the Freudian terms such as "Superego" are useful as they are widely used even by the general public. However, in approach to the Superego, a rational disputation of its contents can be successful and it is not necessary to employ the terminology in practice. In other words, the therapist could employ the Freudian terms but in dealing with a client it is best to discard the terminology. (It is worthwhile pointing out that recent graphics of the human brain have actually located activity in different centers of the brain while the “Ego, Id, and Superego” are active.) It remains, however, a helpful conceptual framework, but not an effective guide to treatment.
The approach favored by Ellis (REBT) is the most well-known, though his personality and misconceptions about him seem to confuse the issue. Beck and Meichenbaum also contribute to the cognitive approach, but a search of the site cogprints contains a wealth of others and the National Association of Cognitive Behavioral Therapists is a definitive group.
It is preferable to help the client to identify the irrational beliefs as this process is important from a cognitive standpoint and helps in disputing them. For this reason, a Socratic technique that allows the patient dispute is more effective than active disputation. Any other techniques that would forward this goal should also be used.
VIEW OF HUMANS
Good vs. Evil
Carl Rogers (the Rogerian approach) believes in the ultimate goodness of humanity and, if one is to be a counselor and subscribe to moralistic notions, this is the best view to have. One can hardly imagine the converse as an effective starting point for counselors. However, it is ultimately counter-productive to carry our own notions of good and evil into the counseling process. While it is possible within particular societies to reach some sort of consensus on these issues, it is best not to impose our abstract beliefs on our clients. Furthermore, since most psychological problems people have is a result of their accepting irrational and unverifiable beliefs, we can not help them if we are constantly judging them as well. We can retain our own moral and religious beliefs, but it is necessary also to understand and empathize with the client's beliefs. If our own biases interfere with this process, we can not help the client. In addition, such terms usually tell us more about ourselves than they do about the client. Therefore, we must suspend the notions of good and evil while counseling. "Productive" and "Counter-productive" seem to me better terms.
In this context, I remember talking to a friend of mine who was almost entirely left-brained if one subscribes to the left-brain vs. right-brain hypothesis as described nicely by Carl Sagan in Dragons of Eden. One time, while reflecting on what seemed to me very strange behavior on the part of a large number of students, I told him that it seemed to me that most people had an inferiority complex. I'll never forget his response: "Of course, exactly half have an inferiority complex and half have a superiority complex. That is what the normal curve is all about." He did not have much grasp on the implications of what he said, but certainly when we evaluate humans we must use something against which to measure them. So, to what are they to be compared? Animals? Mark Twain once said "Man, we are told, is the reasoning animal -- Now I wonder who found that out?"
Determinism
One of the logical problems with the strict Freudian approach, a deterministic, approach is that if our entire personality is determined by the ages of six of seven, it seems futile to do anything about it later. On the other hand, it is important to distinguish between Freud the theoretician and Freud the practitioner.
Perception
Each individual perceives the world differently. Adler was quite right to shift the focus to Individual Psychology. After all, we can start with the most basic concepts of perception and illustrate quite clearly that these differences exist. For example, on a test once given for color perception, I tested color-blind in two out of the three areas. In a later, more extensive test, it was five out of six. Still, I can point to an object and say it is blue or red (different ends of the spectrum) and others will agree with me that the object is indeed that color. Obviously, my perception of color is different than that of someone who was able to "pass" all three sections of that test and therefore has a different perception of reality even though we may use the same terms (such as "blue") to describe it. How much further must we be apart when we use terms such as "depression," "sadness," "fear," and "happiness?" The counselor must be a very attentive listener and use empathetic abilities to be able to understand as much as possible the inner world of the client.
Beyond That?
People are influenced greatly by early events, but are able to change and improve through an understanding of them. Furthermore, if the simple matter of color perception as a result of cones and rods in the physiology of the eye makes a difference, what an incredible difference must a completely different culture make. Gender, place in the family, income level, all these combine to make each human unique. If we remember that, we are in much better shape than someone who attempts to apply a theory blindly.
DEVELOPMENT AND STRUCTURE OF NORMAL PERSONALITY
I do not see much contradiction between any of the theories in this respect although the adherents of the various approaches undoubtedly do. For example, progression through the oral, anal, and phallic stages of the Freudian approach parallels Eriksson’s growth stages. Indeed, Eriksson built his model following Freud's but shifted the emphasis from an exclusively sexual one. In any Human Development textbook we see the stages of normal development as well.
Other theorists also have their own stages of development. For example, Adler believes that ones place in the family determines personality and that all people have the desire to become socially integrated. Glasser indicates that all people develop with the need to gain control.
Whatever the theory, however, "normal" is generally defined in relation to the standards, or norms, of the society. In some cultures, for example, suicide is a noble endeavor -- ancient Rome, Japan, and certain Alaskan tribes hold this view. In our culture, such an idea is considered an example of abnormal thinking. The important goal in therapy is that the individual function well and take satisfaction in his or her life, although some religious sects seem to believe that misery is the intended lot of humanity. I assume, however, that even in such a case they are happy if they are miserable -- an interesting paradox.
The main point is that "normal" development is defined by either the society or the individual. So long as the individual is able to define his or her own normality without arousing the ire of society, that individual is fully functioning. The personality that is "normal" in all respects is not likely to need counseling.
DEVELOPMENT OF ABNORMAL PERSONALITY
This is of far more interest. Freud invented some very interesting and useful terms to describe what is going on inside the mind. It does not matter if we think of the terms as actually representing physical reality, processes, parts of the brain, or use them to clarify some concepts. For example, in his theory, the libido manifests itself in the id of the newborn. It is the drive of the libido (for our purposes not representing sexual drive, but some sort of life-force without any metaphysical ramifications) that needs to be satisfied. But the newborn soon finds that there are restrictions on the expression of purely libidinous desires and develops the ego in order to mediate between the external world, or reality, and the drive. The external world finds the individual difficult to control at all times but manages, through the development of the superego, to implant certain "dos", "don'ts," and "musn'ts" into the individual’s mind -- so much so, that at times the superego's strength is able to overcome the combined will of the id and the ego and make it nearly impossible for the individual to function.
(Again, I would not use the Freudian terminology in dealing with a client, but it helps provide the framework for diagnosis.) Essentially, people with emotional and psychological problems generally hold at least one irrational belief and these beliefs are in the part of the mind Freud referred to as the Superego. Sometimes these beliefs can be deeply submerged into the sub- or un-conscious, a distinction that seems useless. All of these beliefs usually have at their root some sort of self-blame. This blaming or shaming can be directed inwardly ("I am no good") or projected outwardly ("you are no good"), and are entirely irrational and unverifiable.
These beliefs can be inserted into the mind at any time. Perhaps the Freudian are right when they say that fear of the father is the root of a problem. Perhaps Erikson is right when he says that the individual never resolved the trust vs. mistrust issue from early childhood. Perhaps early religious training inculcated the belief that all humans are sinners. Perhaps the individual has unrealistic expectations from herself or from life. Perhaps it is a combination of all these plus a self-indoctrination that perpetuates these beliefs. The source of them is not as important as bringing them to the surface and analyzing them.
GOALS OF COUNSELING
The first and foremost goal is to determine what the client really wants out of counseling and then attempt to facilitate the process. The goals, then, are as varied as the clients. In short, we must find out why the person is in counseling.
There are diverse reasons why someone comes to counseling. They range from a simple straightforward desire on the part of the client to achieve some goal such as loosing weight to having been forced into the situation by our legal system. In all cases, however, counseling is supposed to help the client.
Listed under this subheading are some interesting entries for some of the approaches. In the Freudian approach, we decided, the goal was to make the subconscious become conscious. In Adlerian Therapy, motivations and the overcoming of infirmities was mentioned. In Person Centered Therapy, "Client solves problems" is what is definitive. A problem is that these items could be listed under any of the next two sections ("Role of counselor" and "Diagnosis and Assessment."
ROLE OF THE COUNSELOR
A cognitive approach is generally conceded these days to be most effective. However, a Rogerian approach could be far superior, especially in the early stages where the counselor is trying to learn as much as possible about the client. The advantage of the Rogerian approach is that the stated problem may not be the real one. The counselor needs to listen and sometimes ask questions, indicating all along positive regard for the client, in order to understand the problem as deeply as possible.
Indeed, perhaps the entire first session should be devoted to this approach, depending upon the attitude the client seems to harbor.
But once we find the problem, what then? Rogers believes that continued positive regard and a warm relationship will eventually lead the client to solving the problems on his or her own. Perhaps, given enough sessions, this will work, and with some patients it may be sufficient for the relatively short period of time currently afforded counseling by economic forces. Perhaps the client can identify the irrational belief or beliefs, dispute them, and substitute a more healthy, sane outlook for themselves.
Such clients are rare. Most of them need some guidance for this task. However, while it is effective to use a didactic, confrontational style, it will not work for all patients. Nor is logic alone sufficient. A combination of logic and rhetoric in the classical sense of the term is more likely to be effective. Rhetoric seeks to persuade and uses logic as one of its tools and can be very powerful and effective if used properly. Today Rhetoric is used as a synonym for what someone you disagree with says, but it has a long and honorable tradition. It is supposed to allure the listener or, in this case, client towards accepting a more effective belief.
For this reason, I think in many cases the more Socratic method suggested by Beck would be more appropriate. Through asking questions, one can eventually elicit from the client a statement of the irrational belief. But this is a technique.
DIAGNOSIS AND ASSESSMENT
The DSMV-IV is the official or generally accepted manual for diagnosis. In this era of HMO domination of the field and the HMOs' aversion to treating mental and/or emotional disorders, it is necessary for practical purposes to use this manual in a formal diagnosis. Of more importance, however, to the client is finding out what the problem really is (and by this I mean to imply that it might be different than the formal one). Isolating the irrational belief, bringing it to the conscious level, and helping the client dispute it is the most effective focus. TECHNIQUES OF THERAPY
Once the irrational belief is out in the open, so to speak, the next step is to dispute it. How one goes about this depends a great deal on the client and also on the counselor. In other words, it is the relationship between the two that is the determining factor. In addition, one finds great difficulty in determining a counselor's theoretical approach by observing the techniques used. In other words, a strict Freudian may use a technique developed by the Behaviorists, a Rogerian may wind up in a philosophical discussion with a client or use role-playing. The distinction might well be why the counselor chooses to use that particular technique at that particular time with that specific client.
As I stated above, first the Rogerian approach should be used to formulate a diagnosis. Once the irrational belief is brought to the conscious level, it needs to be disputed. The question now is how and that depends on the patient.
One of my patients was concerned about getting married again because his first marriage failed. Through asking questions, I determined that he actually believed that "all women were the same." Now, this is a deeper problem than meets the eye. An immediate approach would be to point out that this woman was not the same as the first woman and he was not the same as before. There is no rational justification for believing that one marriage would fail simply because the other did. QED. Session over!
This client, moreover, was a rather truculent "macho" personality. Direct disputation might have been fun, but unlikely to succeed given his pride at his "intellect." However, knowing that he actually believed that "all women were the same," I asked more questions:
Q: They are all exactly the same?
A: Yes, exactly.
Q: In every way?
A: Yes, every way.
Q: Are all men the same?
A: Oh, no, of course not. Men have ideas. They think for themselves. They are all different.
Q: Why are they all different?
A: The way they are raised.
Q: I see. Are all men raised exactly the same?
A: No, of course not!
Q: Are all women raised exactly the same?
A: Ah, I see what you’re getting at!! Yes?
This is condensed, but it is accurate. The next step was to give a homework assignment. Mine was as follows: "What you have now is a hypothesis. Let's test it. Without letting anyone know what you are up to, I want you to study women, making a list of hard facts as to the ways they are different and the ways they are similar. Let's see if you can verify it."
Role playing could be important in some instances. Suppose a client thought that his boss was so intolerant that she would not let him lodge even a minor complaint. The irrational belief may be an idea that if his complaint were rejected, he would be crushed, it would be the end of the world. In this case, it might be helpful first to play him while he played her. He might eventually role play the worst possible outcome. At least that is now defined. Would that outcome really be so terrible? Would it really be a reflection on him or on her? To further reinforce the message, reversing the roles, based on his interpretation of her, helped. This actually led to a different outcome once he saw an alternative way of picturing her.
Obviously, much more can be said, but this is only intended as a brief, introductory, remark to help define “cognitive approaches.”
