Cognitive Therapy Research Paper

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Cognitive therapy is a form of psychotherapy that posits that how an individual perceives and interprets events strongly influences how that person responds emotionally and behaviorally. It combines cognitive and behavioral techniques to teach patients to challenge biased perceptions and the underlying assumptions that may cause them to distort current situations. It is best known as an effective treatment for unipolar depression. Since its establishment 30 years ago, it has been applied to a wide range of psychological problems and clinical populations. Outcome studies have demonstrated its usefulness in the treatment of depression and have suggested that cognitive therapy has some preventive effects against future depressive episodes. Current research is investigating whether cognitive therapy can prevent a first episode of depression among those at risk. In addition, cognitive therapy techniques are being used in schools to promote cooperation and self-esteem. Thus, this form of therapy can be used to promote mental health at the individual and community levels.

Outline

I. Cognitive Therapy and Mental Health

II. Principles of Cognitive Therapy

A. Cognitive Organization

B. Cognitive Specificity

C. Continuity Hypothesis

III. Cognitive Model of Depression

IV. Cognitive Risk Factors in Suicide

V. Cognitive Model of Anxiety Disorders

VI. Cognitive Model of Personality Disorders

VII. What Does Healthy Cognitive Functioning Look Like?

VIII. Some Developmental Considerations

IX. How Does Cognitive Therapy Work?

X. The Prevention of Depression

I. Cognitive Therapy and Mental Health

Cognitive therapy is a system of psychotherapy that emphasizes the role of information processing in human behavior and psychological distress. It posits that how people perceive, interpret, and assign meanings to events strongly influences their emotional and behavioral reactions. It also maintains that significant life experiences shape core beliefs about the self and the world. These core beliefs, in turn, affect how new information is incorporated. Cognitive therapy is thus concerned with both the idiosyncratic meanings of events for people and the ways in which these meanings are generated and maintained. Although the content of cognitions (i.e., thoughts and images) may be highly personal, the mechanisms of cognitive processing are believed to be universal.

Cognitive therapy was developed in the 1960s by psychiatrist Aaron T. Beck. It is derived from empirical findings from studies of depressed patients. Beck found that depressed patients’ thinking is saturated with themes of deprivation, defeat, and loss. Moreover, their judgments are absolute and rigid. Usually, information processing proceeds in a fairly flexible manner, so that initial impressions or primary appraisals may be checked and verified or adjusted. Beck observed that during depression this flexibility is lost, making it extremely difficult for depressed persons to generate alternative interpretations of events, solutions to problems, or new ways of behaving. Cognitive deficits, such as impaired perception, recall, and long-term memory, interfere with reasoning. Errors in logic, or cognitive distortions, become more apparent and create a negative bias to thinking.

Cognitive distortions are present in the thinking of nondepressed persons as well, for no one has perfect understanding. However, in the case of depression, anxiety, or other syndromes, these distortions are rigidly applied and initial impressions are not reevaluated. Self-correction is limited. In addition, in psychological distress, errors in thinking are combined with maladaptive assumptions, leading the patient in a negative spiral. Cognitive distortions include overgeneralization, dichotomous thinking, arbitrary inference, selective abstraction, personalization, and maximization and minimization. The goals of cognitive therapy are to return the person to more flexible thinking and to modify maladaptive beliefs and assumptions which may be risks for further depression. Cognitive therapy teaches people to identify and correct the distortions in their thinking to regain flexibility. It also teaches them to assess the utility of their beliefs and assumptions and to modify them if necessary. Beliefs are modified by examining them logically and considering alternative interpretations and through behavioral experiments designed to challenge specific assumptions.

The cognitive model of depression has found support for descriptive aspects of its theory and for its treatment efficacy. Cognitive therapy has also been applied to a number of other psychological disorders, including anxiety, personality disorders, substance abuse, eating disorders, stress, and marital conflict. More recently, it has been applied to nonclinical problems, such as management problems in business and conflict resolution in schools.

An important finding of treatment outcome studies in depression has been the apparent benefit of cognitive therapy in relapse prevention. This finding has generated studies of depression prevention with populations at risk. Thus, cognitive therapy may be helpful in preventing depression, not just in treating people once they have become depressed. Additionally, school intervention programs that teach cognitive skills such as problem solving, disputing negative self-talk, and improving self-esteem promote positive adjustment at a community level. In this sense, cognitive interventions may contribute to public health.

In theory and in practice, cognitive therapy addresses a spectrum of mental health, from treating psychiatric diagnoses to enhancing the functioning of those at risk for depression or poor social adjustment. This research paper reviews the cognitive model of psychopathology, describes characteristics of healthy cognitive functioning and presents information on how cognitive therapy may be used to promote mental health.

II. Principles of Cognitive Therapy

A. Cognitive Organization

Cognitive therapy envisions a cognitive organization that is hierarchically structured and cognitive mechanisms that selectively take in or screen out relevant information. The most accessible cognitions in this hierarchy are voluntary thoughts which appear in stream-of-consciousness reports. Less accessible, but more stable, are automatic thoughts, which arise without awareness and are difficult to inhibit, especially at times of emotional arousal. At the next level are beliefs and assumptions, including values. At the deepest level, out of the person’s awareness, are core beliefs embedded in cognitive structures called schemas. The cognitive model proposes that these schemas are latent until triggered by a personally relevant life event. In depression, for example, a life event might trigger a schema of loss, deprivation, or defeat. This would be the mechanism that sets in motion the negative cognitive shift. As a consequence of the cognitive shift, much positive information is filtered out by cognitive distortions, and negative self-relevant information is accepted. The person is thus flooded by negative automatic thoughts.

Automatic thoughts are important in cognitive therapy because they are accessible and reflect core beliefs. They are also full of cognitive distortions. Cognitive therapy works directly on correcting biased thinking by challenging the validity of automatic thoughts. It also works at a structural level to modify maladaptive beliefs and assumptions contained in schemas. It is presumed that these schema-level beliefs are a cognitive vulnerability to various psychological disorders and, if not addressed, pose a risk of recurrence for that disorder.

B. Cognitive Specificity

Although individuals have idiosyncratic thoughts, themes appear within diagnostic categories. Studies comparing the cognitive content of depression and anxiety have found that the cognitions of depressed patients reflect themes of loss, defeat, worthlessness, and deprivation, and anxious patients express themes of danger and threat.

C. Continuity Hypothesis

The cognitive model of psychopathology emphasizes well-being on a continuum. Various psychopathological syndromes are viewed as exaggerated and persistent forms of normal emotional responses. Thus, there is ‘‘continuity’’ between the content of normal reactions and the excessive responses seen in psychological disorders. This hypothesis fits an evolutionary perspective, for it suggests that disorders are extreme manifestations of adaptive strategies. In addition, the notion of continuity makes psychological syndromes more understandable, because people in general can identify with the less severe forms of the behaviors. Indeed, extrapolating from observations of psychopathology gives information about the more subtle biases common in everyday reactions. For example, the intense fear of negative evaluation in social phobia is an exaggeration of the normal social vulnerability and self-consciousness felt in many social interactions. Positive bias and positive illusion, noted in many nondepressed individuals, have an extreme expression in the expansiveness and self-aggrandizement of mania.

Cognitive therapy research has identified cognitive risk factors for various disorders. As a psychotherapy, it is biased in its attention to deficits and limited in its generalizability from clinical samples. Thus, conceptualizations of mental health must be tempered with evidence from social, developmental, and cognitive psychology, which investigate normal populations but are often biased in the direction of generalizing from contrived, laboratory situations. Cognitive models of several disorders are presented here to elucidate cognitive risk factors to mental health. These risk factors are considered in the design of interventions to treat and prevent psychological distress. In addition, contributions from other branches of psychology are presented to consider how healthy cognitive functioning can be promoted.

III. Cognitive Model of Depression

The cognitive model posits that in nonendogenous, unipolar depression, life events activate highly charged negative schemas which override more adaptive schemas and set negatively biased cognitive processing in motion. The activation of schemas is the mechanism by which depression occurs, not its cause. Depression may be caused by any combination of genetic, biological, stress, or personality factors. Regardless of its cause, the same cognitive changes occur in depression. Cognitive distortions bias perceptions and interpretations, judgments and problem-solving skills become limited, and thinking reflects the cognitive triad: a negative view of the self as a failure, a negative view of one’s personal world as harsh and unyielding, and a negative view of the future as hopeless. As a consequence of pessimism, hopelessness, or apathy, the depressed person becomes less active, avoids social contact, and takes fewer risks. Reduced performance is then taken as a sign of failure or worthlessness, reinforcing the negative view of the self.

Although the cognitive model is not explicitly causal, it does propose that schemas containing negative beliefs about the self and the world are a cognitive vulnerability to depression. Examples of depressogenic schemas are, ‘‘I am unlovable’’ and ‘‘I can never get what I want.’’ Schemas are believed to be established by early learning experiences which are reinforced over time. As they are used to explain further events, schemas become anchored and are both self-perpetuating and difficult to change.

Cognitive therapy also considers the interaction of personality and stressful life events in the onset of depression. Two broad personality types have been identified among depressed patients: autonomous and sociotropic. Autonomous individuals are most likely to become depressed when thwarted from achieving their goals or when confronted with failure. Sociotropic types are most sensitive to personal rejection or to loss of a relationship. Although these are pure types at opposite ends of a continuum of personality styles, they allow investigation of the relationship between life events and various cognitive vulnerabilities. Current research supports the association between sociotropy and depressive symptoms.

Beck’s original formulation of depression describes nonendogenous, unipolar depression. He later refined his theory to include six separable but overlapping models: cross-sectional, structural, stressor– vulnerability, reciprocal interaction, psychobiological, and evolutionary. This reformulation was made to describe comprehensively the onset and maintenance of various types of depression. It was articulated in response to such developments in psychology as the growing interest in Bowlby’s attachment theory, the emergence of evolutionary psychology, and findings on marital interaction and depression. For example, the original cognitive model exemplifies the stressor– vulnerability model. The maintenance of depression seen in marital discord demonstrates the reciprocal interaction model.

A further clarification of the cognitive theory of depression addressed the misconception that cognitive therapy states that only the thinking of depressed persons is inaccurate or distorted. Research from the field of social cognition demonstrates that the thinking of nondepressed persons tends to be distorted or biased in an optimistic way, rather than being entirely realistic or rational. It also appears that the thinking of mildly depressed persons is more accurate in some specific ways than is the thinking of euthymic individuals. Beck conceives of bias as operating in either a positive or negative direction. According to his formulation, the nondepressed cognitive organizationhas a positive bias, as it shifts toward depression, the positive cognitive bias is neutralized, and as depression develops, a negative bias occurs. In bipolar cases, there is a pronounced swing into an exaggerated bias as the manic phase develops.

A negative bias in thinking is most likely to occur when data are not immediately present, are not concrete, are ambiguous, and are relevant to self-evaluation. An important feature of the cognitive bias in depression seems to be a perception that current negative circumstances cannot improve. Thus, a depressed person may perceive a situation accurately, but lack the persistence and creativity necessary to solve the problem.

IV. Cognitive Risk Factors in Suicide

Research on suicide risk was a natural outgrowth of Beck’s depression research, and his prospective studies have contributed to the understanding of psychological processes in suicide, particularly the role of hopelessness in predicting suicide. Hopelessness is conceived of as a relatively stable schema, incorporating negative expectations of the future.

Other researchers have identified additional cognitive risk factors for suicide that emerge even with the level of depression and degree of pathology controlled. They are low self-concept, dysfunctional assumptions, the absence of positive beliefs or reasons for living, cognitive rigidity, and poor problem-solving skills. The last two risk factors, cognitive rigidity and poor problem-solving skills, have received attention recently because of their pervasiveness in psychological disorders. Two examples of cognitive rigidity are dichotomous thinking and perfectionism. Evidence for the relationship between all-or-nothing thinking and suicidal behavior is long-standing. In addition, dichotomous thinking is found in a range of psychological disorders, including personality disorders. It is also characteristic of the thinking of normal adolescents.

Recent research also indicates a relationship between perfectionism and suicide risk. Among inpatients, for example, a perfectionistic attitude toward the self and sensitivity to social criticism have been found to be associated with suicide ideation independent of depression and hopelessness. Other research has found that a certain type of perfectionism—perceived expectations for the individual by society—is related to suicide ideation. The belief that the world holds unrealistic and unbending expectations for an individual represents a component of the cognitive triad, the negative view of the world.

Perfectionism may generally inhibit healthy functioning. Analysis of the data from the Treatment of Depression Collaborative Study, which compared the efficacies of pharmacotherapy, cognitive therapy, and interpersonal therapy, found that subjects who had perfectionistic attitudes had a significantly negative relationship to therapeutic outcome, regardless of the type of treatment modality they received. In contrast, subjects with relatively low levels of perfectionism were responsive to all forms of intervention. Perfectionism may be thought of as a risk factor for depression and suicide, and as a challenge to psychotherapy in general.

Problem-solving deficits are of interest not only because of their demonstrated relationships to depression and suicide, but also because social problem-solving is an important skill in general adjustment. Problem solving is being taught in schools as a way to reduce conflict and promote mental health.

Problem-solving deficits have been found in suicidal children, adolescents, and adults, and these deficits become compounded as problems become interpersonal in nature. Suicidal persons have difficulty accepting problems as a normal part of life and are not inclined to engage in problem solving. Once they engage in problem solving, their solutions show more avoidance, more negative affect, less relevance, less versatility, and less reference to the future than do the solutions of nonsuicidal persons.

An important aspect of problem solving among suicide ideators appears to be a tendency to focus on the potential negative consequences of implementing any solution. This feature reflects how pessimism affects motivation in depression and is congruent with the theory of helplessness depression.

A number of researchers have constructed and tested models of how various suicide risk factors might interact. It appears that hopelessness, problem-solving skills, and self-concept are independent risk factors. Beck’s observations of patients hospitalized for suicidal ideation shed some light on how self-concept, problem-solving skills, and hopelessness may appear state-like for some patients and trait-like for others. One group studied was composed of depressed persons. Their hopelessness, suicidal ideation, self-concept, and problem-solving abilities improved when their depression remitted. The second group was composed of patients with alcoholism, personality disorders, and antisocial behavior problems. Their negative views of themselves were reinforced by society. This group was characterized by cognitive rigidity, impulsivity, and poor problem-solving skills, which persisted between suicidal crises. Indeed, these characteristics may have predisposed these patients to future suicidal episodes. Thus, for some, poor problem-solving is temporary; for others, it is more chronic. It appears that once suicide becomes an alternative, restricted problem-solving ability can establish it as a stereotyped response in a very limited behavioral repertoire.

V. Cognitive Model of Anxiety Disorders

Whereas the cognitive themes in depression are deprivation, defeat, and loss, the cognitive theme in anxiety disorders is danger. Following the continuity hypothesis, anxiety reactions are on a continuum with normal physiologic responses, but are exaggerated reactions to perceived threat. Cognitive therapy views anxiety from an evolutionary perspective, as originating in the flight, freeze, or fight responses apparent in animal behavior. These innate responses to physical danger became less adaptive in humans over the millennia as danger became less physical and more psychosocial in nature.

The cognitive model of anxiety emphasizes the roles of beliefs and interpretations of events in maintaining and escalating anxiety. Anxious cognitions reflect unrealistic perceptions of danger, catastrophic interpretations about loss of control, or perceived negative changes in a relationship. As in depression, there are underlying beliefs, such as, ‘‘the world is a dangerous place,’’ which make one vulnerable to anxiety. Cognitive distortions support those underlying beliefs and contribute to the overestimation of the probability of a feared event, the overestimation of the severity of the event were it to happen, the underestimation of one’s ability to cope with the feared event, and the underestimation of ‘‘rescue factors’’ such as the presence of people or environmental factors that could help or reduce risk.

The contribution of cognitions to anxiety is exemplified in the cognitive model of recurrent panic. In this case, the person’s catastrophic misinterpretation of his or her own physiology escalates anxiety to the point of panic. The sequence is as follows: a variety of factors (e.g., mild anxiety, caffeine, exercise, excitement) create mild sensations that are interpreted as signs of internal disaster. Consequently, there is a marked increase in anxiety which leads to a further heightening of bodily sensations. This creates a vicious cycle, which culminates in a panic attack. Stress-induced hyperventilation may be part of this cycle if somatic sensations are interpreted as a sign of imminent danger. In the case of panic, the feared stimulus is one’s own physiology. Once a person has had a panic attack, he or she becomes hypervigilant to any signs of physiological arousal. One’s own physiology becomes the feared stimulus. Treatment, therefore, includes exposure to physical sensations.

Cognitive therapy, which uses cognitive techniques alone or in combination with behavioral techniques, can almost eliminate panic attacks after 12 to 16weeks of treatment.

VI. Cognitive Model of Personality Disorders

Cognitive therapy conceptualizes personality disorders as legacies of hominid evolution. They are seen as exaggerated expressions of primitive ‘‘strategies,’’ which at one time influenced survival and reproductive success. For example, the adaptive strategy of attachment becomes exaggerated as ‘‘I am helpless’’ in the dependent personality.

In addition, the repetitive nature of maladaptive behaviors seen in personality disorders indicates the frequency with which maladaptive schemas are triggered. Beck and his associates have found that the maladaptive schemas in personality disorders are triggered in many if not most situations, have a compulsive quality, and are extremely difficult to modify or control. Compared with other people, the dysfunctional attitudes found in persons with personality disorders are rigid, overgeneralized, absolute, and resistant to change.

The dysfunctional beliefs in personality disorders are thought to be a result of the interaction between the person’s genetic predisposition and exposure to specific undesirable or traumatic events. Maladaptive behavior patterns may result from reinforcement of such behaviors over a person’s lifetime. Such maladaptive behaviors may arise from avoidance or from compensation or overcompensation for dysfunctional beliefs. For example, a person who fears abandonment might avoid relationships altogether, cling to partners and drive them away, or end relationships before they can be left by the other parties. Any of these behaviors can reinforce the dysfunctional belief that the person will inevitably be abandoned.

VII. What Does Healthy Cognitive Functioning Look Like?

Cognitive therapy is derived from research on clinical populations, particularly depressed patients. Characteristics of the diagnostic groups studied are assumed to be extreme manifestations of qualities that are also found in normal people. Among depressed patients, for example, thinking is characterized by cognitive distortions or errors in logic, by cognitive rigidity, and by maladaptive core beliefs. Does this mean that the thinking of nondepressed people is free of distortions or an accurate reflection of reality? It does not.

Considerable evidence from cognitive and social psychology testifies to the presence of illusion or a general, enduring pattern of error, bias, or both in the information processing of normal people. However, the bias in thinking is positively skewed. Experimental studies, typically done with college student volunteers, show that nondepressed thinking is characterized by unrealistically positive views of the self, exaggerated perceptions of control, and unrealistic optimism.

This is apparent in attributional or explanatory style. The explanatory style of depressed persons is to attribute causality of negative, uncontrollable events to internal, stable, and global causes. One fails a test because one is stupid, not because that particular test was especially difficult. Nondepressed people, who have positive illusions concerning control and self-perception, are better able to externalize failure and thus not damage their general sense of self-esteem.

It appears from several lines of evidence that mildly depressed people, those with low self-esteem, or both have more balanced self-perceptions, more evenhanded assessments of their future circumstances, and a more accurate sense of personal control than do nondepressed persons. In contrast, both clinically depressed and euthymic people have biased thinking.

It is not surprising that many of the same cognitive mechanisms operate in different mood states, but they operate to different ends. Studies in social cognition support many of the clinical observations on which cognitive therapy is based. In 1989, Janoff-Bulman wrote about the benefits of illusion for mental health. She describes how preverbal interactions with responsive caregivers establish supraordinate schemas that are positively biased and largely reflect reality at the time they are established. One need only substitute the experience of a child with unresponsive, neglectful, or depriving caregivers to arrive at maladaptive schemas. The early interactions among people receiving good care teach them that the world is benevolent and controllable, and that they are worthy of care. Although later experience may somewhat contradict or qualify these assumptions, they will remain fundamentally intact. Evidence that does not confirm positive assumptions can be ignored, dismissed, or reinterpreted to fit previously held beliefs. This process is the same as that in depression: cognitive distortions screen out positive information or distort neutral information to maintain negative schemas. Only traumatic negative events pose a serious challenge to the equilibrium of positive illusions.

Parallels between the cognitive processes in depression and those in well-being also appear in Taylor and Brown’s theory of cognitive adaptation. They present a model of normal cognitive processing in which social and cognitive filters make information largely positive as opposed to the disproportionately negative bias that results from the mental filters operating in depression. These authors conclude that the mentally healthy person appears to have the capacity to distort reality in a direction that enhances self-esteem, maintains a sense of personal efficacy, and promotes an optimistic view of the future. This positive triad is in striking contrast to the cognitive triad in depression.

For both depressed and nondepressed people, biased thinking is most apparent in situations that are ambiguous and that are relevant to self-evaluation. For both negative and overly positive thinking, ambiguous information tends to be interpreted to fit with prior beliefs or schemas.

Just as the cognitive model of psychopathology might overemphasize the negative aspects of biased cognitive processing and thus appear to endorse rationality, models from cognitive and social psychology might overemphasize the benefits of positive illusion for mental health. Some researchers have addressed various types of illusions and the circumstances under which they appear helpful and not so helpful.

Taylor’s research on cognitive adaptation to threatening events such as rape and cancer found that illusions of meaning, mastery, and self-esteem fostered positive adjustment. Individuals who made causal attributions that maintained a sense of personal control and who could construct some personal benefit from the negative experience fared better psychologically than those unable to use illusion. Taylor concludes that illusion is essential for normal cognitive functioning. She also argues that having an accurate self-perception should not be a criterion of mental health, as has been customarily believed.

It also appears from the work of others that illusions are only adaptive if they do not stray too far from the truth. Illusions that are too inflated may lead to self-defeating behavior. A small positive distortion of the truth, rather than unbridled optimism, seems optimal.

Janoff-Bulman proposes that positive illusions are most beneficial at the level of core beliefs or schemas. She sees conceptual (or cognitive) systems as hierarchically organized. Higher-order postulates represent one’s most abstract, global, and generalized theories about oneself and the world. Lower-order postulates are narrow generalizations that relate to specific domains of life, such as one’s abilities. These hierarchical distinctions are compatible with Beck’s notions of core schemas and more accessible assumptions, respectively. Janoff-Bulman argues that higher-order postulates, which are least subject of all cognitions to empirical validation or invalidation, may contain positive inaccuracies without being problematic. However, inaccuracies and positive illusions at the level of lower-order postulates are maladaptive. In other words, it is not harmful to have a generally positive view of oneself as a competent person as long as one is aware of one’s limitations in specific areas.

According to Janoff-Bulman’s theory, the advantage of positive higher-order assumptions (or schemas) is that they enable a person to attempt to tackle new situations. Thus, positive illusion at this level benefits affect and motivation. One can see how such optimism might allow someone to engage in creative problem solving when faced with a novel situation.

Another benefit of generalized positive illusions about the self relates to efficacy in problem solving. People with high self-esteem appear better able to discriminate soluble from insoluble problems than are people with low self-esteem. They are more able than people with low self-esteem to know when to quit and to feel comfortable quitting. They may also choose to work only on problems that can be solved, thereby reinforcing their sense of self-efficacy.

In contrast to Taylor, Janoff-Bulman believes the healthiest people probably have a good sense of their strengths and weaknesses, their possibilities and limitations. The key appears to be maintaining positive illusions at the level of fundamental beliefs while aiming for and accepting accuracy at the level of everyday, specific interactions with the world. Healthy people can thus respond to environmental feedback and learn.

Healthy cognitive functioning is creative and flexible enough to reexamine strategies that no longer work. No doubt, healthy beliefs contain inaccuracies, but they are adaptive in that they allow one to maintain a sense of self-worth while trying to learn from one’s experiences. Healthy functioning also recognizes emotions as important sources of information about the self and the environment. Cognitive therapy allows patients to reappraise and empirically test their lower-order postulates within the context of a caring and collaborative therapeutic relationship. Although schema change at the level of higher-order postulates is more difficult to achieve, longer term cognitive therapy may allow for these fundamental changes.

VIII. Some Developmental Considerations

Research in cognitive development, social cognition, and child psychology lends further insight into what healthy cognitive functioning looks like. The unrealistic optimism and self-confidence apparent in well-adjusted adults has also been found in healthy children. Studies have compared ‘‘helpless’’ and ‘‘mastery- oriented’’ children in their responses to failure. Mastery-oriented children are those who have a sense of control over an experimental task; helpless children have no such sense of control. Mastery-oriented children were less discouraged by failure than were helpless children. In fact, they did not seem to recognize that they had failed. Instead, they focused on how to overcome defeat. In addition, they expected success in the future and attributed success to their own ability. They exemplified the nondepressed explanatory style articulated by the learned helplessness model of depression. In contrast, the helpless children demonstrated an explanatory style that may be a cognitive vulnerability to depression.

The adaptive explanatory style may not be exclusive to confident children, but may be the rule for all very young children. Some developmental psychologists report that learned helplessness is relatively rare in very young children. They review studies that demonstrate that children around 3 years of age typically overestimate their skills on a wide variety of tasks and have unrealistically positive expectations for success. This may be highly adaptive for the same reason it is adaptive in adults: self-efficacy motivates further action. Unrealistic optimism gives young children the opportunity to try new skills and to practice them. Researchers hypothesize that ignorance of their limitations allows children to try more diverse and complex behaviors that exceed their grasp at the present time. This allows them to practice skills and may foster long-term cognitive benefits.

Kendall’s research in cognitive–behavior therapy with children has identified two types of thinking errors in children, cognitive deficiencies and cognitive distortions. Cognitive deficiencies refer to an absence of thinking. Youngsters with such deficiencies lack careful information processing and often act without thinking. Impulsivity is a result of cognitive deficiencies. Cognitive distortions occur among those who engage in information processing, but who do so in a biased or dysfunctional way. Depressed and anxious children demonstrate cognitive distortions in their misperceptions of social and environmental situations and in their self-perceptions. Children with aggressive behavior demonstrate both cognitive deficiencies and cognitive distortions, because they over-interpret signs of hostility and react without careful thought. Targeting cognitive deficiencies in therapy requires stopping nonthoughtful activity and channeling activity into problem solving. Targeting cognitive distortions calls for the identification of faulty thinking and the correction of misperceptions, misattributions, and misinterpretations.

Both developmental theory and clinical studies support the notion that particular types of cognitive distortions are to be expected at certain stages of normal development. For example, dichotomous thinking and overgeneralization emerge in the preoperational stage of cognitive development. Dichotomous thinking is also viewed as characteristic of normal adolescent thinking. However, these natural proclivities may interact with maladaptive schemas and persist into adulthood.

IX. How Does Cognitive Therapy Work?

Cognitive therapy combines behavioral and cognitive techniques in a collaborative effort with the patient to examine and test the validity and utility of the patient’s maladaptive beliefs. The patient’s beliefs and assumptions are viewed as hypotheses to be tested. In the course of therapy, alternative perspectives, interpretations of events, and solutions to problems are considered. Through logical examination of beliefs and behavioral experiments to test specific assumptions, the patient learns more adaptive ways of thinking.

Despite the demonstrated efficacy of cognitive therapy, the mechanisms by which it works have not yet been determined. Beck and others believe that cognitive therapy relies on empirical hypothesis testing to produce changes in beliefs. An explicit goal of the therapy is to teach patients this strategy so that they may apply it in the future, thereby preventing relapse. Some developmental psychologists explain change in cognitive therapy with Piagetian theory. In cognitive therapy, the presentation of contradictory evidence creates a cognitive imbalance or disequilibrium which can lead to a new and improved balance of knowledge.

There has been some debate as to whether cognitive therapy works by teaching compensatory skills to manage triggered schemas or whether schema change itself can be achieved. It may be that schema change is only possible with longer treatment, whereas compensatory skills operate early in therapy.

One cognitive feature that seems to change with cognitive therapy is explanatory style. Research has found that explanatory style and severity of depression improved together over a course of cognitive therapy and remained stable at follow-up. It has therefore been hypothesized that explanatory style is a mechanism of change for depressed patients receiving cognitive therapy. Undoing a pessimistic explanatory style may be an active ingredient in the therapy. If it is possible to reduce a pessimistic style, it may be possible to reduce the risk of future depressive episodes. Evidence for change in explanatory style among euthymic groups demonstrates that such training is feasible, so perhaps cognitive therapy can be used to prevent an initial depressive episode. For use with euthymic groups, such as business managers or students, cognitive therapy is modified slightly. There is less emphasis on behavioral activation strategies, which occur early in the treatment of depression, and greater emphasis on cognitive strategies to challenge maladaptive thoughts and change explanatory style.

X. The Prevention of Depression

A number of outcome studies that examined the efficacy of cognitive therapy for depression found differential relapse rates among those treated with cognitive therapy, with or without medication, and those treated with medication alone. Specifically, it appears that cognitive therapy for depression prevents relapse. Currently, there is no evidence of a preventive effect after termination of antidepressant medication or any other psychotherapy. Interpersonal psychotherapy, another efficacious treatment for depression, appears to reduce risk only as long as it is continued.

As a result of these findings, there is interest in discerning whether cognitive therapy can truly prevent relapse and whether it can prevent a first episode of depression among populations at risk.

The Penn Prevention Program used a school-based, cognitive–behavioral intervention to prevent a first episode of depression in 10- to 13-year-old children. The children were identified as being at-risk for depression on the basis of depressive symptoms and their reports of parental conflict. The cognitive–behavioral techniques were designed to teach children coping strategies to use when confronted with negative life events, thereby increasing their sense of mastery and competence. In addition to preventing depressive symptoms, the intervention attempted to address problems associated with depression, such as academic difficulties, poor peer relations, low self-esteem, and behavior problems.

The program consisted of a cognitive component, a social problem-solving component, and a coping skills component. The cognitive component taught flexible thinking and how to evaluate the accuracy of beliefs. It also included explanatory style training to foster more accurate, less pessimistic attributions. For situations in which an accurate interpretation of events was negative, children were taught to focus on solutions or on ways to cope with emotions. Coping techniques included decatastrophizing about potential outcomes of the problem, distraction, steps to distance oneself from stressful situations, relaxation training, and ways to seek social support. In this way, investigators tried to address both cognitive distortions and cognitive deficiencies. The cognitive interventions addressed dysfunctional thinking, and the problem-solving and coping skills components prevented impulsive actions.

Those children who received the intervention showed significant reductions in depressive symptoms and improved classroom behavior compared with controls. These differences persisted at 6-month followup. The decrease in depressive symptoms was greatest in the children most at risk for depression.

A controlled prevention trial was conducted by Munoz among adults at risk who comprised a multiethnic, low-income sample. This cognitive–behavioral intervention also resulted in a significantly lower incidence of depressive symptoms among those receiving treatment than those in the control group. In addition, there was a lower incidence rate of major depressive episodes in the treatment group, but the cases were too few to be statistically significant.

Prevention of actual depressive episodes was an outcome criterion in a study by Clarke and associates of adolescents at risk by virtue of their subclinical, depressive symptomotology. This 15-session, cognitive– behavioral intervention taught adolescents to identify and challenge negative or dysfunctional thoughts. Participants had a total incidence of unipolar depression of about half of that of the control group, and this persisted through a 12-month follow-up.

Other controlled trials of cognitive therapy and other modalities for the prevention of depression are underway. In the meantime, cognitive therapy skills are being used to promote general social adjustment in school settings. School-based programs nationwide are applying cognitive–behavioral techniques as part of interpersonal skills training and conflict resolution. Cognitive skills such as disputing negative self-talk and problem solving are part of programs that typically include emotional awareness, communication skills, and behavioral self-control strategies. These programs are an example of health promotion, because they are applied at the community level and decrease the likelihood of occurrence of a range of psychological problems. Although cognitive therapy was designed as a treatment for psychological disorders, it may be beneficial in the prevention of psychological distress and in the promotion of well-being.

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