Cognitive Therapy: Current Status and Future Directions
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ME62CH28-Beck ARI 4 December 2010 14:36 Cognitive Therapy: Current Status and Future Directions Aaron T. Beck1 and David J.A. Dozois2 1Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania; email: [email protected] 2Department of Psychology, University of Western Ontario, London, Ontario, Canada; email: [email protected] Annu. Rev. Med. 2011. 62:397–409 Keywords First published online as a Review in Advance on cognitive vulnerability, psychotherapy, treatment outcome, cognitive Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org August 3, 2010 behavior therapy The Annual Review of Medicine is online at med.annualreviews.org Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Abstract This article’s doi: Cognitive therapy is a system of psychotherapy with a powerful theoret- 10.1146/annurev-med-052209-100032 ical infrastructure, which has received extensive empirical support, and Copyright c 2011 by Annual Reviews. a large body of research attesting to its efficacy for a wide range of psy- All rights reserved chiatric and medical problems. This article provides a brief overview 0066-4219/11/0218-0397$20.00 of the conceptual and practical components of cognitive therapy and highlights some of the empirical evidence regarding its efficacy. Cog- nitive therapy (often labeled generically as cognitive behavior therapy) is efficacious either alone or as an adjunct to medication and provides a prophylaxis against relapse and recurrence. 397 ME62CH28-Beck ARI 4 December 2010 14:36 OVERVIEW coordinated, goal-oriented strategies (e.g., From its inception more than 45 years ago approaching pleasure, avoiding pain) (13, 14). The fight-flight response, for instance, arises Cognitive schema: (1–3), cognitive therapy has been theory driven. a well-organized Specifically, Beck’s objectives for deriving and from four systems (13): cognitive (perception of cognitive structure of evaluating this system of psychotherapy in- threat), affective (feelings of anxiety or anger), stored information and volved an overall plan to construct a compre- motivational (the impulse to confront or flee memories that forms hensive theory of psychopathology that maps the threatening stimulus), and behavioral (the the basis of core beliefs implementation of action). In this construct, about self and others clearly onto the treatment approach, to inves- tigate scientific support for the theory, and onset of a particular condition (e.g., panic to test the efficacy of therapeutic interven- disorder) is believed to occur when these tions (3, 4). Cognitive theory and therapy were different systems shift from a fairly quiescent first developed for depression (1, 2) and later state to a highly activated state. In the example systematically applied to suicide prevention of panic disorder, this might occur when the (5), anxiety disorders (6), personality disorders fight-flight response is activated by “false (7), substance abuse (8), and, most recently, alarms” (e.g., misperceiving bodily sensations schizophrenia (9, 10). as harmful to the organism). Cognitive theory Cognitive therapy (CT), often discussed un- suggests that psychopathology is characterized der the generic label cognitive behavior therapy by the activation of a conglomerate of related (CBT), is now widely represented in training or contiguous dysfunctional beliefs, meanings, programs in psychology, psychiatry, medicine, and memories that operate in coordination social work, nursing, and other allied health with affect, motivation, behavior, and physio- professions that value evidence-based practice logical responses. Different psychopathological (11). CT and CBT have been described as “the conditions are associated with specific biases fastest growing and most heavily researched that influence how an individual incorporates systems of psychotherapy on the contemporary and responds to new information. scene” (12, p. 332). This article provides a brief According to Beck’s model (1–3, 6, 15, 16), overview of the conceptual, practical, and em- the cognitive appraisal of internal or external pirical aspects of CT. After highlighting some stimuli influences and is, in turn, impacted by of its basic concepts and the research pertain- these other systems. Thus, although cognition ing to Beck’s cognitive theory, we discuss the plays a key role in this model (i.e., the as- general approach to treatment and review the signment of meaning is crucial to understand- literature on its efficacy. We conclude by out- ing maladaptive behavior), it is recognized that lining some directions for future research. mental health problems involve a complex in- terplay among diverse and interrelated systems (17). Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Within the cognitive system are different COGNITIVE THEORY levels of cognition, ranging from surface-level Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Cognitive theory is based on the presumption thoughts to “deeper” cognitive schemas (18, that information processing is crucial for 19). Cognitive schemas are organized structures human adaptation and survival. Without the of stored information that contain individuals’ ability to process information from the envi- perceptions of self and others, goals, expecta- ronment, synthesize it, and formulate a plan tions, and memories. These elements are well- for dealing with it, we would not survive. The organized within the cognitive structure (20) cognitive (or information processing) system is and influence the screening, coding, categoriza- intricately tied to other affective, motivational, tion, and interpretation of incoming stimuli and and behavioral repertoires. Each of these the retrieval of stored information. Schemas repertoires, or systems, serves an individual are adaptive insofar as they afford efficient pro- function and also operates in synchrony toward cessing of information; however, when they 398 Beck · Dozois ME62CH28-Beck ARI 4 December 2010 14:36 become negatively biased, maladaptive, rigid, proximal to a given situation than are other lev- and self-perpetuating, they can contribute to els of cognition, they are functionally related to psychopathology. one’s deeper beliefs and schemas and seem to Diathesis-stress Maladaptive cognitive schemas are believed arise associatively as different aspects of one’s model: to develop during early periods of the life core belief system are activated. a psychological theory span and become increasingly consolidated and When negative cognitive schemas are acti- that predicts that organized as new experiences are assimilated vated, as in depression, they are not only identi- psychiatric disorders into the existing belief structure (3, 15). Poor fiable but can be shown to have an influence on result from the interaction of a early attachment experiences and other adverse information processing, as manifested by cog- predisposition (e.g., events (e.g., childhood maltreatment), for ex- nitive biases, and have an impact on symptom genetic, cognitive ample, may contribute to the development of development. When a depressive episode has diatheses) and negative a maladaptive belief system. Cognitive theory remitted, the negative schemas are deactivated life events. When an is essentially a diathesis-stress model. In other (or vice versa). underlying vulnerability is strong, words, it is possible to have a maladaptive belief Another aspect of Beck’s model is content less stress is necessary system and not exhibit symptoms so long as the specificity (16, 17). That is, different emotional to trigger the behavior cognitive schema (and related systems) is not experiences and forms of psychopathology are or disorder; when the activated. Once triggered by external events, related to a unique cognitive profile or set of predisposition is weak, drugs, or endocrine factors, however, the cog- beliefs (see Table 1 for some examples of sys- a greater amount of stress is typically nitive schema triggers a cascade of information- tematic biases associated with different disor- needed before an processing biases (1, 4, 15, 16, 18). These may ders). To illustrate, depression is related to individual develops the be attention, memory, or interpretational bi- thoughts and beliefs concerning personal loss, disorder ases. For instance, individuals with anxiety dis- deprivation, and failure (15). Persons with clini- Automatic thoughts: orders perceive themselves as vulnerable and cally significant anxiety tend to overestimate the the flow of cognitions the world as dangerous. Such individuals at- probability of risk while simultaneously under- (considered the tend selectively to threat-pertinent information estimating their resources for coping with po- cognitive byproducts of activated schemas) at the expense of information that is inconsis- tential threats. Their thoughts focus on themes that arise in our tent with threat or information that suggests of the self as vulnerable, the world as danger- day-to-day lives and one has sufficient resources for dealing with it. ous, and the future as potentially catastrophic are not accompanied An individual who is vulnerable to depression, (6). A person with dependent personality disor- by direct deliberation to consider another example, may have an un- der has a view of the self as weak, helpless, and or volition derlying belief that he or she is unlovable. This incompetent (7). belief may become especially salient when