Historical evolution

The psychological origins of cognitive psychotherapy go back to the various developments of several schools of psychology.

The modern founders of this psychotherapy are Albert Ellis and Aaron Beck.

Ellis (1913) progressively modified his therapeutic model, starting from a rather classical psychoanalytic perspective, passing through a neo-Freudian perspective, and arriving at his own model. Over the course of these modifications, he observed that the success rate of his treatments increased, and that patients, although they might have an adequate understanding of their behavior (insight), generally did not change it and stagnated at that level. In 1958, he published his famous A-B-C model for therapy. In this model, he asserted that emotional disorders do not stem directly from the events of present life or from past events, but from certain irrational beliefs or demands that the subject himself has acquired and in which he “indoctrinates himself.” At the same time, he was moving closer to behavior therapy by proposing active methods for modifying these demands. His therapy constitutes what is known as “rational-emotive therapy.”

Cognitive psychotherapy is the youngest of the major orientations in psychotherapy. Emerging over the course of the 1970s, it acquired its prestige when it demonstrated, in a famous study by the NIMH (National Institute of Mental Health), that it was capable of obtaining excellent results in the treatment of depression.

Beck, in particular, is the one who developed and provided very useful answers for the therapeutic approach to depression. He observes that, in this disorder as in other emotional disorders (Beck, 1967, 1976), the structure of individuals’ experiences determines their feelings and behaviors. This concept of cognitive structure often receives other names, such as “cognitive schema” and, in the clinical field, “personal assumptions” (Beck, 1979). They are equivalent to irrational beliefs in Ellis’s conception.

The primary elements are: on the psychopathological level, the triad of negative views, the hypothesis of the existence of vulnerability schemas, the presence of dysfunctional schemas and the activation of dysfunctional mechanisms; on the therapeutic level, interventions on automatic thoughts, the confrontation of distortions and cognitive restructuring (Fernández-Álvarez, 2000).

What is revolutionary about the new scientific paradigm of depression according to Beck?

In the first place, it focuses on the patient’s personal paradigm. In the second place, it conceptualizes this paradigm in terms of a cognitive revolution. In this sense, what is called the new scientific paradigm of depression holds that “the patient’s personal paradigm, when he is in a depressive state, gives rise to a distorted view of himself and of the world. His negative ideas and beliefs seem to him a truthful representation of reality, even when they seem implausible to others, and to himself when he is not depressed.”

Basic postulates of the classic model

According to Beck’s classic model, the general postulates on which cognitive therapy rests are the following:

1) Ideas or beliefs influence (and modify) affective states. Some are responsible for the genesis of psychological disorders. The success of therapy depends on the possibility of changing these beliefs.

2) The development of a disorder rests on the individual’s cognitive vulnerability to producing depressive symptoms. This vulnerability is the result of the operation of certain schemas or patterns of inadequacy, failure or loss.

3) These schemas are represented by dysfunctional attitudes of the type “if someone I love doesn’t love me, I am nothing.” The automatic thoughts that favor the appearance of depressive symptoms make use of cognitive distortions.

4) What produces distorted actions is the activation of different schemas. There are three main types:

5) When the individual comes up against certain negative events that activate his cognitive vulnerability, negative signs develop with regard to himself, the world and the future.

6) As a consequence, the negative symptoms that characterize depression appear.

The systematic errors that occur in the thinking of the depressed person maintain the patient’s belief in the validity of his negative concepts, even in the presence of contrary evidence (Beck, 1967).

Alternative models

Several modifications have been introduced into the original model, some of which have been supported by Beck himself. These changes have been part of the natural evolution of a model put to the test in clinical practice and in research. But they have also been the fruit of the criticisms addressed to the initial model, which can be summarized as follows:

• Not taking into account the weight of negative environmental factors and overestimating internal factors.
• The finding that depressed people do not distort more than non-depressed people: they simply have a greater tendency to do so in a more negative way.
• The questioning of the hypothesis concerning the effect of cognition on affect as a unidirectional cause.
• The inconsistency of the theory’s objectivity and of the idea that it would be up to the therapist to decree what is real.
• Criticisms of the emphasis placed on rational and conscious processes.

New models of cognitive psychotherapy have emerged, which their proponents present as distinct from those of Ellis and Beck mentioned above. These new models are called “constructivist,” as opposed to the “rationalist” models.

Fundamentally, they differ from the previous ones on several points: according to Mahoney and Gabriel (1987), one cannot conceive of an objective “reality” independent of the subject; nor can one always assert the primacy of cognition over emotion or over action; finally, they hold that therapy is constituted not as psychoeducational work of correcting erroneous cognitions, but as a reconstruction of the patient’s own cognitive system’s coherence. Among the notable therapeutic lines of this movement are the “developmental cognitive therapy” of Mahoney (1991), the “structural cognitive therapy” of Guidano and Liotti (1985) and the “narrative cognitive therapy” of Gonçalves (1992).

Cognitive distortions

Depressed people are prone to distortions in information processing. They maintain their belief in the validity of their negative concepts, even when they encounter contrary evidence (Beck, 1976, 1979).

The cognitive distortions that occur most frequently and that underlie dysfunctional beliefs or assumptions are the following:

These ways of distorting make it difficult to benefit from positive experiences or from the correction of perceptions. The thinking of these people is dominated by negative schemas that organize cognitions, which contain the core beliefs and underlying assumptions that generate biases in information processing.

These schemas are activated in the face of negative events, or remain silent, except in chronically disturbed forms, where their activation is continuous.

Cognitive psychotherapy: what and how

Cognitive therapy postulates that the possibility of recognizing and examining patients’ negative beliefs and their tendencies in the way they process information can reduce their distress and make them more effective in facing the challenges of life.

To put it simply, thoughts influence feelings and behavior; by changing thoughts, feelings and behaviors will change.

The most important role of the therapist will be to help patients use techniques to identify and examine their thoughts, and thus modify dysfunctional beliefs and behaviors.

The therapist’s ultimate goals are for patients to be able to use these thoughts independently.

These skills are important not only for reducing symptoms, but also for reducing the frequency of relapses.

Therapy is conducted in a structured and collaborative manner, in order to achieve its objectives through three actions: exploring, examining and experimenting, which will help the patient in the process of replacing negative or dysfunctional thoughts with others that are more adaptive or functional.

The first step therefore consists in exploring one’s beliefs or, in other words, one’s system of personal meanings.

The second step consists in examining these beliefs or personal meanings, trying to seek new interpretations, perspectives that make them more flexible.

The third step, or experimentation, which involves testing the validity of dysfunctional beliefs, serves to call these beliefs into question.

These steps are not necessarily linear: they can be used in whatever order is appropriate.

Cognitive therapy can be applied to a variety of disorders, such as depression, for the treatment of which it was originally designed (Beck, 1979), but also, as is well known, through subsequent adaptations, to other disorders such as anxiety disorders, personality disorders, eating disorders, etc.