Cognitive therapy (CT): definition, application, and effectivity

Cognitive therapy is a type of therapy whose main objective is to help people identify erroneous beliefs and thought patterns. Therapists help patients change these thoughts and beliefs so they can positively influence their mood and behavior. During therapy sessions, patients learn coping skills and get tools that allow them to respond to various situations and triggers in a healthier manner. 

Cognitive therapy is about problem-solving. While the development of cognitive therapy is attributed to Dr. Beck in the 1960s, its origins date back to ancient times. Cognitive therapy is just one of many techniques that cognitive-behavioral therapy uses to treat patients with different problems and concerns. 

Uses of cognitive therapy are numerous including academic achievement, addiction, anxiety disorders, bipolar disorder, low self-esteem, phobia, schizophrenia, substance abuse, suicidal ideation, and weight loss. Since thoughts dictate emotions and behavior, cognitive therapy serves as a psychotherapy approach to noticeably reduce the intensity of mental health problems and improve a patient’s quality of life. 

What is Cognitive therapy (CT)?

Cognitive therapy (CT) is a form of psychotherapy that empowers patients to identify and correct false beliefs that lead to negative behaviors and moods. This type of therapy is patient-centric, goal-oriented, time-sensitive, collaborative, and educational. Cognitive therapy in psychology is based on an information-processing model. The cognitive therapy model teaches that the way people perceive their experiences can influence their behavioral, emotional, and psychological reactions. 

The fundamental assumption of cognitive therapy is that thought precedes mood. The focus is on present thinking, communication, and behaviors rather than past experiences. Cognitive therapy is all about problem-solving, MedicineNet reports. 

The term cognitive therapy is often used as a synonym for cognitive-behavioral therapy (CBT). While they do have a lot in common, these terms should not be used interchangeably. 

Cognitive therapy is a therapeutic technique concerned with identifying and correcting negative beliefs as well as automatic assumptions that lead to an impaired state of mind, as mentioned above. 

On the flip side, CBT is a wide spectrum of techniques that go beyond cognitive therapy. Instead, CBT is basically any method focused on changing behavior by correcting dysfunctional thought processes. Some techniques are concerned with behavioral elements, whereas others with cognitive aspects. 

Basically, CBT refers to various techniques to manage mental health problems, while cognitive therapy is one of those techniques, Positive Psychology explains. 

Who created Cognitive therapy?

Aaron Temkin Beck, an American psychiatrist, created cognitive therapy in the 1960s at the University of Pennsylvania. Dr. Beck is regarded as the father of both cognitive therapy and cognitive-behavioral therapy (CBT). He developed CT with the belief that an individual’s experiences result in thoughts or cognitions. Aaron Beck’s cognitive therapy was developed specifically as a treatment for depression.

In the 1950s, Dr. Beck designed and conducted experiments whose main objective was to test psychoanalytic concepts of depression. However, his research failed to validate theories that depression was associated with retroflected hostility. Dr. Beck didn’t let these unsuccessful attempts discourage him from learning more about depression and uncovering more effective ways to treat it. Instead, he started further investigations regarding the nature of this mental health condition.

During the work on these experiments, Dr. Beck realized the patients experienced a flood of negative thoughts that appeared spontaneously. He named them automatic thoughts. Dr. Beck also discovered the content of automatic thoughts belonged to three categories such as negative ideas about themselves, the future, and the world. These cognitions are called a cognitive triad. 

One of the major findings from the research was that people accepted these thoughts as is, without taking any time to reflect or challenge them. 

For that reason, Dr. Beck started helping patients identify and analyze these thoughts. By doing so, he found, that patients were able to think in a more realistic manner. As a result, their emotions and behavior also improved.

During his prolific career, Dr. Beck published a wide range of books and other works on the subject of cognitive therapy and CBT. Some of these include Cognitive therapy and emotional disorders (1975), Cognitive therapy for depression (1979) as well as The integrative power of cognitive therapy (1988).

Once Dr. Beck developed cognitive theory and therapy for depression, he and his colleagues focused on developing a cognitive approach to managing other conditions. Dr. Beck’s cognitive therapy is based on a cognitive formulation that varies from one mental health condition to another.

While Dr. Beck developed CT therapy, many other therapists contributed to its development. In fact, the roots of cognitive therapy can be traced back to ancient times, specifically Stoicism. 

Stoicism is a school of philosophy from ancient Greece and Rome in the early 3^rd century BC. This philosophy maximizes positive emotions, helps a person hone their virtues of character, and reduces negative emotions. Stoic philosophers believed that a person could use logic to identify and eliminate false beliefs that cause distressing emotions. 

Stoics also believed all nature is to be accepted and also recognized that we don’t have complete control in every aspect of life, but we can control our thoughts and feelings. Using logic to identify irrational thoughts, accepting our circumstances, and making a clear distinction between things we can and can’t control is what makes Stoicism similar to cognitive therapy.

Stoic philosophers inspired many therapists and cognitive theorists. Before Dr. Beck developed the cognitive therapy we know today, an American psychologist Dr. Albert Ellis worked on similar ideas in the 1950s. Dr. Ellis named his approach rational therapy, which later turned to rational emotive therapy, and finally rational emotive behavior therapy. This approach focused on helping patients identify negative thoughts and irrational beliefs that contributed to emotional or behavioral problems.

The cognitive revolution in psychology occurred in the 1970s. Merging cognitive therapy techniques and behavioral modification techniques also led to the development of cognitive-behavioral therapy. 

Major contributions to the development and evolution of cognitive therapy came from psychologists and psychotherapists Arnold Lazarus, Donald Meichenbaum, Michael J. Mahoney, and Marvin Goldfried, just to name a few. 

Nowadays, cognitive techniques are among the most common (and effective) approaches in the management of various mental health problems and substance use disorders.

When did Cognitive therapy become popular?

Cognitive therapy became popular in the 1970s, when the internal thought processes, i.e. self-talk, began to be considered as targets and mechanisms of change alike. The emphasis was on enhancing cognitive skills rather than modifying behavior, a paper from the Child and Adolescent Psychiatric Clinics of North America reported.

The 1970s and 1980s were mainly reserved for developing protocols to use cognitive psychotherapy to treat various mental health problems.

Cognitive therapy is divided into three waves. The first wave occurred before Dr. Beck, the second wave belongs to Dr. Beck and other psychotherapists who played a role in the development of cognitive therapy, and the third wave started in 1990. Cognitive therapy became more mainstream with the third wave, which focuses on more comprehensive life goals and accepting our thoughts within context instead of judging them. 

The popularity of cognitive therapy keeps growing with the reduction of social stigma around mental health problems and addiction. 

Where is Cognitive therapy used?

Cognitive therapy is used for the treatment or management of various mental health conditions or challenges affecting a person’s psychological and emotional health and well-being. Some of the most common uses of cognitive therapy are listed below:

• Academic achievement
• Addiction 
• Anxiety disorders
• Bipolar disorder
• Low self-esteem
• Phobia
• Schizophrenia
• Substance abuse
• Suicidal ideation
• Weight loss 

1. Academic achievement

Academic achievement refers to the extent to which a student, institution, or teacher has attained their short- and long-term educational goals. The academic environment can be competitive and puts a lot of pressure on everyone involved. Achieving academic success is a dream for many, but it can take its toll on their mental health. In fact, evidence confirms that mental health can predict academic outcomes.  

Mental health problems can impair academic performance. That’s where cognitive therapy steps in. Cognitive therapy works by helping students correct distorted thinking and maladaptive patterns of behavior, which can be behind academic struggles. Behavioral modification through cognitive therapy helps students achieve the academic success they study for. 

Instead of focusing on negative self-talk that says some academic goals are out of reach, cognitive therapy empowers a person to understand those thoughts aren’t rational. The patient adopts new skills and coping mechanisms that allow them to resist or eliminate those thoughts and embrace more realistic thought patterns. This leads to wiser choices and positive behavior change.

How quickly cognitive therapy improves academic performance depends on the patient and the progress they’re making. Some people may need sessions over the course of 90 days i.e. three months. Others may need more or less than that.

2. Addiction

What is addiction? Addiction is a neuropsychological disorder indicated by a compulsive need to use substances or do certain activities despite the harm they cause. People can develop an addiction to alcohol, drugs, gambling, pornography, sex, shopping, stealing, and many other things. A growing body of evidence confirms that people with mental health problems such as depression, anxiety, or PTSD are more likely to become addicted to something.

Some people have dual diagnoses meaning they have both addiction and a mental health disorder although one doesn’t necessarily have to cause the other.

The cognitive theory states that people choose addictive over healthy behaviors due to their expectations. They expect that the benefits and risks of addictive behaviors outweigh those of healthy behaviors. For instance, a person may believe that refusing to satisfy cravings can lead to harm. In this case, cognitive therapy works by enabling a person to develop more accurate expectations of craving and addiction. 

They realize that the thoughts they have are irrational and start making healthier decisions. A therapist also works on addressing underlying mental health problems too. 

How quickly a person recovers from addiction through cognitive therapy depends on the severity of the addiction and the type of treatment. In inpatient programs, it may take 30 to 90 days or longer. 

3. Anxiety disorders

Anxiety is defined as a feeling of unease, intense fear, worry, panic, or feeling threatened in certain situations or places. In fact, anxiety is a term that refers to various disorders with these symptoms. Some of these disorders include PTSD, generalized anxiety disorder, panic disorder, social anxiety, and others. 

When left untreated, anxiety disorders can have disastrous consequences such as recurring panic attacks and other complications that affect a person’s daily functioning. Cognitive therapy is helpful for patients with anxiety. 

It works by enabling a person with anxiety to understand their thoughts are irrational. Focusing on these thoughts worsens their symptoms and contributes to panic. During cognitive therapy sessions, patients learn how to correct these irrational beliefs in order to reduce the intensity of symptoms they’re experiencing. 

For example, a study from Dialogues in Neuroscience confirmed that cognitive therapy works for persons with generalized anxiety disorder and other types of anxiety. Cognitive therapy teaches patients to challenge thoughts that overestimate risk and identify and modify catastrophic thinking.

Patients with anxiety often feel like they have no control over their thoughts or the situation they’re in. The role of cognitive therapy is to help them regain that control. 

For some people, cognitive therapy for anxiety disorders may work within one to two months, whereas others need three to four months. 

4. Bipolar disorder

Bipolar disorder is a type of mental health condition that causes extreme mood swings indicated by episodes of emotional highs (mania) and lows (depression). Failing to treat bipolar disorder can cause even more severe depression or full-blown mania. Patients usually need a combination of medications and therapy to improve their quality of life.

Cognitive therapy for bipolar disorder works by addressing depressive symptoms that patients experience. For example, it helps patients address and overcomes feelings of guilt and other negative thoughts they may have about their manic episodes too. 

Studies show that the cognitive approach is effective at reducing the severity of mania and depressive symptoms, and improving psychosocial functioning in participants with bipolar disorder. This kind of therapy can also reduce relapse. 

Relying on medications only isn’t enough, which is why cognitive therapy stabilizes a patient’s mood and keeps their life on track.

With effective treatment, episodes in persons with bipolar disorder may improve in about three months. Keep in mind that bipolar disorder requires lifelong management, which is why it’s important for patients to see a cognitive therapist as long as it’s necessary. This is important even if a person feels fine at the moment.

5. Low self-esteem

Low self-esteem is a low opinion of oneself. A person with low self-esteem lacks confidence in who they are or what they can do. While having low self-esteem isn’t a mental health problem per se, it is closely linked with depression, anxiety, and other conditions. 

A study from the Annals of General Hospital Psychiatry found that low self-esteem and the onset of psychiatric disorders form a vicious cycle. Low self-esteem makes a person more susceptible to the development of psychiatric conditions. In turn, the presence of a psychiatric condition makes a person more likely to have self-esteem issues.  

Low self-esteem prevents a person from achieving their full potential and also worsens their mental health. Cognitive therapy is one of the most important strategies to improve self-esteem. It works by targeting assumptions such as lack of ability or other thoughts a person may have about themselves. The therapist helps a patient challenge these thoughts so they can understand those beliefs are irrational and inaccurate. 

The goal of cognitive therapy is to make sure a patient becomes more confident and overcomes the mental blocks created by negative thought patterns. 

How quickly cognitive therapy improves self-esteem isn’t the same for everyone. Three to six months work for most people, though.

6. Phobia

Phobia is defined as an irrational and uncontrollable or persistent fear of something, someone, or a situation. It’s not the same as fear, which is a normal reaction. Phobia occurs due to an unrealistic or exaggerated sense of danger about an object or some situation. 

When left untreated, phobias can significantly impact and limit a person’s quality of life. Cognitive therapy enables a person to manage their phobia by helping them to gradually and slowly change the way they think. The therapy is based on the interconnectedness of beliefs, thoughts, and behaviors. A therapist may choose to combine cognitive therapy and exposure therapy. 

What cognitive therapy does is that it doesn’t simply aim to convince a person their phobias are irrational and inaccurate. The therapist teaches patients skills to challenge their thoughts so they can adopt a more realistic perspective. Patients also learn how to react to triggers of their phobias in a healthier manner. By slowly changing their thought pattern, patients with phobias can put their problems under control so they can have a normal and healthy life. 

In one study, 17 sessions were necessary for a patient with social phobia to experience significant improvement. Some people may need more or less than that. 

7. Schizophrenia

Schizophrenia is a serious mental health disorder indicated by an abnormal interpretation of reality. People with this disease have disordered thinking, hallucinations, and delusions that affect their daily functioning. Schizophrenia interferes with an individual’s ability to think clearly, make decisions, perceive reality, or manage emotions.

Cognitive therapy helps persons with schizophrenia through the development of social and problem-solving skills. Initially, cognitive therapy for schizophrenia was developed to address residual symptoms caused by medications, but today it is considered an effective intervention.

The Lancet published an interesting study that found that cognitive therapy decreased psychiatric symptoms and is a safe and acceptable alternative for patients who don’t want to take antipsychotic drugs. Cognitive therapy also improved personal and social functioning among participants.

Since patients with schizophrenia have an abnormal perception of reality, cognitive therapy enables them to improve the way they perceive the world around them. 

Schizophrenia is a serious disease that requires lifelong management, even when symptoms subside. It may take several months to feel better with regular therapy sessions. 

8. Substance abuse

Substance abuse is the use of illegal drugs or the abuse of prescription medications and other substances. Substance abuse doesn’t mean a person is addicted, but it indicates problematic use of a specific substance. It can lead to addiction as well as social, physical, emotional, and other problems in a person’s life. 

A person with mental health problems has a higher substance abuse risk. That happens because they may start using alcohol or drugs as an escape from their thoughts and emotions. At the same time, substance abuse can worsen existing mental health problems.

Cognitive therapy for substance abuse works by helping people dismiss false beliefs or irrational thoughts that trigger substance abuse. Plus, it teaches them more effective communication skills and provides self-help tools for a better mood. By focusing on correcting irrational thoughts that lead to substance abuse, a patient is one step closer to overcoming their problem.

For example, a person may be using some substance to perform better or relax. Their mind keeps telling them it’s impossible to achieve that without the drug. The thought pattern leads to action where a person indeed keeps taking the substance. Cognitive therapy targets that faulty thought system by showing a person the thoughts that triggered substance abuse are inaccurate.

Since substance abuse isn’t addiction per se, it may take a couple of weeks for a person to overcome this problem with cognitive therapy. Of course, these effects may vary from one person to another. 

9. Suicidal ideation

Suicidal ideation is a term that refers to thinking about suicide with or without a plan to kill yourself. People start having suicidal thoughts and tendencies due to several causes including depression and addiction.

Cognitive therapy stands as a practical method for the prevention of suicidal ideation and tendencies. It reduces symptoms of mental illnesses linked to a higher risk of suicide including depression, anxiety, and psychosis. 

The cognitive theory suggests that a person considers suicide if they see no solution to the problem that is causing them pain. The therapy works by identifying the perceived unsolvable issue in order to decrease cognitive distortions and errors in logic. Cognitive therapy also aims to improve a person’s problem-solving skills, boost their motivation, and lower perceived emotional pain. 

Through cognitive therapy, a patient learns every problem has a solution. They also learn that some thoughts in our minds aren’t correct. Once they start thinking beyond that, it’s possible to reduce the risk of future suicidal tendencies.

There is no specific timeframe during which cognitive therapy needs to work. People with different conditions may need a few weeks or months to feel better. It could be the same for suicidal ideation too. 

 10. Weight loss 

Weight loss is a mission for many people, but it can have a major impact on mental health. A growing body of evidence confirms that weight loss interventions can beneficially affect the mental health and well-being of a person. But, the attempts to lose weight can be a major source of stress. When left unmanaged, this problem can lead to serious complications and unhealthy moves to lose weight.

Cognitive therapy for weight loss works by enabling patients to understand and change some eating and lifestyle habits. By addressing these habits, a person can adopt healthier routines that lead to sustainable weight loss. In this case, sustainable weight loss refers to the result a person can maintain without the yo-yo effect.

The biggest obstacle to successful weight loss is in a person’s mind. That irrational thinking only aggravates unhealthy eating habits, sedentary lifestyles, and other problems. Cognitive therapy empowers a person to change unhealthy patterns so they can maintain their goals. 

Changing habits is a process, but some people can achieve it in as little as four weeks. Continuing therapy beyond that point is useful because it delivers much-needed support to keep up with weight loss intervention. 

What is the process of Cognitive therapy?

The process of cognitive therapy is simple and structured, so the patients know what to expect every time. 

The first session is reserved for assessing a patient’s situation or mental health condition. Here, a patient shares about difficulties they’re facing. The therapist would proceed to carry out the necessary evaluation to diagnose a problem unless a person had already been diagnosed with a specific mental disorder or addiction. Then, they create the best cognitive treatment plan bearing in mind the severity of the symptoms a person is experiencing. 

Other sessions have a pretty much set format. At the very beginning of the session, a therapist and patient do a brief. This is the opportunity for a patient to inform the therapist about everything that happened since the last session, how they felt or managed their symptoms, and everyday challenges. During this time, the therapist builds a bridge between the last and current sessions. Patients are generally asked whether some parts of previous sessions were confusing and needed clearing up.

If patients had homework, the therapist would ask a few questions to see whether they followed it through. At this point, the patient describes how they performed a certain task and what happened next.

Once homework is reviewed, the therapist presents the agenda for the current session. The agenda usually consists of the main issue and takes up most time during the session. Patients talk about the specific issue, whereas therapists help them overcome irrational thoughts or provide guidance on how to cope more effectively. 

After that, patients usually get homework again so they can practice skills the therapist showed during the session. These are usually some simple exercises specific to a mental health problem being treated. 

The session is concluded with a simple review when patients have the opportunity to ask questions or express concerns about everything that’s bothering them.

By the end of the treatment, i.e. final sessions ensure a patient becomes their own therapist. That means the therapy strives to empower a patient to independently solve problems and challenges in their life.

How many sessions are required for CT?

How many sessions are required for CT depends on several factors such as the type and severity of mental health disorder, how long a person has had symptoms, how quickly a patient is making progress, and the level of support received from friends and family. 

In other words, a specific number of sessions that suits every patient doesn’t exist. Some people need 5 to 20 sessions, whereas others 6 to 24 cognitive therapy sessions.

A study from BMC Psychiatry found therapy is most effective with 8 or more sessions. 

Each session lasts 30 to 60 minutes, generally 45 minutes. At the beginning of cognitive therapy treatment, patients usually have longer sessions. As they are making progress, the duration of sessions reduces. 

Initially, therapy sessions are on a weekly basis. They become less frequent when a patient achieves notable improvements in their symptoms and quality of life. For instance, a therapist may propose having sessions once in two weeks or once a month. The therapist sets the frequency of sessions that suits patients the most.

It’s also recommended that patients have booster sessions 3, 6, and 12 months after completing cognitive therapy treatment. 

Who performs Cognitive therapy?

A licensed cognitive therapist performs cognitive therapy. In order to become a cognitive therapist, it’s necessary to meet various requirements regarding education level, courses, internships, and practice. 

A good cognitive therapist has various skills and abilities that allow them to help patients and clients. They need people skills, meaning a cognitive therapist must be able to love working with people and collaborating with other healthcare professionals. A cognitive therapist also needs to be compassionate and insightful, but not judgmental. They also need excellent communication skills to instruct their patients on techniques of cognitive therapy so they can change their irrational beliefs and thought patterns.

Additionally, a cognitive therapist needs analytical skills to draw conclusions from the information they gather from patients, problem-solving skills to create the most suitable treatment plan, and listening skills to truly understand the problems of their patients. Cognitive therapist also displays wonderful observational abilities in the way they read people’s facial expressions, actions, reactions, body language, social interactions, behavior, and attitudes.

The skills and abilities of cognitive therapists don’t stop there. They also extend to a thorough understanding of human development, business skills, strict adherence to patient confidentiality, understanding of various mental health disorders, and a complete understanding of psychotherapeutic approaches.

What does a Cognitive therapist do?

A cognitive therapist aims to help patients identify their thoughts and behaviors, especially about their surroundings and relationships, so they can regain more control over these thoughts and positively influence their behaviors. They also prescribe medications for the management of a specific mental health problem, if necessary. 

The main scope of work is to talk with a patient, set goals for each session to make sure the time is spent productively, keep patients on track, and model healthier behaviors. The cognitive therapist also reflects on a patient’s progress and regression. To help a patient get the most from therapy, the cognitive therapist tends to recommend various exercises they can do between the sessions.

Exercises that cognitive therapists may recommend depend on the specific needs of each patient. They usually include journaling, reading assignments, and practicing mindfulness and relaxation. 

The cognitive therapist may also coach or use exposure therapy to decrease the intensity of fear in patients with anxiety. They may also give thought exercises and openly challenge a patient’s beliefs. The role of a cognitive therapist is also to do all paperwork that makes it easy to track how far a patient has come.

Is Cognitive therapy effective?

Cognitive therapy is effective, which is confirmed by multiple scientific studies over the decades after its development. Back in 1983, when cognitive therapy started gaining popularity, the Journal of the Royal Society of Medicine published a study that showed that cognitive therapy exhibited a powerful therapeutic effect on the management of depression. 

Later, the Journal of Consulting and Clinical Psychology published a review that confirmed that cognitive therapy resulted in a greater degree of change in depression symptoms compared to a no-treatment control, behavioral therapy, pharmacotherapy, and other approaches.

The most recent piece of evidence on this subject was published in February 2022 in the Mindfulness journal. The study focused on the role of mindfulness-based cognitive therapy in the management of depression. Results showed the treatment was effective and can be safely delivered in primary care. Participants with severe depression benefited most from the treatment, with 35.6% of them considered recovered. 

Cognitive therapy and CBT effectively treat patients with unipolar major depression. In fact, the effects of CT are comparable to or superior to pharmacotherapy, a paper from American Family Physician reports. Not only is CT effective on its own, but also works well in combination with other approaches such as medications. The same paper also confirms the efficacy of cognitive therapy in relapse prevention. In this aspect, cognitive therapy was more effective than medications. More precisely, patients had a lower risk of relapse after completing cognitive therapy than after discontinuing medications.