Cognitive Psychotherapy

Written by Doug Berger, M.D., Ph.D.

Cognitive therapy deals with changing one's dysfunctional cognitions (thoughts), emotions, and behavior. Identifying and correcting one's negative or distorted automatic thoughts is the key. These autonomatic thoughts occur rapidly while an individual is in the midst of a particular situation. The more the situation stresses the person's emotionally sensitive issues, the more they are likely to react with a distorted thought that will then affect their emotional state adversely. A brief list of these automatic thoughts includes: all-or-none thinking, magnification, personalization, selectively extracting the negative out of a situation, catastrophizing, minimizing, "should" statements, and labeling (self and/or others). Underlying (unconscious) cognitive schemas (e.g., "no one loves me") are thought to be at the crux of the propensity for development of cognitive distortions.

Patients with problems such as depression and anxiety, or interpersonal difficulties, have many negative and maladaptive automatic thoughts which can lead to behaviors (e.g., helplessness, withdrawal, aggression, or avoidance) that make the problem worse, resulting in more disturbed mood and leading to more dysfunctional thoughts, in other words a vicious cycle. Cognitive therapy attempts to help patients recognize and change these cognitive errors through discussion with the therapist, outlining and listing the situations and distortions in writing, and homework practice. Behavioral change may be necessary to modify long-standing maladaptive patterns of behavior that reinforce the distortions.

Cognitive therapy may be very useful as an adjunct to help patients see how their thoughts make thier mood bad or worse. It doesn't say anything about the causes of the distortions or the underlying schemas, however, or how they pan-out in interactions with others. Psychodynamic psychotherapy is usually required for a deeper understanding of oneself as it deals more with the unconscious concomitants of one's emotional life and how these impinge on relationships.

Some studies have shown that antidepressant medication can reverse the cognitive distortions of patients with serious depression. It may bethat distortions are more likely the result of biological factors (i.e., one's neurochemicals controlling mood are disturbed) in severe depression, while distortions resulting from one's personality style may be more of a cause of disturbed mood in more milder conditions. So even though the jury is still out on the exact causes of one's distortions, it makes clinical sense to give patients an idea of how their distortions may be contributing to their emotional trouble.

Combining a few forms of psychotherapy is usually the most helpful. Medication may be needed in combination with psychotherapy for more severe symptoms, or if the patient has not responded to a number of psychotherapies, depending on the problem. Though many people have understandable reluctance to go the medication-route, the principles of: 1.) "If you don't try it you'll never know if it works", and 2.) "If you don't like the medication you can stop it", can prevent that select group of people who really need the extra biological jump-start from wallowing for years in unnecessary emotional distress. If one's brain chemicals (neurotransmitters) are really disordered to the point that psychotherapy alone does not help, these chemicals will probably not normalize just because the person wants to "do it on their own" any more than a diabetic can will themselves to produce insulin. People may conclude that the problem results from a situation in their lives rather than a disorder in mood-regulating neurotransmitters because their life-situations are easier to see, and because the prospect of having a brain-chemical disorder feels like another emotional burden to bear. While this is understandable, and while this author is a strong proponent of the value of psychotherapy, this can end up to be a "cognitive distortion" that impairs their getting important help.