Mental Health Therapies - Cognitive and behavior therapies

Cognition is the term used for the grouping of the mental processes of perceiving, recognizing, conceiving, judging, and reasoning. Cognition is based on how not just humans but all living creatures adjust their experiences, how they make sense of these experiences, and how they relate present experiences to past ones embedded in memory. This is called the cognitive paradigm and is commonly accepted by psychologists. Cognitive theory is based on the idea that the learning process is very complex and one's belief system and ways of thinking are very important when it comes to determining and affecting behavior and feelings.

Psychoanalyst Aaron Beck (1921–) developed cognitive therapy. Beck was intrigued by how people spoke to themselves through their own self-communication system. When his patients experienced thoughts that they were hardly aware of and these thoughts did not seem to stem from the free association technique practiced in sessions, Beck stressed that the patient focus on these thoughts, which he renamed automatic thoughts. These unformed thoughts were often connected to unpleasant feelings or memories within the patient.

Through the isolation of and focus on these unformed thoughts, Beck was able to identify negative themes that characterized the way patients considered both present and past situations. From these unformed thoughts, patients formed rules for themselves, which Beck called schemas. These schemas, especially within depressed people, were self-defeating and often leaned toward the negative.

Techniques and Goals of Cognitive Therapy

Like Alfred Adler, Aaron Beck believes in an active approach to therapy, including the use of direct dialogue with the patient. Another significant approach to cognitive therapy is based on the ideas of cognitive therapist Albert Ellis, who asserted that negative feelings and activities are caused by irrational beliefs within a person. For example, a child may believe that in order to win the love of his parents he must be a "perfect" son. This, of course, is an irrational thought—no one can be absolutely perfect.

Through a technique called rational-emotive therapy, Ellis and other cognitive therapists who follow his beliefs guide their patients in challenging their irrational beliefs and assist them in replacing such thoughts with new, more positive ones. In the case of the "perfect" son, a cognitive therapist would help him see that although it would be great if he could be perfect, he doesn't have to be without fault to win the love of his parents.

Cognitive therapists see the patient as active in the situation, with the patient's past knowledge imposing a "perceptual funnel" on his experience. The patient is guided into fitting new information into an organized network of already accumulated knowledge, called schema. New life information may fit the schema; if not, the patient reorganizes the new information to fit the schema. In this way, conflicts and issues are unearthed, discussed, and conquered.

Behavior Therapy

The idea of behaviorism was developed primarily by American psychologist John B. Watson, who said that psychology was the study of observable behavior instead of an examination of the patient's subjective experiences. Behaviorism focuses on the study of this observable behavior instead of on consciousness. This is a switch in previous focus from learning to thinking.

Behavior therapy has its history in the experimental psychology and learning processes of humans and animals. Its main focus is to change certain behaviors instead of uncovering unconscious conflicts or problems. The learning/behavioral paradigm states that abnormal behavior is made up of responses learned the same way that normal behavior is learned. Through behaviorism, therapists use ways of learning as part of their technique in helping a patient.

CLASSIC CONDITIONING. Classic conditioning, also called respondent conditioning, was actually discovered by accident by Russian physiologist Ivan Pavlov (1849–1936). One day, while studying the digestive system of his subject (a dog), Pavlov realized that when a bell was rung right before feeding the dog, the dog would salivate before the food was even brought out. The food, then, becomes an unconditioned stimulus (UCS), and the dog's response, salivating, is an unconditioned response (UCR). When the food is preceded by a neutral stimulus, or the ringing of a bell, the sound of the bell, called the conditioned stimulus, or CS, makes the dog salivate, which is the conditioned response (CR).

Extinction is another aspect of this classic conditioning; it refers to what happens to the CR when the repeated sound of the bell is not followed by the food. From this, the dog salivates fewer and fewer times until the CR eventually disappears.

There seems to be no limit, then, to the wide array of stimuli that could be introduced to subjects and followed with the study of different conditioned responses. The study of classical conditioning showed psychologists that there might be a relationship between classical conditioning and the development of emotional disorders.

OPERANT CONDITIONING. Whereas classical conditioning focuses on the introduction of a conditioned stimulus on the subject before introducing an unconditioned stimulus, operant conditioning focuses on the background and results of behavior. The operant theory, based on the work of E.L. Thorndike (1874–1949) and B.F. Skinner (1904–1990), actually formed the roots of much of behavior therapy today.

Operant conditioning is a type of learning based on the effects of consequences on behavior, where one's behavior is changed by systematically changing the surrounding circumstances. Through study, Thorndike developed a principle called the law of effect, which says that behavior followed by consequences that are satisfying to the subject will be repeated, and that behavior followed by negative consequences will be discouraged.

Skinner introduced the concept of operant conditioning. He adjusted Thorndike's law of effect by shifting the focus from the linking of stimuli and responses to the relationships between those responses and their consequences. He also introduced the concept of a discriminative stimulus, or an external event that tells an organism that if it performs a certain behavior, a certain consequence will occur.

B. F. Skinner. (The Library of Congress.)
B. F. Skinner. (The
Library of Congress

A classic example of operant conditioning involves the Skinner box, wherein a subject, often a small animal such as a pigeon, is placed into a closed box with a box of lighted knobs. The psychologist will record the number of the subject's pecks at each light according to what each lighted knob corresponds; for example, if the pigeon has been deprived of water, it will peck at the knob corresponding to water more times than it pecks at the other knobs. The subject can even be trained to peck at specific colored lights by reinforcing one knob over another.

Operant conditioning, like classical conditioning, is useful in behavior therapy's study of emotional disorders or abnormalities, but is also helpful in the study of conduct disorder, autism (see Chapter 12: Mental Illness), and children and their behaviors as they age (the concept of a child's "time out"—where a child is sent to his room or asked to sit quietly after misbehaving—for example, is an operant tool).

MODELING. Modeling, another behavior therapy tool, is the learning of a behavior by observing and imitating it. This is especially apparent in children, who learn a significant amount through modeling. Modeling is also a very effective treatment for severely disturbed patients, such as schizophrenics (see Chapter 12: Mental Illness), because it teaches them new social behavior that can improve their functioning in the outer world.

Modeling utilizes cognitive behaviors (perception, reasoning, etc.) to effectively absorb the modeled behavior. Modeling has developed and has been effectively used as a form of cognitive behavior therapy because it provides the subject with a "code" or plan in which to learn the new behavior. Researchers have learned that when subjects have a model or plan to follow, the new information is better retained. Also, the use of this code or plan helps subjects to pattern their own actions on what they have seen modeled. What was at first seen as a simple form of learning has been realized as an effective form of cognitive behavior therapy.

Cognitive Behavior Therapy

Cognitive behavior therapy is just one mode of therapy that falls under the larger umbrella of cognitive and behavior therapies. Cognitive behavior therapy combines pieces of cognitive therapy, which aims to change a person's thinking to affect a change in behavior, and pieces of behavior therapy, which aims to change a person's behavior. Cognitive restructuring is a term utilized by therapists to define a changing thought pattern that is thought to cause an emotional disturbance. This restructuring is administered in many ways by cognitive behavior therapists.

Rational-Emotive Behavior Therapy

The basis of rational-emotive behavior therapy comes from cognitive behavior therapist Albert Ellis, who believed that antisocial, negative feelings and activity are caused by irrational beliefs based on a code one makes for oneself about how to live. Mistakenly, people put extreme demands on themselves and those around them, as when a person who strives to be perfect makes a mistake and feels overwhelmingly terrible; the person will use that internal communication system to punish himself. In addition, people will occasionally attempt to decipher what occurs around them, and these discoveries sometimes cause conflict. Ellis stressed the importance of the therapist's attention on the patient's beliefs instead of what is causing the conflict.

Those who practice rational-emotive behavior therapy differ in the ways in which they persuade patients to adopt new ways of communicating with oneself. Some therapists have been known to tease, coerce, or bully their patients into realizing new forms of self-communication. Others take a different approach and suggest that patients discuss their irrational beliefs and then gently guide them toward a more rational way of living. With this behavior therapy technique, Ellis and his supporters helped their patients rethink their original, negative beliefs and guided them into restructuring those thoughts or beliefs. For example, the man who made the mistake is coached into rethinking the scenario and inserts a realistic thought: although it would be nice to be perfect, everybody makes mistakes at some point.

Rational-emotive behavior therapy (REBT) is a relatively young technique in the field of mental health therapy, and studies about it are still being conducted. The technique has been shown to reduce anxiety and to help patients gain control of some forms of excessive anger and depression, but it has also worked as a preventive tool for untroubled people to help them deal with everyday stress. It has also been used experimentally in classrooms to delay and possibly reduce the amount of emotional problems later in life.

Behavioral Medicine

Behavioral medicine, also called health psychology, is another developing mental health therapy technique in the field of medicine. It is the interdisciplinary study of ideas and knowledge taken from medicine and behavior science (psychology). It is called interdisciplinary because it incorporates the knowledge of many different medical practitioners, from social workers to psychiatrists and researchers. It is used to understand physical and mental illness as well as to prevent and treat psychophysiological disorders, or physical maladies caused by emotional distress, such as stress and other illnesses that involve the psyche. Behavioral medicine has also been used to study and treat acute and chronic pain.

A patient being monitored for stress via biofeedback. (Photograph by Will & Deni McIntyre. Photo Researchers, Inc. Reproduced by permission.)
A patient being monitored for stress via biofeedback. (Photograph by
Will & Deni McIntyre. Photo Researchers, Inc.
Reproduced by permission.)

BIOFEEDBACK. One of the first behavioral medicine techniques finding great success is biofeedback, which uses extremely sensitive machines to provide patients with information on their blood pressure, skin temperature, brain waves, and other bodily functions. The patient, painlessly hooked up to these machines, is given an auditory or visual sign when there is a change in the patient's condition. Learning the signal before one's blood pressure raises, for example, can lead a patient to train himself to identify what behaviors or situations might be causing his raise in blood pressure. The patient, then, can eventually teach himself to control his blood pressure if he has learned from biofeedback to recognize when a raise might occur.

Biofeedback can be a very effective way to combat other stress-induced conditions, such as anxiety, hives, and tension headaches, but it has also proven helpful for patients with attention-deficit disorder (ADD), depression, and other "minor" emotional disturbances (see Chapter 13: Mental Illness).


Based on the control theory, which states that people are responsible for their lives and actions, reality therapy was established to help people make choices, both simple and difficult, and ultimately control their behavior.

Psychiatrist William Glasser (1925–), who developed this form of therapy, was not satisfied with psychoanalysis' belief that patients should deny responsibility for their behavior and instead blame others and their past for their problems. Glasser stresses that the relationship between therapist and patient should be friendly, open, and accepting. As the patient commits to therapy and what it uncovers, Glasser believes he can guide the patient toward altering his ways of thinking and feeling.

In reality therapy, talking about one's feelings is accepted, but is not a major focus of the therapy. Instead, Glasser stresses helping clients make changes in their lives and maintaining those changes. The therapist, according to Glasser, should not accept excuses on the patient's part, as this would hinder the healing process.

This therapy technique has attracted interest with professionals in many fields, including therapists, school counselors, substance abuse counselors, and corrections employees. Institutional populations such as mental hospitals and prisons, with their more challenging populations, have also had success with the use of reality therapy.

Reality therapy has specific goals. Its aim is to help patients find what they psychologically lack, such as feelings of belonging, freedom, power, and fun. The therapist meets with the patient to assess if his needs are being met, and works with him to attain these things, reestablishing or perhaps even establishing for the first time a positive life experience.

PAIN MANAGEMENT. The adapting of pain into one's life does not seem like something one would want to learn at all, but for many people pain is a part of every day. Dealing with that maladaptive pain (pain that does not fit with one's situation and seriously limits one's enjoyment of life) without its taking over can be difficult. Researchers have learned that if patients are distracted from their pain, the pain may be lessened when it occurs or may not even be felt at all. Cognitive psychologists have also found that, since everyone has a limited amount of attention to channel toward one stimulus, distracting the patient away from the pain and toward something else guides the patient into focusing all attention on the other stimulus. This human limitation can actually prove beneficial to the sufferer of pain.

The importance of distraction in pain management is consistent with studies done in cognitive psychology, and there is more to come in the field of pain management as new ways of healing are increasingly chosen over more conventional forms of medicine.

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