Cognitive counseling principles and practice

Cognitive Counseling

This is a template and guideline ONLY. Please do not turn in as final paper.

What is It?

Cognitive counseling, as defined by most of the experts in the field, consists of a therapy which emphasizes observing and managing a person's thought patterns. It focuses on decreasing negative thinking to the point that the basic thought patterns change to result in more positive feelings. The therapy also attempts to alter the "tone of voice" the individual uses for thinking.

That our thoughts are bonded to our emotions or feelings is the basis of cognitive therapy. There are four defined cognitive therapies: Cognitive-Behavioral, Rational-Emotive, Reality, and Transactional Analysis. Counselors in these fields help patients (or clients) to clarify their distorted thinking and to solve every-day practical problems, especially those that cause emotional discomfort. The roots of problems are not emphasized strongly, but, instead, their present-day thinking, because that is what causes them their suffering.

These variants of an approach to therapy involve some common traits to include: the tendency for the therapy to be of short duration, a mutual, shared relationship between the patient and the counselor, and homework between therapy sessions. This field of therapy is best-suited to handle anxiety, anger and mild depression problems.

The "behavioral" part of cognitive-behavioral therapy is based on the idea that experience gives us our primary learning. The therapy attempts to assist the client to analyze his or her behavior, define their problems, and choose some goals.

This therapy incorporates behavioral experiments, role-playing, homework, assertiveness training, and self-management training. It, like cognitive, includes a collaborative relationship between client and therapist and is also, usually, of short duration (Counseling Approaches).

This field of therapy also assists the client to understand their unhealthy thoughts and the way they keep the individual stuck. Negative thoughts are identified such as: "I never do anything right," or "If I don't succeed all the time, I am a failure."

If the therapy is somewhat successful, the results should be that the client's thoughts change and that leads them to different, more positive behaviors. Hopefully, self-esteem and confidence are improved as well.

Over hundreds of clinical trials, for many different health problems and disorders, this form of therapy is one of the few that has really been "reality" tested and found successful. We will discuss cognitive behavioral in detail later.

All cognitive therapies, in contrast to other forms of psychotherapy, are usually more pointed toward the present, more time-limited, and more problem-solving oriented. Most of what the client does is solve existing problems. In addition, they learn abilities they can use forever. The skills they learn involve identifying their own distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.

Cognitive Therapy History

Cognitive therapy, though founded in this century, has its roots under other names and in previous centuries.

During the late 1800s, doctors, neurologists and psychiatrists surmised that the mind rotated around the brain -- that is, it was the brain, that physical part of our central nervous system located within the skull -- that was the seat of the mind. The mind has been defined as "the human consciousness that originates in the brain and is manifested especially in thought, perception, emotion, will, memory, and imagination, i.e. The collective conscious and unconscious processes that direct and influence mental and physical behavior (American Heritage Dictionary).

It was proposed back then that mental states could affect physical function. In the 1870s, G.M. Beard, M.D., read a paper at the American Neurological Association. It related to the causes and cures of disease, and discussed the influence of the mind on that activity. He said back then precisely what cognitive therapy proves today, that the impact on humans brought about by emotions, in a systematic way, were as permanent as those brought about through medicine. Most of Beard's colleagues of the day did not accept his views.

Also in that same timeframe of the 1870s, the American Journal of Insanity (AJI) published a paper by J.Tobey, M.D., that talked about the influence of the doctor or psychiatrist to excite the mental state "which acts beneficially on the body."

Over the next thirty years, others joined in the chorus. Most notably, in 1901, Richard Dewey, M.D., published a paper in the AJI titled "Mental Therapeutics in Nervous and Mental Diseases." He wrote, "The so-called functional nervous diseases are strikingly affected by mental influences.... Often a long course of training and practice in substituting safe expectations for fear and apprehension [is needed].[T]he cure consists of a process of rebuilding in the patient healthful lines of thought and association and of forming new habits of thought and action by a process [like] education." Dewey's colleagues supported his views (Ozarin).

These ideas were further developed by John Whitehorn, M.D., who followed Meyer at Johns

Hopkins (1941-1960). He noted that the way he talked with patients differed from that of other psychiatrists. Basic to his approach was the premise that individuals react to other people and situations in a learned manner that depends on the "attitudes and sentiments" by which they establish relationships and negotiate in interpersonal transactions. He advocated a therapy promoting learning that builds a patient's expectations about his or her ability to deal with anxiety-provoking situations. The therapist guides the patient in a collaborative process to correct misperceptions, assume more realistic attitudes, and seek solutions to deal with disturbing people and situations (Ozarin).

Dr. Aaron Beck

Finally, dissatisfied with the more conventional paths to psychotherapy, Dr. Aaron Beck began developing the field of cognitive therapy at the University of Pennsylvania School of Medicine in the 1970s.

As a part of his study, anger issues in the dreams of depressed patients were what Beck was looking for. He saw that more than self-anger was a partiality within his patient's self-analysis of their dreams. From this breakthrough Beck developed his wide-ranging theory and treatment of depression.

From Beck's research, he contended: people with emotional difficulties tend to commit characteristic "logical errors" which slant objective reality to the path of self-deprecation. Beck challenged the notion that depression results from anger which is then turned inward. Beck also challenged the idea of having the focus on the content of the depressive's negative thinking and biased interpretation of events (Beck).

To focus on the content, Beck's approach to the treatment of depression consists of placing a heavy emphasis on core beliefs. A key factor of this therapeutic process involves restructuring distorted beliefs which have a pivotal impact on changing dysfunctional behaviors (Melton).

Cognitive behavior therapists place a heavy emphasis on examining cognitions among individual family members as well as on the family beliefs. With this serious emphasis on relationships, Beck's belief is: therapeutic sessions typically have the therapist take the lead.

The therapist helps the client make a list of his/her responsibilities, set priorities, and develop a realistic plan of action. Therapists also use cognitive rehearsal techniques to identify and change negative thoughts. Cognitive therapy perceives psychological problems as stemming from commonplace processes such as faulty thinking, failing to distinguish between fantasy and reality, and making incorrect inferences on the basis of inadequate or incorrect information.

By changing thinking, behavior, and emotional responses, therapists assist clients in overcoming challenges and difficulties. If the client can learn to combat self-doubts in the therapy session, he/she may be able to apply their newly acquired cognitive and behavioral skills in real-life settings (Melton).

Beck's cognitive therapy consists of the many approaches lessoning psychological suffering through therapy. Therapy aids in helping clients self-signal to correct faulty conceptions. This decisive approach permits the therapist and practitioner to value the integrative nature of cognitive behavior therapy.

Universities and colleges across the globe launched a rigorous investigation of the field at that time, and continuing today. It is now, along with its "brother" variations, one of the most popular, most widely researched and practiced of the modern-age psychotherapies (Melton).

During these thirty-plus years, an enormous amount of research supports the affectivity of cognitive therapies for depression, anxiety and a long list of further mental problems. As a matter of fact, studies done indicate that this form of therapy is as good for patients with depression as is antidepressant medication, and the results are that the depression is less likely to recur.

Then there are all the side effects that the antidepressant involves, which the therapy does not entail. However, sometimes with more severe symptoms, patients are given counseling as well as medication, and some milder side effects may occur.

Other disorders that may be treated with some form of cognitive therapy include:

generalized anxiety, panic, social anxiety, obsessions, worry, & phobias; couples, marital, divorce, and loneliness problems; relapse prevention for substance abuse; eating disorders;

sexual dysfunction; and medical disorders affected by psychological problems, such as insomnia, chronic pain, GI problems, headaches, and high blood pressure.

Theory

The way we perceive situations influences how we feel. That is the cognitive concept upon which cognitive therapy is based. For example, one person reading this paper might think, "Wow! This sounds good, it's just what I've always been looking for!" And feels happy. Another person reading this information might think, "Well, this sounds good but I don't think I can do it." This person feels sad and discouraged. So it is not a situation which directly affects how a person feels emotionally, but rather, his or her thoughts in that situation. When people are in distress, they often do not think clearly and their thoughts are distorted in some way (Beck).

Cognitive therapy helps people to identify their distressing thoughts and to evaluate how realistic the thoughts are. Then they learn to change their distorted thinking. When they think more realistically, they feel better. The emphasis is also consistently on solving problems and initiating behavioral change (Beck).

Thoughts intercede between some sort of stimulus, such as an external event, and feelings. The motivator (stimulus) brings out a thought -- which might be a weighted judgment -- which turns into to an emotion. In other words, it is not the stimulus that somehow brings out an emotional response, but our judgment of or feelings about that stimulus.

Two other assumptions buttress the method of the cognitive counselor or therapist: First, that the patient is mentally and physically capable of recognizing his or her own thoughts and of altering them. And, secondly, that sometimes the thoughts brought out by a stimulus of some kind alter or fail to reflect reality accurately.

A "real" example of different thoughts about the same situation and the resulting emotions is the case of a person being turned down for a job. She thinks and feels like she lost the employment opportunity because she was inept. She could become depressed, and she might not apply for the same kind of job again. However, if she feels she was not hired because the other candidates' resumes were stronger, she might feel frustrated and disappointed but not necessarily depressed, and the experience probably wouldn't keep her from applying for other similar jobs.

Cognitive therapy suggests that psychological distress is caused by distorted thoughts about stimuli giving rise to distressed emotions. The theory is particularly well developed (and empirically supported) in the case of depression, where clients frequently experience unduly negative thoughts which arise automatically even in response to stimuli which might otherwise be experienced as positive (Mulhauser).

For instance, a depressed client hearing "please stop talking in class" might think

"everything I do is wrong; there is no point in even trying." The same client might hear "you've received top marks on your essay" and think "that was a fluke; I won't ever get a mark like that again," or he might hear "you've really improved over the last term" and think "I was really abysmal at the start of term." Any of these thoughts could lead to feelings of hopelessness or reduced self-esteem maintaining or worsening the individual's depression (Mulhauser).

Cognitive Behavior Therapy

The first cousin of Aaron Beck's theories and practice of cognitive therapy is cognitive behavioral therapy (CBT).

The goal of cognitive therapy or cognitive behavioral therapy (CBT) is to comprehend how emotions, behaviors and thoughts interrelate, and how they may be "manipulated" by an outside stimulus -- including events which may have occurred early in the client's life.

The goal of cognitive counseling/therapy is not to correct every thought distortion in a client's perspective -- just those which may be the cause of his distress. The therapist will attempt to understand experiences from the patient's point-of-view, and the client and therapist will work together with a practical outlook, pursuing the client's thoughts and assumptions. The therapist assists the client in learning how to test these by comparing them to reality and against other assumptions.

A client who is afraid of dying in an automobile accident is causing her great concern when it comes time to leave for work, might write down their estimate of the odds of dying in a car crash at various points in the morning -- when they first get up. Then she might repeat that exercise when she is nearly ready to leave the house, again when she is almost to the car, and, finally, when she is driving to work. (These odds might be: 1,000 to 1 against (dying) when first getting out of bed; 20 to 1 against when nearly ready to leave the house; 2 to 1 against when almost to the car; 5 to 1 in favor of dying in a car crash when actually driving.) The patient can see that their estimated odds of actually dying in a car crash are changing minute to minute as they eat breakfast and get ready to depart. This can force them toward making the estimates more realistic in the first place and reducing the anxiety which accompanies the thought that one is very likely to die in a crash while driving.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. All have similar characteristics:

External things, like people, situations, and events do not cause our emotions or the way we behave -- our thoughts do. This is a help to us because it means we can alter the way we think about things in order to change the way we feel and act even when the circumstance doesn't change.

The client receives less than 20 sessions. Psychoanalysis can take years. CBT is briefer because of its highly instructive nature and the fact that it makes use of homework assignments. Clients are helped to understand at the very beginning of the therapy that there will be a point when the therapy will end and that ending is a joint decision made by the therapist and client. CBT is never an open-ended process.

CBT therapists believe that the clients change because they learn how to think differently and they act on that. In other forms of counseling, the good relationship between client and therapist is given the credit for why people get better. Therefore, CBT therapists focus on teaching rational self-counseling skills.

The counselor's part in the therapy is to pay attention, instruct, and provide support, while the patient's role is to express concerns, absorb the lessons, and take action concerning each lesson. The therapist's objective is to learn what their clients want out of life and then help them achieve it.

Most people seeking counseling do so because, basically, they do not want to feel the way they have been. Some of the CBT therapies emphasizing stoicism teach the benefits of feeling calm when confronted with undesirable situations. They also stress that we will have our unwelcome circumstances whether we are upset about them or not. If we are concerned or emotionally upset about our troubles, we have two problems -- the problem, and the fact that we are concerned or bothered by it. If we can learn to calmly accept a problem, we are in a better position to make use of our intelligence, energy, and resources to fix whatever is troubling us.

CBT counselors want to understand their patients' problems. They ask questions and patients are supportively asked to question themselves about how they are feeling.

CBT therapists do not "capture the prey" for the clients -- they teach them how to hunt! In other words, clients are not told what to do but how to do something. CBT counselors keep an agenda for each session and teach specific techniques or concepts during that lesson. Counselors show clients how to think and act in ways that will allow them to obtain the things they want.

The objective of CBT counseling is to assist clients to discard their unwanted responses and to acquire new ways of reacting. What CBT is not, is "just talking." One of the main priorities of CBT is long-term results. People who comprehend how and why they are doing well, know what to do to continue doing well.

Inductive thinking allows us to self-analyze our thoughts and determine if they are guesses, and if so, question and test them. And if we find our guesses are incorrect (because we have new information), we can adjust our thinking to be in line with what the new situation is. Our thinking is always based on fact. The client learns to assess the facts of his situation to determine if he really should waste his time getting upset over his perceived idea of what the circumstances are.

Homework. Like writing or math, you can't learn when you don't practice. Reading is assigned as part of the CBT sessions. Goal achievement could take a very long time if a person were only to think about the techniques and topics taught for one hour per week. That's why CBT therapists assign reading assignments and encourage their clients to practice the techniques learned.

Rational Emotive Behavior Therapy

The first discrete, intentionally therapeutic approach to CBT to be developed was Rational Emotive Therapy (RET), which was originated by Albert Ellis, Ph.D. In the mid-1950's. Ellis developed his approach in reaction to his disliking of the in-efficient and in-directive nature of psychoanalysis. The philosophic origins of RET go back to the Stoic philosophers, including Epictetus and Marcus Aurelius. Epictetus wrote in The Enchiridion, "Men are disturbed not by things, but by the view which they take of them." The modern psychotherapist most influential to the development of RET was Alfred Adler (who developed Individual Psychology). Adler, a neo-Freudian, stated, "I am convinced that a person's behavior springs from his ideas." Ellis was also influenced by behaviorists, such as John Dollard, Neal Miller, and Joseph Wolpe, and George Kelly (psychology of personal constructs) (NACBT, 2008).

Ellis developed and popularized the ABC model of emotions, and later modified the model to the A-B-C-D-E approach. In the 1990's Ellis renamed his approach rational emotive behavior therapy (NACBT, 2008).

Rational emotive behavior therapy (REBT) views human beings as 'responsibly hedonistic' in the sense that they strive to remain alive and to achieve some degree of happiness. However, it also holds that humans are prone to adopting irrational beliefs and behaviors which stand in the way of achieving their goals and purposes. Often, these irrational attitudes or philosophies take the form of extreme or dogmatic 'musts', 'shoulds', or 'oughts'; they contrast with rational and flexible desires, wishes, preferences and wants. The presence of extreme philosophies can make all the difference between healthy negative emotions (such as sadness or regret or concern) and unhealthy negative emotions (such as depression or guilt or anxiety). For example, one person's philosophy after experiencing a loss might take the form: "It is unfortunate that this loss has occurred, although there is no actual reason why it should not have occurred. It is sad that it has happened, but it is not awful, and I can continue to function." Another's might take the form: "This absolutely should not have happened, and it is horrific that it did. These circumstances are now intolerable, and I cannot continue to function." The first person's response is apt to lead to sadness, while the second person may be well on their way to depression. Most importantly of all, REBT maintains that individuals have it within their power to change their beliefs and philosophies profoundly, and thereby to change radically their state of psychological health (Mulhauser, An Introduction to Rational Emotive Behavior Therapy).

As we mentioned, REBT utilizes Ellis' 'ABC framework' -- depicted in the figure on the next page -- to clarify the relationship between activating events (A); our beliefs about them (B); and the cognitive, emotional or behavioral consequences of our beliefs (C). The ABC model is also used in some renditions of cognitive therapy or cognitive behavioral therapy, where it is also applied to clarify the role of mental activities or predispositions in mediating between experiences and emotional responses (Mulhauser, An Introduction to Rational Emotive Behavior Therapy).

In addition to the ABC framework, REBT also employs three primary insights:

1. While external events are of undoubted influence, psychological disturbance is largely a matter of personal choice in the sense that individuals consciously or unconsciously select both rational beliefs and irrational beliefs at (B) when negative events occur at (A)

2. Past history and present life conditions strongly affect the person, but they do not, in and of themselves, disturb the person; rather, it is the individual's responses which disturb them, and it is again a matter of individual choice whether to maintain the philosophies at (B) which cause disturbance.

3. Modifying the philosophies at (B) requires persistence and hard work, but it can be done (Mulhauser, An Introduction to Rational Emotive Behavior Therapy).

Therapeutic Approach

The goal of REBT counseling is assisting patients to exchange extreme concepts, complete with 'musts' and 'shoulds', with more flexible ones. This is inclusive of accepting that people (including themselves) are imperfect, and acquiring the knowledge to tolerate more frustration while attempting to reach their goals. Although REBT therapy emphasizes the same conditions as counseling that is person-centered -- empathy, unconditional positive regard, and counselor genuineness -- REBT views these characteristics as neither required nor satisfactory for therapeutic change to occur.

REBT attempts to teach the client to acknowledge that a problem exists, and to identify problems about the problem, (like feeling guilty about being depressed). The idea is for the patient to identify his or her "sub-conscious" irrational belief that created the original quandary and learn to understand both why that belief is irrational and why a rational thought would be preferable.

The client challenges their irrational belief and employs a variety of cognitive, behavioral, emotive and imagery techniques to strengthen their conviction in a rational alternative. (For example, rational emotive imagery, or REI, helps clients practice changing unhealthy negative emotions into healthy ones at (C) while imagining the negative event at (A), as a way of changing their underlying philosophy at (B); this is designed to help clients move from an intellectual insight about which of their beliefs are rational and which irrational to a stronger 'gut' instinct about the same.) They identify impediments to progress and overcome them, and they work continuously to consolidate their gains and to prevent relapse (Mulhauser, An Introduction to Rational Emotive Behavior Therapy).

All through the process of REBT counseling, the therapist may take a very instructive role, arguing the client's illogical beliefs, disputing the patient's answers to homework assignments to help the client overcome their irrational beliefs, and forcing the client to confront and accept the discomfort that goes along with the change process.

Reality Therapy

Reality therapy, developed by Willam Glasser MD, is a therapy that centers on the future. The basic concept is that no matter how bad things are or what has occurred in the past, our future can be a success because it is based on behaviors of our own choice. Dr. Glasser began teaching reality therapy in 1965 and founded the Institute for Reality Therapy in 1967. In 1996, it was renamed and is now the William Glasser Institute.

Reality therapy is based on choice theory -- that behavior is central to our existence and is driven by five basic "Maslow-esque needs." Reality therapy has become a widely-accepted technique by people throughout the world. The concepts of this type of therapy extend into many and varied areas of therapy and counseling. It is even utilized by parents, educators, and social workers.

The term choice theory is also the work of Glasser. Choice theory posits that behavior is central to our existence and is driven by five genetically driven needs, similar to those of Abraham Maslow: Survival, belonging/connecting/love, power/competence, freedom/responsibility, and fun/learning (Reality Therapy).

The goal of reality therapy is to assist people to reconnect. Unsatisfactory or absent relationships with people we want or need around us are the source of almost all human problems. First, the counselor connects with the individual in therapy. Then, using this effort as a paradigm, the counselor shows the client how he or she can begin to connect with the people they need around them.

There are two major components to reality therapy: create a trusting environment, and employ techniques for helping a person discover what they really want.

Creating a relationship like this is not easy and involves a number of factors and practices:

Focus on the present and avoid discussing the past because all human problems are caused by unsatisfying present relationships (Reality Therapy).

Avoid discussing symptoms and complaints as much as possible since these are the ways that counselees choose to deal with unsatisfying relationships.

Understand the concept of total behavior, which means focus on what counselees can do

directly -- act and think. Spend less time on what they cannot do directly; that is, change their feelings and physiology. Feelings and physiology can be changed, but only if there is a change in the acting and thinking (Reality Therapy).

Avoid criticizing, blaming and/or complaining and help counselees to do the same. By doing this, they learn to avoid these extremely harmful external control behaviors that destroy relationships.

Remain non-judgmental and non-coercive, but encourage people to judge all they are doing by the Choice Theory axiom: Is what I am doing getting me closer to the people I

need? If the choice of behaviors is not getting people closer, then the counselor works to help them find new behaviors that lead to a better connection.

Teach counselees that legitimate or not, excuses stand directly in the way of their making needed connections (Reality Therapy).

Focus on specifics. Find out as soon as possible who counselees are disconnected from and work to help them choose reconnecting behaviors. If they are completely disconnected, focus on helping them find a new connection.