Therapeutic Techniques

Therapeutic Techniques
In terms of the therapeutic process, the focus is initially on the automatic
thoughts of patients. Once patients are relatively adept at identifying and
modifying their maladaptive automatic thoughts, the therapy begins to focus
on the maladaptive underlying beliefs or schemata. As previously noted,
these beliefs are fundamental beliefs that people hold about themselves.
These beliefs are not as easy to identify as the automatic thoughts. Rather,
they are identified in an inferential process. Common patterns are observed;
for example, the person may seem to be operating by the rule “If I
am not the best _____, then I am a failure,” or “If I am not loved by my
spouse or mate, then I am worthless.” As in the case of the earlier cognitive
work with automatic thoughts, these beliefs are carefully evaluated for their
adaptability or rationality. Maladaptive beliefs are then modified to more
adaptive, realistic beliefs.

A variety of techniques have been developed by cognitive therapists for
modifying maladaptive cognitions. One example of these techniques is selfmonitoring. This involves the patient’s keeping a careful hour-by-hour record
of his or her activities, associated moods, or other pertinent phenomena.
One useful variant is to have the patient record his or her mood on a
simple zero-to-one-hundred scale, where zero represents the worst he or she
has ever felt and one hundred represents the best. In addition, the patient
can record the degree of mastery or pleasure associated with each recorded
activity.

A number of hypotheses can be tested using self-monitoring, such as “It
does not do any good for me to get out of bed,” “I am always miserable; it
never lets up,” and “My schedule is too full for me to accomplish what I
must.” By simply checking the self-monitoring log, one can easily determine
if one’s miserable mood ever ceases. A careful examination of the completed
record is a far better basis for judging such hypotheses than is the patient’s
memory of recent events, because his or her recollections are almost
always tainted by the depression.

As therapy progresses and patients begin to experience more elevated
moods, the focus of treatment becomes more cognitive. Patients are instructed
to observe and record automatic thoughts, perhaps at a specific
time each evening, as well as recording when they become aware of increased
dysphoria. Typically, the thoughts are negative self-referents (“I am
worthless” or “I will never amount to anything”), and initially, the therapist
points out their unreasonable and self-defeating nature. With practice, patients
learn “distancing,” or dealing with such thoughts objectively and evaluating
them, rather than blindly accepting them. Homework assignments
can facilitate distancing: The patient records an automatic thought, and
next to it he or she writes down a thought that counters the automatic
thought, as the therapist might have done. According to Beck, certain basic
themes soon emerge, such as being abandoned, as well as stylistic patterns
of thinking, such as overgeneralization. The themes reflect the aforementioned
rules, and the ultimate goal of therapy is to assist the patient to modify
them.

Finally, cognitive therapy has been applied to a variety of psychological
disorders with striking success. For example, studies from seven independent
centers have compared the efficacy of cognitive therapy to antidepressant
medication, a treatment of established efficacy. Comparisons of cognitive
therapy to drugs have found cognitive therapy to be superior or equal to
antidepressant medication. Further, follow-up studies indicate that cognitive
therapy has greater long-term effects than drug therapy. Of special significance
is the evidence of greater sustained improvement over time with
cognitive therapy.

Cognitive therapy has been successfully applied to panic disorder, resulting
in practically complete reduction of panic attacks after twelve to sixteen
weeks of treatment. Additionally, cognitive therapy has been successfully applied
to generalized anxiety disorder, eating disorders, and inpatient depression.