Current Medical Diagnosis & Treatment in Psychiatry

Modern Approaches

Modern cognitive and cognitive-behavioral approaches to psychotherapy got their impetus from two converging lines of development. One branch was developed by theorists originally trained in dynamic psychotherapy. Theorists such as Albert Ellis, the founder of rational-emotive therapy, and Aaron Beck, the founder of cognitive therapy, began their careers adhering to dynamic principles in theory and therapy but soon became disillusioned with that approach and came, over time, to focus on their patients’ conscious beliefs. Both ascribe to an antecedent events, a person’s beliefs, affective and behavioral consequences (ABC) model, which states that it is not just what happens to someone at point A (the antecedent events) that determines how the person feels and what he or she does at point C (the affective and behavioral consequences) but that it also matters how the person interprets those events at point B (the person’s beliefs). For example, someone who loses a relationship and is convinced that he or she was left because he or she is unlovable is more likely to feel depressed and fail to pursue further relationships than is someone who considers his or her loss a consequence of bad luck or the product of mistakes that he or she will not repeat the next time around. Both theorists work with patients to actively examine their beliefs to be sure that they are not making situations worse than they necessarily are. Ellis typically adopts a more philosophical approach based on reason and persuasion, whereas Beck operates more like a scientist, treating his patients’ beliefs as hypotheses that can be tested and encouraging his patients to use their own behaviors to test the accuracy of their beliefs.

The other major branch of cognitive-behaviorism involves theorists originally trained as behavior therapists who became increasingly interested in the role of thinking in the learning process. Bandura and Michael Mahoney represent two exemplars of this tradition, as do other theorists such as Donald Meichenbaum and G. Terence Wilson. These theorists tend to stay closer to the language and tenets of traditional behavior analysis and are somewhat less likely to talk about the role of meaning in their patients’ responses to events. They are also as likely to focus on the absence of cognitive mediators (ie, covert self-statements) as on the presence of distortions. For example, Meichenbaum developed an influential approach to treatment, called self-instructional training, in which patients with impulse-control problems are trained to modulate their own behaviors via the process of verbal self-regulation.

These approaches focus on the role of information processing in determining subsequent affect and behavior. Beck, for example, has argued that distinctive errors in thinking can be found in each of the major types of psychopathology. For example, depression typically involves negative views of the self and the future; anxiety, an overdetermined sense of physical or psychological danger; eating disorders, an undue concern with shape and weight; and obsessions, an overbearing sense of responsibility for ensuring the safety of oneself and others. Efforts to produce change involve having the patient first monitor fluctuations in mood and relate those changes to the ongoing flow of automatic thoughts, subsequently using one’s own behavior to test the accuracy of these beliefs. For example, a depressed patient who believes that he or she is incompetent will be asked to provide an example of something he or she should be able to do but cannot. The patient is then invited to list the steps that anyone else would have to do to carry out the task. The patient is then encouraged to carry out those steps just to determine whether he or she is as incompetent as he or she believes (typically, the patient is not).

Similarly, patients with panic disorder often misinterpret innocuous bodily sensations as signs of impending physical or psychological catastrophe, such as having a heart attack or “going crazy.” The therapist provides a rationale that stresses the role of thinking in symptom formation and encourages the patient to test his or her belief in the imminence of the impending catastrophe by inducing a panic attack right in the office. As the patient experiences extreme states of arousal and panic with no subsequent consequences (ie, neither dying nor “going crazy"), he or she comes to recognize that the initial arousal was not a harbinger of impending doom (as first believed), and the patient no longer begins to panic at the occurrence of arousal. In essence, like the behavioral approaches based on classical conditioning, modern cognitive and cognitive-behavioral interventions emphasize the curative process of exposing oneself to the things one most fears as a way of dealing with irrational or unrealistic concerns.

These approaches appear to be well established in the treatment of unipolar depression, panic disorder, social phobia, generalized anxiety disorder, and bulimia. For these disorders, cognitive and cognitivec-behavioral interventions appear to be at least as effective as other competing alternatives (including medications) and quite possibly more enduring. There are consistent indications that cognitive-behavioral therapy may produce long-lasting change that reduces the likelihood that symptoms will return after treatment ends. The evidence is more mixed with respect to substance abuse, marital distress, and childhood conduct disorder, although at least some indications are promising. Cognitive and cognitive-behavioral interventions are typically not thought to be particularly effective in patients who have formal thought disorder, although recent studies suggest that the interventions may reduce delusional thinking in psychotic patients who receive neuroleptic drugs.

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