Cognitive and Cognitive Behavioral Therapies

Cognitive and cognitive behavioral treatments arose from the work of Aaron Beck (you may have heard of the Beck Depression Inventory), Albert Ellis, Donald Meichenbaum, and others starting around the late 1960s. More recently the movement has been given a boost of publicity, mainly in the treatment of “OCD” – obsessive compulsive disorder. It has been used most successfully on very circumscribed problems such as phobias, obsessive behavior, and to some degree depression.

According to the cognitive therapies, your problems are caused by distorted thinking. Correct the thinking and the symptoms go away, given a little practice and some behavioral interventions (Behavior Therapy). Treatments are often highly structured, with “homework assignments” and at times quite rigid specification of what will happen, what will be covered, in each session.

The cognitive therapies are very seductive. They make the problem and the solution sound enticingly simple: Identify the distorted thoughts, correct them, and all will be well; all that is needed are some help with clear thinking, some “coping skills” (such as think of consequences before you act, or break down unwieldy problems into more tolerable portions), some practice, and you will watch your depression melt away on a “mood graph”. The claim is also made that cognitive treatments are backed by better research and are more “scientific” than other treatments. Finally, and perhaps most appealingly, cognitive treatment is usually billed as being faster than psychodynamic treatment.

Unfortunately, things do not really work out this way. Many patients have come to me after a course of cognitive treatment. So let’s discuss a few misconceptions. First there is a new term bandied about in their favor: “Evidence based treatment”. The idea is that these treatments have a supposedly greater scientific basis than do the psychodynamic treatments. Frankly, this isn’t quite true. The creation of these treatments did come from the laboratory more than from clinical experience, as compared with psychodynamic and psychoanalytic treatments, but when it comes to evaluating the results, things are much murkier. While there are some studies showing good results with cognitive treatments, much of the research is being criticized as flawed even by authors in the cognitive therapy field. (See also Types of Psychotherapy – II). More importantly, there is also plenty of evidence for the effectiveness of psychodynamic treatments as well.

Second, the outcome research in cognitive therapy shows the need for other kinds of treatment. Cognitive therapies are not so successful when used in isolation. A recent book on the cognitive treatment of Post Traumatic Stress Disorder (PTSD) points out that while cognitive therapies help with some of the symptoms, psychodynamic treatment is more effective in addressing the depression that usually accompanies PTSD. This is why even the cognitive therapists recommend an initial consultation with a broadly experienced therapist to see if this kind of treatment is really appropriate in a given case; only after that consultation does one begin any more specialized treatment such as cognitive behavior therapy, psychoanalysis, hypnosis, etc. (See also Why Go and Why Go – II)

Third, as I hope I made clear in the earlier pages of this website, it is never so simple to identify distortions in thinking. People resist awareness of those distortions, often fight hard – unintentionally – to avoid awareness of exactly that which is upsetting them; please note that this is true even when the person seems to have some grasp on what hurts, such as the patient who complains “I have low self esteem and never believe anything I do is good enough”. Remember Ron became aware of his low self esteem and feelings of fragility, aware of how he distorted events and perceived failure in himself when none existed, but he then began using that awareness in service of resistance that is, to avoid facing his anger and hostility which despite his progress in therapy were continuing to ruin his relationships. See the pages What's a Personality? through What's the Cure? and of course resistance for more on this topic, and of course it's covered in much more depth in the book Stop Lying.

Fourth and perhaps most important, cognitive therapy is often part of a course of psychodynamic treatment, and the differences between the two are much less substantial than is popularly believed. Even the founder of it all, Aaron Beck, points out that “both forms of treatment are insight therapies” (Cognitive Treatment of the Emotional Disorders by Aaron Beck, page 313) and that “both psychoanalysis and cognitive therapy attempt to produce such structural change by modifying the cognitive organization that produces unrealistic thinking” (p. 314). When Beck goes on to say, however, that cognitive treatment stays close to the conscious level, unlike psychoanalysis, he is not describing the kind of psychodynamic treatment discussed in this website. As I emphasized on the early pages (e.g., A Note On How Psychotherapy Works), psychotherapy is logical, accessible and data driven. Moreover, when Beck and especially Albert Ellis talk about uncovering hidden assumptions in a person’s thinking, the “underlying cognitive schemata”, they are engaged in the same kind of discovery as is described in the case examples throughout this website. Underlying cognitive schemata are in fact unconscious cognitive schemata. On the other hand, cognitive therapy often minimizes the issue of resistance, and without addressing resistance therapy really doesn’t happen – Ron, for example, might have stayed stuck in his angry and hostile behavior in his relationships and at work, even though he was feeling somewhat better because he had uncovered his underlying – unconscious – feelings of worthlessness that were causing some of his symptoms. Cognitive therapy is thus a useful set of tools to be used as part of a more comprehensive treatment.

So why is cognitive therapy getting such press these days? Two reasons, I think. First, as I said its simplicity is seductive to the public. Second, the cognitive therapists are writing all the books for general readership. When I searched several Barnes & Noble stores “cognitive” was in the title of many books on psychotherapy written for the public. The only book I found on the shelves which discusses what is currently the most influential psychodynamic point of view – “relational psychoanalysis” – was a collection of papers written for other professionals; arcane and unwieldy material hardly suitable for the layman.

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