COGNITIVE BEHAVIORAL THERAPY
Adults on the autism spectrum can be prone to depression,
anxiety,
obsessive-compulsive
disorders, bipolar
disorders and other mental health issues. Cognitive behavioral
therapy (CBT) is one of a range of treatment options. It is a psychotherapy
based on modifying everyday thoughts and behaviors, with the aim
of positively influencing emotions.
The general approach developed out of behavior
modification and Cognitive Therapy, and has become widely used to
treat mental disorders. The particular therapeutic techniques vary
according to the particular kind of client or issue, but commonly
include keeping a diary of significant events and associated feelings,
thoughts and behaviors; questioning and testing assumptions or habits
of thoughts that might be unhelpful and unrealistic; gradually facing
activities which may have been avoided; and trying out new ways
of behaving and reacting.
Relaxation and distraction techniques are also
commonly included. Cognitive Behavioral Therapy is widely accepted
as an evidence-based,
cost-effective psychotherapy for many disorders. It is sometimes
used with groups of people as well as individuals, and the techniques
are also commonly adapted for self-help manuals and, increasingly,
for self-help software packages.
The basics of Cognitive Behavioral Therapy
Cognitive Behavioral Therapy is based on the idea
that how we think (cognition), how we feel (emotion) and how we
act (behavior) all interact together. Specifically, our thoughts
determine our feelings and our behavior. Therefore, negative - and
unrealistic - thoughts can cause us distress and result in problems.
One example could be someone who, after making
a mistake, thinks "I'm useless and can't do anything right."
This impacts negatively on mood, making the person feel depressed;
the problem may be worsened if the individual reacts by avoiding
activities. As a result, a successful experience becomes more unlikely,
which reinforces the original thought of being "useless."
In therapy, the latter example could be identified
as a self-fulfilling prophecy or "problem cycle," and
the efforts of the therapist and client would be directed at working
together to change this. This is done by addressing the way the
client thinks in response to similar situations and by developing
more flexible thought patterns, along with reducing the avoidance
of activities. If, as a result, the client escapes the negative
thought pattern, the feelings of depression may be relieved. The
client may then become more active, succeed more often, and further
reduce feelings of depression.
Thoughts as the cause of emotions in CBT
With thoughts stipulated as being the cause of
emotions rather than the outcome or by-product, cognitive therapists
reverse the causal order more generally used by psychotherapists.
Therefore, the therapy is to identify those irrational or maladaptive
thoughts that lead to negative emotion and identify what it is about
them that is irrational or just not helpful; this is done in an
effort to reject the distorted thoughts and replace them with more
realistic alternative thoughts, in a process sometimes referred
to as cognitive-shifting.
Cognitive Behavioral Therapy is not an overnight
process. Even after patients have learned to recognize when and
where their thought processes go awry, it can take months of concerted
effort to replace an irrational thought process or habit with a
more reasonable, salutary one.
The cognitive model says that a person's core
beliefs (often formed in childhood) contribute to 'automatic thoughts'
that pop up in every day life in response to situations. Cognitive
Therapy practitioners hold that clinical
depression is typically associated with negatively biased thinking
and irrational thoughts. Cognitive Behavioral Therapy is often used
in conjunction with mood stabilizing medications to treat bipolar
disorder.
Types of Cognitive Behavioral Therapy
Cognitive Behavioral Therapy can be seen as an
umbrella term for many different therapies that share some common
elements. While similar views of emotion have existed for millennia,
the earliest form of Cognitive Behavior Therapy was developed by
Albert Ellis in the early 1950s. Ellis eventually called his approach
Rational Emotive Behavioral Therapy, or REBT, as a reaction against
popular psychoanalytic and increasingly humanistic methods at the
time. Aaron T. Beck independently developed another Cognitive Behavioral
Therapy approach, called Cognitive Therapy, in the 1960s.
Cognitive Therapy rapidly became a favorite intervention
to study in psychotherapy research in academic settings. In initial
studies, it was often contrasted with behavioral treatments to see
which was most effective. However, in recent years, cognitive and
behavioral techniques have often been combined into cognitive behavioral
treatment. This is arguably the primary type of psychological treatment
being studied in research today.
Cognitive Behavioral Group Therapy (CBGT) is a
similar approach in treating mental illnesses, based on the protocol
by Richard Heimberg. In this case, clients participate in a group
and recognize they are not alone in suffering from their problems.
A sub-field of Cognitive Behavior Therapy used
to treat Obsessive
compulsive disorder makes use of classical conditioning
through extinction (a type of conditioning) and habituation. (The
specific technique, Exposure with Response Prevention (ERP) has
been demonstrated to be more effective than the use of medication--typically
SSRIs--alone.) Cognitive Behavioral Therapy has also been successfully
applied to the treatment of Generalized Anxiety Disorder , health
anxiety, Social phobia and Panic Disorder. In recent years, Cognitive
Behavioral Therapy has been used to treat symptoms of schizophrenia,
such as delusions and hallucinations. This use has been developed
in the UK by Douglas Turkington and David Kingdon.
Other types of Cognitive Behavioral Therapy include
Dialectical Behavior Therapy, Self-Instructional Training, Schema-Focused
Therapy and many others.
Cognitive Behavioral Therapy has a good evidence
base in terms of its effectiveness in reducing symptoms and preventing
relapse. It has been clinically demonstrated in over 400 studies
to be effective for many psychiatric disorders and medical problems
for both children and adolescents. It has been recommended in the
UK by the National Institute for Health and Clinical Excellence
as a treatment of choice for a number of mental health difficulties,
including post-traumatic stress disorder, OCD, bulimia nervosa and
clinical depression. Cognitive Behavioral Therapy most closely allies
with the Scientist-Practitioner Model of Clinical Psychology, in
which clinical practice and research is informed by a scientific
perspective; clear operationalization of the "problem"
or "issue;" an emphasis on measurement (and measurable
changes in cognition and behavior); and measurable goal-attainment.
Depression and cognitive behavioral therapy
Negative thinking in depression can result from
biological sources (i.e., endogenous depression), modeling from
parents, peers or other sources. The depressed person experiences
negative thoughts as being beyond their control: the negative thought
pattern can become automatic and self-perpetuating.
Negative thinking can be categorized into a number
of common patterns called "cognitive distortions." The
cognitive therapist provides techniques to give the client a greater
degree of control over negative thinking by correcting these distortions
or correcting thinking errors that abet the distortions, in a process
called cognitive restructuring.
Negative thoughts in depression are generally
about one or more of three areas: negative view of self, negative
view of the world and negative view of the future. These constitute
what Beck called the "cognitive triad." An approach to
depression based upon attribution theory in social psychology is
related to the concept of attributional style. First put forth by
Lyn Abramson and her colleagues in 1978, this approach argues that
depressives have a typical attributional style —they tend to attribute
negative events in their lives to stable and global characteristics
of themselves. There is considerable evidence that depressives do
exhibit such an attributional style, but it is important to remember
that Abramson et al. do not claim that an attributional style of
this nature is necessarily going to cause depression — only that
it will lead to clinical depression if combined with a negative
event. This theory is sometimes known as a revised version of learned
helplessness theory.
In 1989, this theory was challenged by Hopelessness
Theory. This theory emphasized attributions to global and stable
factors, rather than, as in the original model, internal attributions.
Hopelessness Theory also emphasizes that beliefs about the consequences
of events and rated importance of events may be at least as important
in understanding why some people react to negative events with clinical
depression as are causal attributions.
The ABCs of Irrational Beliefs in CBT
A major aid in cognitive therapy is what Albert
Ellis called the ABC Technique of Irrational Beliefs. The first
three steps analyze the process by which a person has developed
irrational beliefs and may be recorded in a three-column table.
* A - Activating Event or objective situation.
The first column records the objective situation, that is, an event
that ultimately leads to some type of high emotional response or
negative dysfunctional thinking.
* B - Beliefs. In the second column, the client
writes down the negative thoughts that occurred to them.
* C - Consequence. The third column is for the
negative feelings and dysfunctional behaviors that ensued. The negative
thoughts of the second column are seen as a connecting bridge between
the situation and the distressing feelings. The third column C is
next explained by describing emotions or negative thoughts that
the client thinks are caused by A. This could be anger, sorrow,
anxiety, etc.
For example, Gina is upset because she got a low
mark on a math test. The Activating event, A, is that she failed
her test. The Belief, B, is that she must have good grades or she
is worthless. The Consequence, C, is that Gina feels depressed.
Reframing
After irrational beliefs have been identified,
the therapist will often work with the client in challenging the
negative thoughts on the basis of evidence from the client's experience
by reframing it, meaning to re-interpret it in a more realistic
light. This helps the client to develop more rational beliefs and
healthy coping strategies.
From the example above, a therapist would help
Gina realize that there is no evidence that she must have good grades
to be worthwhile, or that getting bad grades is awful. She desires
good grades, and it would be good to have them, but it hardly makes
her worthless. If she realizes that getting bad grades is disappointing,
but not awful, and that it means she is currently bad at math or
at studying, but not as a person, she will feel sad or frustrated,
but not depressed. The sadness and frustration are likely healthy
negative emotions and may lead her to study harder from then on.
Cognitive Behavioral Therapy with or without drugs for depression
A large-scale study in 2000 showed substantially
higher results of response and remission when a form of cognitive
behavior therapy and an anti-depressant drug were combined than
when either method was used alone.
The American Psychiatric Association Practice
Guidelines (April 2000) indicated that among psychotherapeutic approaches,
cognitive behavioral therapy and interpersonal therapy had the best-documented
efficacy for treatment of major depressive disorder, although they
noted that rigorous evaluative studies had not been published.
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