The Cognitive Model

At the heart of cognitive therapy lies a deceptively simple idea. Perceptions of ourselves, the world and the future shape our emotions and behaviours. What and how people think profoundly affects their emotional well being. As Shakespeare's Hamlet put it'... is nothing either good or bad, but thinking makes it so . . . ' From this principle comes the idea that if we evaluate and modify any dysfunctional thinking, we can profoundly affect our emotional

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

Figure 2.1 Factors involved in the development of evidence-based cognitive therapy. Salkovskis (2002). Reprinted with permission.

wellbeing. Enduring changes occur when people are able to modify dysfunctional beliefs and learn healthier and more adaptive beliefs.

This central feature of cognitive therapy is based on two broader assumptions. First, that a broader bio-psycho-social context is implicated in the development and maintenance of emotional disorders. Cognitive therapy theorists and researchers have themselves emphasized different biological factors (Gilbert, 1984; Beck, 1999) and social factors (Gotlib & Hammen, 1992). Biological and social theories of emotional disorders are not seen as competing theories, but rather as complementary theories operating at different levels of analysis with different points of focus. Second, even though a client's presenting problems arise in a bio-psycho-social context, the client's perspective and agency are seen as the main

Table 2.1 Typical belief content among people diagnosed with a range of emotional disorders

Emotional disorder Depression

Generalised anxiety disorder Panic disorder

Eating disorder

Hypochondriasis

Anti-social personality disorder

Medical disorders, where patients report significant degrees of pain

Typical thought content

Negative view of the self, the world and the future

Fear of physical or psychological danger

Fear of imminent physical or psychological disaster

Fear of being physically unattractive, out of control

Concern about serious insidious medical disorder

I have been unfairly treated and am entitled to my fair share by whatever means it takes

This pain is intolerable and there is nothing I can do to control it

Table 2.2 Cognitive distortions

Distortion

All-or-nothing thinking: the person sees things in black-and-white categories.

Overgeneralisation: the person sees a single negative event as a never-ending pattern of defeat.

Mental filter: the person picks out a single negative detail and dwells on it exclusively, so that perceptions of all of reality become darkened.

Fortune telling: the person makes negative predictions about the future without realising that the predictions may be inaccurate.

Emotional reasoning: the person assumes that negative emotions necessarily reflect the way things are.

Shoulds, musts, and oughts: people try to motivate themselves with shoulds and shouldn'ts, as if they had to be whipped and punished before they could be expected to do anything.

Personalisation: people see themselves as the cause of some negative external event, for which they are in reality not primarily responsible.

Example

'My performance is not perfect, so I must be a total failure.'

'I'm always messing up everything.'

People notice that they have put on a few pounds and think, 'I am overweight, I am horrible', ignoring other parts of their life -that they have a nice smile, people like them, they are holding down a job or raising a family.

'I'll never get a job or have a relationship.'

'I feel hopeless, therefore thing are hopeless.'

'I shouldn't sit here, I should clean the house.'

For example, if someone yells at you, you might think 'I did something wrong', but maybe the other person is having a bad day or has a bad temper.

focus in cognitive therapy. Cognitive theory takes into account the broadest range of factors that can help understand why a client presents with a particular set of problems, and then focusses on how the client has shaped this through a process of making sense of their lives. A powerful illustration is the work of Victor Frankl, a survivor of Auschwitz who went on to describe how he was able to draw meaning from his experience and how this process enabled him to survive Auschwitz and its aftermath (Frankl, 1963).

Cognitive theory has been continually developed as research examines its basic tenets. The most enduring descriptions of cognitive theory of emotional disorders propose that schema interact with situations through processes of selective attention and inference, thereby generating individual emotional reactions (Beck, 1976). These schemata are conceptualised as relatively stable, so that similar situations will tend to produce similar emotional reactions because the same schema are being activated. In people at risk for emotional disorders, these predisposing maladaptive schemata lie dormant and become activated only in the presence of schema-triggering situations. Each emotional disorder is characterised by a particular set of unique schemata: the content specificity hypothesis (Table 2.1). Across emotional disorders, a range of cognitive distortions drive processes of selective attention and maladaptive inference (Table 2.2).

In recent reformulations, cognitive theory has been articulated as a theory primarily of the maintenance of emotional disorders, For example, for depression it has been proposed that schema become activated only during the onset and course of emotional disorders (Miranda & Persons, 1988). In the case of depression, schema are described as comprising a particular triad of negative beliefs about the self, the world and the future, and that a depressed person sees a large array of situations in a schema-congruent way. Once activated, schema-congruent processes trigger a stream of negative ruminative automatic thoughts (e.g., 'My partner will be angry that I have achieved nothing today') that are congruent with underlying core beliefs (e.g., 'I am a loser') and dysfunctional assumptions (e.g., 'If I take on challenges, I will fail'). This relationship between triggers that activate underlying schema, core beliefs, dysfunctional assumptions, negative automatic thoughts and emotional, behavioural and somatic reactions has become the conceptual basis for cognitive therapy (Figure 2.2).

A generation of researchers has empirically examined cognitive theories of emotional disorders. This research has examined the basic cognitive dimensions of personality and psychopathology, idiosyncratic processing and memory and the role of cognitive factors in diathesis-stress models. It is beyond the scope of this chapter to review this literature but we note several significant developments to cognitive theories of emotional disorders (see Beck, 1996; Power & Dalgleish, 1997; Teasdale & Barnard, 1993). First, they introduce a more integrative model of emotional disorders, explicitly drawing in cognitive, motivational, behavioural and physiological response systems. This suggests that cognitive products such as images, thoughts, and ruminative thinking may be powerfully shaped by reciprocal processing in physiological, emotional and behavioural response cycles. Second, reformulated cognitive theories move away from linear processing models to parallel modular processing models. Cognitive, motivational and behavioural systems operate simultaneously and cognitive products (such as thoughts, images, memories, plans) can emerge in awareness as a product of these systems. These models are postulated as a potentially more complete explanation of how an individual adapts to changing circumstances, tackling the complexity, predictability, regularity and uniqueness of normal and abnormal reactions. These more integrative and complex theories are only just being subjected to research and interested readers are referred to Beck (1996) and Dalgleish & Power (1998).

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