Articles

Cognitive Therapy - Worth Talking About
Jane Fry MSc, Dip CT - Issue 21, Spring 2004
The Michael Palin Centre, London
There are several psychological therapies, such as Rational Emotive Therapy and Neurolingistic Programming, which can be thought of as being cognitive in nature, however the term 'Cognitive Therapy' typically refers to the theoretical ideas and clinical programmes of Aaron Beck (1976).

Beck initially developed Cognitive Therapy in the 1960's to understand and treat depression, from which he himself suffered. It is now widely used as the treatment of choice for numerous emotional difficulties and is increasingly referred to in work with people who stammer.

Cognitive Therapy is not concerned with teaching clients to 'think positively' or to be more 'rational' in the face of adversity. It is concerned with helping people to cope with difficulties more effectively by being more flexible in how they look at and respond to situations, developing more effective problem-solving skills, maximising the use of more helpful self-talk, and developing life-enhancing core beliefs.

The philosophy
Beck openly acknowledged the influence of his contemporary George Kelly, and those familiar with Kelly¹s Personal Construct Psychology will recognise philosophical similarities. Both are based on the assumption that there is no one objective or 'true' reality, a world-view which can be traced back to the writings of Kant and Sartre. Instead, individuals are seen as creating their own subjective 'reality', fuelled by the need to impose meaning on an otherwise unpredictable world. This happens through a continuous process of interpreting, appraising, or in Kelly's terminology 'construing'.

While the process of interpreting is adaptive because it provides order and predictability, difficulties can arise when we get it wrong (as anyone who has ever jumped to a conclusion in error will know). While it is human nature to make mistakes, Beck was interested in the patterns of 'appraisal', 'information processing' or 'thinking biases' which create particular emotional vulnerabilities or which limit the way people function in the world.

Ultimately, both theories emphasise the optimism, flexibility and choice inherent in concluding that if things can be viewed in one way they can also be viewed in another and that the better option may be that which more accurately fits the facts, or which is simply more helpful and encouraging.

The style of therapy
Cognitive Therapy differs from some other forms of psychotherapy in that it focuses on specific problems and has a structure to the way that the work unfolds. As with other counselling approaches, it is undertaken collaboratively with an emphasis on therapist and client sharing their curiosity about the problem as well as their insights into how to manage it differently.

Any introduction to Cognitive Therapy would be incomplete if it did not refer to Socratic questioning. Writing two and a half thousand years ago, Socrates described himself as an 'intellectual midwife', whose questioning delivered the thoughts of others into the light of day. He helped his students learn by posing questions rather than providing instruction, and claimed that his 'wisdom' lay in his knowing how little he knew. In that spirit, cognitive therapists aim to ask questions out of genuine curiosity in order to help clients to explore and review their thoughts, assumptions and beliefs. This is referred to as ŒSocratic questioning¹ or 'guided discovery'.

Cognitive Therapy focuses on the development of self-help skills and aims to avoid the pitfalls that can be encountered when therapists adopt or allow themselves to be placed in the 'expert' role. 'Relapse' is predicted, normalised and planned for, and the client¹s capacity for managing the future is emphasised throughout.

Information processing
Cognitive Therapy is based on theories of information processing. At its simplest level the cognitive model states that emotions, physiological sensations and behaviour are linked in an important way to the process of appraisal and interpretation. In other words, how people feel emotionally and physically, and how people behave, generally has something to do with what they are thinking.

For example, when people feel anxious or nervous it is related to their perceiving some form of threat or danger, particularly if the feared event seems highly likely, if there is a lot at stake, and if the individual does not feel able to cope with the worst if it were to happen. When this occurs, a natural 'wired in' response is to experience physical sensations associated with anxiety (such as increased heart rate, or more rapid breathing) and to adopt some precautionary measure (eg, avoiding the source of threat).

Similarly, a physiological event such as a moment of stammering, may trigger a chain reaction of thoughts about the event (ie, I got it wrong, that was terrible) which in turn may trigger a range of emotions such as frustration or embarrassment, and further somatic and behavioural responses such as going red or deciding not to say any more.

The role of behaviour in maintaining problems
Within a cognitive framework, individuals' attempts to cope with problems are seen as one of the factors that contribute to problems being maintained. A vicious circle is established in which the individual's reaction to the problem results in negative predictions being confirmed and negative perspectives reinforced.

Examples
David is a 16 year old who has concluded that his anxiety about stammering is related to his assumption that if he stammers people will not want to talk to him, that they will think he's 'thick' and that they will stare at him pityingly. He copes by saying as little as possible in problematic situations, such as classroom discussions, and by looking away during moments of stammering. However, because he participates less, he does not get the positive responses from others that he would like, which reinforces his belief that others do not value him. When he speaks, he is more likely to stammer because he is feeling Œrattled¹ and because he looks away at these moments, he does not have any actual information about what people do at these times.

Sue constantly worries that she will stammer on a particular word and copes by avoiding it altogether. While this 'gets her off the hook', it not only prevents her from finding out whether she can in fact say the word without stammering, or whether her worst fears about stammering are realised, it also serves to reinforce the fear associated with the word.

Ben reports times when he 'knows' that he will stammer. At these times he notices that he tenses up and gets an 'adrenalin hit' which means that his heart rate, his breathing and his speech rate all become faster and muscle tension increases. When this happens he stammers more, thus 'proving' himself right.

Identifying NATs
Clients begin in therapy by learning how to identify their Negative Automatic Thoughts or 'NATs'. These are spontaneous, fleeting, 'gut-level' cognitions which have an impact on how people feel emotionally. They often go unnoticed because they come and go so quickly, however, when clients learn to tune into their NATs they usually discover recurring themes as well as particular Œhot¹ thoughts which make sense of their emotional reactions to events.

Typically, people who stammer report that their NATs are in the form of predictions that they will have difficulty (ie, I¹ll get stuck, I won't make sense, I can't), and predictions or assumptions about the consequences of this. These tend to focus on how other people will respond (ie, they'll laugh at me', 'they won't listen') or what other people will make of them ('they'll think I¹m thick', 'they'll think less of me'). When clients go over situations in their minds afterwards (post-mortem thinking) their NATs are frequently in the form of self-criticism (ie, 'that was rubbish', 'I should've handled that'), or general judgements about the self (ie, I'm useless).

Working with NATs
The wind was against them now, and Piglet¹s ears streamed behind him like banners as he fought his way along
Supposing a tree fell down, Pooh, when we were underneath it?
Supposing it didn¹t² said Pooh, after careful thought. (The House at Pooh Corner, A.A. Milne)

Having learnt to identify their negative automatic thoughts, clients are then invited to examine their predictions more critically and to view their thoughts simply as thoughts rather than as inevitable and absolute 'facts'. They are invited to look for the evidence that both supports and disconfirms their predictions, (for example, by observing others' reactions to their stammering), to think about alternative explanations for events, to construct more helpful self-talk, and to recognise thinking biases. Inevitably this means that time is spent thinking and talking about specific predictions, assumptions or beliefs and weighing up various perspectives. However, cognitive change and behavioural change are seen as equally important and clients are thus encouraged to experiment with change in the real world as a way of testing their predictions.

David begins in therapy by learning to identify his negative automatic thoughts. In order to test his prediction that people will look at him pityingly, he designs an experiment in which he will make a point of looking at people when he stammers and noticing their responses. He makes a note over a week of how many times people do indeed look pityingly, and how many people respond in a neutral or reinforcing way.

The best way to gain a sense of Cognitive Therapy is to try it out for oneself.

With this in mind, review the following 'thinking traps' that are described in any Cognitive Therapy text and notice which ones are familiar!

All or nothing thinking
This is where you look at things in absolute, black and white terms rather than considering a continuum of possibilities. Perceiving something to be a 'total failure' or 'rubbish' because it is not 100% perfect is an example of all or nothing thinking.

Catastrophising/fortune telling
You expect that the worst will happen even when there is no evidence to suggest that it might. You don¹t consider other possible outcomes which might be just as, if not more likely (eg, It's going to be total disaster or I won't be able to do this at all).

Mind-reading
You make assumptions about what other people are thinking or are going to think (eg, they think I'm an idiot).

Over-generalisation
You make a sweeping conclusion on the basis of one event, that goes far beyond the current situation (eg, the photocopier jams when you¹re in a particular rush and you think 'this always happens to me').

Mental filter
You dwell on the negatives and magnify them or blow them out of proportion, while ignoring or minimising the positives. When people engage in 'post-mortem' thinking they go over in their minds all the things that went wrong and don¹t pay attention to the things they did well.

Finally, next time you find yourself troubled by something, try out some of the questions that cognitive therapists encourage clients to ask themselves:

Is there any evidence to counter my thoughts or suggest they are not 100% true?

Is there another way of looking at things? Is mine the only possibility or might someone else see things differently?

What is the evidence that supports this idea? (Facts that anyone would agree with not my interpretations)

What is the worst that could happen?

Am I over-estimating the chances of disaster? (like Piglet)

Am I being a 'fair judge' or am I ignoring my strengths or positives about the situation and looking on the black side?

Supposing the worst did happen, what could I do to handle it? Am I under- estimating how well I could deal with things?

The process of therapy
Cognitive Therapy is not for everyone, but it provides a helpful framework for clients who are 'psychologically minded', who see their fear of stammering as part of the problem, and who feel that the model Œfits¹ for them. In the course of therapy clients learn to identify their negative automatic thoughts, before learning to question these in a way that opens up other possible ways of seeing things and other ways of responding. Clients are helped to develop problem-solving skills, to experiment with testing out their predictions and assumptions, and also to build up more supportive and positive beliefs about themselves.

Taking it further
There are a variety of self-help books available which support the use of Cognitive Therapy and they provide an excellent starting place for any therapist with an interest in developing knowledge in this area. The Michael Palin Centre can offer introductory one-day workshops for clinical teams or local Special Interest Groups, and this can be arranged by contacting Jane on Jane.Fry@nhs.net However, this is a psycho-therapeutic approach and formal training is essential to use Cognitive Therapy fully and effectively. Formal training normally takes place within the context of a post-grad diploma or Masters course. There are many courses available in the UK. Information about these can be found at: www.babcp.org.uk

Any practice of Cognitive Therapy, following training, should be supported by regular supervision.

In essence, Cognitive Therapy provides a framework for understanding how we all work. The best place to start then, is to get curious about one¹s own negative predictions, assumptions and beliefs, and to get to work with them first!

Further reading
Beck, J.S. (1995) Cognitive Therapy: Basics and Beyond. London: The Guildford Press.

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press.

Butler,G.,& Hope, T.(1995) Manage Your Mind: The Mental Fitness Guide. Oxford: OUP.

Butler,G. (1999) Overcoming Social Anxiety and Shyness: A Self-help Guide Using Cognitive-Behavioural Techniques.London: Robinson.

Stallard, P. (2002) Think Good Feel Good: A Cognitive Behaviour Therapy Workbook for Children and Young People. Chichester: John Wiley & Sons Ltd.