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Cognitive Therapy

Cognitive Behaviour Therapy:
  1. GIVEN BY AARON BECK, (1970), Initially for depression, currently being used for anxiety, schizophrenia, OCD, Mania etc.
  2. Cognitive therapy or Cognitive Behavior Therapy – (CBT) is a kind of psychotherapy which aims at correcting maladaptive methods of thinking, thus providing relief from symptoms.
  3. The various cognitive errors and faulty cognitive schemas are described below:-
According to Beck there is Negative triad in Depression –
  1. Negative view of self
  2. Negative view of future
  3. Negative view of Environment
  • Cognitive therapy is a short-term, structured therapy that uses active collaboration between patient and therapist to achieve its therapeutic goals, used with depression, panic disorder, obsessive-compulsive disorder, personality disorders, and somatoform disorders.
  • Cognitive Theory of Depression according to which cognitive dysfunctions are the core of depression, and affective and physical changes and other associated features of depression are consequences of cognitive dysfunctions. Depression can be explained by the cognitive triad, which explains that negative thoughts are about the self, the world, and the future.
The three components of cognitive therapy are
  1. Didactic aspects                              
  2. Cognitive techniques    
  3. Behavioral techniques.
  1. Didactic aspects include explaining to patients the cognitive triad, schemas, and faulty logic. Therapists must tell patients that they will formulate hypotheses together and test them over the course of the treatment. 
  2. Cognitive techniques includes four processes:
    1. Eliciting automatic thoughts
    2. Testing automatic thoughts
    3. Identifying maladaptive underlying assumptions
    4. Testing the validity of maladaptive assumptions:
  • Eliciting Automatic Thoughts—also called cognitive distortions, are cognitions that intervene between external events and a person’s emotional reaction to the event.
  • Testing Automatic Thoughts—Acting as a teacher, a therapist helps a patient test the validity of automatic thoughts. The goal is to encourage the patient to reject inaccurate or exaggerated automatic thoughts after careful examination.
  • Identifying Maladaptive Assumptions— Identifying the patterns representing rules or maladaptive general assumptions that guide a patient’s life, which inevitably lead to disappointments and failure and, ultimately, to depression
  • Testing the Validity of Maladaptive Assumptions—therapists ask patients to defend the validity of their assumptions
  1. Behavioral and cognitive techniques go hand in hand; behavioral techniques test and change maladaptive and inaccurate cognitions.
    Common cognitive errors derived from assumptions include overgeneralizing, selective abstraction, excessive responsibility, assuming temporal causality, self-references, catastrophizing, and dichotomous thinking.
Cognitive errors in Depression Conditions

Adaptive and maladaptive schemas
No matter what happens, I can manage somehow.
If I work at something, I can master it
I am a survivor
Others can trust me
I am lovable
People respect me.
I can figure things out.
If I prepare in advance, I usually do better.
I like to be challenged
There is not much that can scare me.
I must be perfect to be accepted.
If I choose to do something, I must succeed.
I am a fake
Without a woman [man], I am nothing
I am stupid.
No matter what I do, I won’t succeed.
Others can’t be trusted.
I can never be comfortable around others.
If I make one mistake, I will lose everything.
The world is too frightening for me.
Important Indications of Cognitive Therapy in Psychiatry
  1. Cognitive therapy can be used alone in the treatment of mild to moderate depressive disorders or in conjunction with antidepressant medication for major depressive disorder.
  2. It is one of the most useful psychotherapeutic interventions currently available for depressive disorders, and it shows promise in the treatment of other disorders.
  1. Criteria that justify the administration of cognitive therapy alone:
    1. Failure to respond to adequate trials of two antidepressants
    2. Partial response to adequate dosages of antidepressants
    3. Diagnosis of dysthymic disorder
    4. Variable mood reactive to environmental events
    5. Variable mood that correlates with negative cognitions
    6. Mild somatoform disorders (sleep, appetite, weight, libidinal).
  2. Indications for combined therapies (medication plus cognitive therapy):
    1. Partial or no response to trial of cognitive therapy alone
    2. Partial but incomplete response to adequate pharmacotherapy alone
    3. Poor compliance with medication regimen
    4. Presence of severe somatoform disorders and marked cognitive distortions (e.g., hopelessness)
    5. Impaired memory and concentration and marked psychomotor difficulty
    6. Major depressive disorder with suicidal danger.
Behavior Therapy
  1. Behavior therapy involves changing the behavior of patients to reduce dysfunction and to improve quality of life.
  2. Behavior therapy represents clinical applications of the principles developed in learning theory.
  3. Behavioral views differ from cognitive views in holding that physical, rather than mental, events control behavior.
Systematic Desensitization
  1. It is based on the behavioral principle of counterconditioning, whereby a person overcomes maladaptive anxiety elicited by a situation or an object by approaching the feared situation gradually, in a psychophysiological state that inhibits anxiety.
  2. Patients attain a state of complete relaxation and are then exposed to the stimulus that elicits the anxiety response.
  3. The negative reaction of anxiety is inhibited by the relaxed state, a process called reciprocal inhibition.
  4. Works best in cases of a clearly identifiable anxiety provoking stimulus. Phobias, obsessions, compulsions, and certain sexual disorders.
  5. Consists of three steps: Relaxation training, hierarchy construction, and desensitization of the stimulus.
    1. Relaxation Training—Relaxation produces physiological effects opposite to those of anxiety. Mental imagery is a relaxation method in which patients are instructed to imagine themselves in a place associated with pleasant relaxed memories.
    2. Hierarchy Construction—When constructing a hierarchy, clinicians determine all the conditions that elicit anxiety, and then patients create a hierarchy list of 10 to 12 scenes in order of increasing anxiety.
    3. Desensitization of the Stimulus—patients proceed systematically through the list from the least, to the most, anxiety provoking scene while in a deeply relaxed state. The rate at which patients progress through the list is determined by their responses to the stimuli.
Therapeutic-Graded Exposure
  1. Similar to systematic desensitization, except that relaxation training is not involved and treatment is usually carried out in a real life context.
  2. This means that the individual must be brought in contact with the warning stimulus to learn firsthand that no dangerous consequences will ensue. Exposure is graded according to a hierarchy.
  1. Similar to graded exposure in that it involves exposing the patient to the feared object in vivo; however, there is no hierarchy Patients are encouraged to confront feared situations directly, without a gradual buildup, as in systematic desensitization or graded exposure.
  2. The success of the procedure depends on having patients remain in the fear generating situation until they are calm and feel a sense of mastery.
  3. Imaginal flooding means the feared object or situation is confronted only in the imagination, not in real life.
  4. The technique works best with specific phobias.
Participant Modeling
  1. The participant-model technique has been used successfully with agoraphobia by having a therapist accompany a patient into the feared situation.
  2. Patients learn a new behavior by imitation, primarily by observation like with phobic children who are placed with other children of their own age and sex who approach the reared object or situation.
Assertiveness Training
Assertive behavior enables a person to act in his or her own best interest, to stand up for herself or himself without undue anxiety to express honest feelings comfortably, and to exercise personal rights without denying the rights of others.
Social Skills Training
  1. Patients with depression often experience a lack of social reinforcement because of a lack of social skills, and social skills training have been found to be efficacious for depression.
  2. Social skills training programs for patients with schizophrenia cover skills in the following areas: conversation, conflict management, assertiveness, community living, friendship and dating work and vocation, and medication management.
Aversion Therapy
  1. Aversion therapy has Deer, used for alcohol abuse, paraphiiias, and other behaviors with impulsive or compulsive qualities.
  2. When a noxious stimulus (punishment) is presented immediately after a specific behavioral response, theoretically, the response is eventually inhibited and extinguished.
  3. However punishment does not always lead to the expected decreased response and can sometimes be positively reinforcing.
  4. Eye Movement Desensitization and Reprocessing
  5. Involve inducing saccades whine a person is imagining or thinking about an anxiety producing event which can yield a positive thought or image that result in decreased anxiety, used in post-traumatic stress disorders and phobias.
Positive Reinforcement
When a behavioral response is followed by a generally rewarding event, such as food, avoidance of pain, or praise it tends to be strengthened like tokens that they can use to purchase luxury items or certain privileges, known as token economy, which can successfully alter behavior.
Important Indications of Behavior Therapy
  • Agoraphobia, alcohol dependence anorexia nervosa, bulimia nervosa, phobias, paraphilias, schizophrenia and sexual dysfunctions.
Interpersonal therapy (IPT)
  1. It assumes that the development and maintenance of some psychiatric illnesses occur in a social and interpersonal context and that the onset, response to treatment, and outcomes are influenced by the interpersonal relations between the patient and Significant others.
  2. Goal of IPT is to reduce or eliminate psychiatric symptoms by improving the quality of the patient’s current interpersonal relations and social functioning.
  3. The typical course of ITP lasts 12 to 20 sessions over a 4 to 5 month period.
IPT moves through three defined phases:
  1. The initial phase is dedicated to identifying the problem area that will be the target tor treatment
  2. The intermediate phase is devoted to working on the target problem area and
  3. The termination phase is focused on consolidating gains made during treatment and preparing the patients for future work on their own.
  4. Interpersonal problem areas include; grief, interpersonal and role disputes, role transitions.
  5. Combination of Psychotherapy with Psychotropic Drugs
  6. Indications for Combined Therapy
  7. Patients with major mental disorders such as schizophrenia or bipolar disorder.
  8. To relieve distress when the signs and the symptoms of the patient’s disorder are so prominent that they require more rapid amelioration than psychotherapy alone may be able to offer.
  1. Improved medication compliance
  2. Better monitoring of clinical status
  3. Decreased number and length of hospitalizations
  4. Decreased risk of relapse
  5. Improved social and occupational functioning. 

Behavior Therapy

It is a type of psychotherapy (Broadly defined) which is based on theories of learning, and aims at changing maladaptive behavior and substituting it with adaptive behavior.
  1. Systematic Desensitization (SD)
  2. Aversion Therapy
  3. Operant Conditioning Procedures for Increasing a Behavior
    1. Positive Reinforcement – the desirable behavior is reinforced by a reward.
    2. Negative Reinforcement – on performance of the desirable behavior, punishment can be avoided.
    3. Modeling
    4. Flooding
    5. Operant Conditioning Procedures for Decreasing a Behavior
      • Timeout – the reinforcement is withdrawn for sometime, contingent upon the undesired response. This is often used in therapy with children.
      • Punishment
      • Satiation - the undesired response is positively reinforced, so that tiring occurs.
Supportive psychotherapy (relationship – oriented psychotherapy) – offer the patient support by an authority figure during a period of illness, turmoil or temporary decomposition. It also has the goal of restoring and strengthening the patient defenses and integrating capacities that have been impaired.
Brief Psychotherapy        
Short term treatment methods to help people deal with current problems and crises.
  1. Group psychotherapy: Emotionally ill people meet in a group guided by therapist to help one another effect personality change.
  2. Family therapy – Focuses altering the interaction among family members and improves functioning
  3. Couple therapy (Marital) – Designed to modify the interaction of two people who are in conflict with each other over one parameter or variety of other parameters, social, emotional, sexual or economic.
  4. Biofeed back – it relies on instrumentation to measure moment to moment physiological process. E.g. Anxiety disorders – Principle – Autonomic Nervous system can be voluntarily controlled.
  5. Psychosocial treatment and rehabilitation - Refers to the use of various methods to enable people who are severely mentally ill to develop social and vocational skills for independent living. E.g. Social Skill training
  6. Interpersonal behaviors required for community survival for independence and for establishing, maintaining and deepening supportive, socially rewarding relationships.
  7. Contingency Management – In this the reward is set for the desired behavior – usually done for Drug Dependence Management other Method is Token economy.
  8. Token economy – Exchanging tokens as reward for desired behavior usually used for teaching skills to mentally retarded child.
Psychosurgery is a surgical intervention, to sever fibres ,with intent of modifying behaviour. First done by Lima & Moniz
  1. Chronic severe ,incapacitating obsessive -compulsive disorder.
  2. Chronic depression not responding to treatment
  3. Severe, uncontrolled aggressive behaviour.
  1. Stereotactic Subacute tractotomy: sub caudate lesion is produced. recommended in severe depression ,severe OCD.
  2. Stereotactic limbic leucotomy: subcaudate tractotomy and limbic leucotomy.
  3. Amygdalotomy: used for severe, pathological, uncontrolled aggression.
    At present, psychosurgery is an uncommon procedure. 
Therapy / School Proponent
Analytical psychology
Transactional analysis
Client-centered psychotherapy
Group therapy
Cognitive therapy
Cognitive behavior therapy
Classical conditioning
Operant conditioning
Dual sex therapy
Therapeutic community
Rational emotive therapy
Primal therapy
Will therapy
Gestall therapy
Existential logo therapy
Recipocal inhibition
Progressive muscular relaxation
Charater analysis
Token economy
Ayllon & Arzin                                                         
Sigmund Freud
Carl Gustav Jung
Eric Burne
Carl R Rogers
James BraidQ
Joseph PrattQ
Aaron T BeckQ
Donald MeichenbaumQ  
John Broadus Watson
Ivan Petrovich PavlovQ
Burrhus Frederic SkinnerQ
William Master, Virginia JohnsonQ
Maxwell Jones   
Jacob L Morengo  
Albert Ellis
Arthur Janov
Otto rank
Frederich Perls
Victor E Frenkel
Joseph Wolpe
E. Jacobson
Wilhelm Reich                                                         

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