COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapy (CBT) is a combination of cognitive and behavior therapies that are directive, time-limited, structured, and place great emphasis on homework exercises. While cognitive therapy emphasizes the role of cognitive processes in the origin and maintenance of psychological disorders, behavior therapy focuses on principles of learning theory and the role of reduced reinforcement in the creation and maintenance of these disorders. In cognitive therapy, individuals learn to identify and monitor distorted, negative thinking, to become aware of the relationship between such thoughts and negative assumptions about oneself—and of the association between thoughts and feelings. Individuals also learn to apply techniques to challenge these thoughts. In behavior therapy, individuals are taught to track the frequency of targeted behaviors and to understand the relationship between these behaviors and their antecedents and consequences. Furthermore, individuals learn techniques to increase or decrease particular events, and are taught skills such as problem solving, relaxation, and assertiveness. Both cognitive therapy and behavior therapy assume that psychological problems can be alleviated by teaching individuals new skills to identify negative thoughts, form adaptive thoughts, and alter maladaptive behavior patterns.

CBT is effective in treating the psychological problems of older adults. In a review of empirically validated psychological treatments for older adults (Gatz et al., 1998) reported that behavioral and environmental interventions can help older adults with dementia, sleep disorders, and depression.

Potential sources of change in psychotherapy with older adults

Potential modifications to psychotherapeutic regimens may be necessary due to the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. It is important to keep in mind that these changes represent hypotheses in need of empirical investigation. Outcomes of psychological interventions with older adults indicate that maturational changes with aging have no negative impact upon the use of CBT with older adults.

Development. Slowing in cognitive processes and memory changes may require changes in cognitive-behavioral therapy. For instance, therapeutic conversation may need to be slower and simpler with older clients. Furthermore, it may be necessary for therapists to repeat new material, to ask the client to summarize the information to make sure that he or she understands it, and to ask the client to take notes on important points to increase recall of information and the effectiveness of the therapeutic intervention.

Changes in therapy may also arise as a result of the more positive aspects of maturation. Older adults have many useful strengths and existing skills as a result of the stability of crystallized intelligence and the development of expertise in several life domains. Rediscovering these skills, rather than teaching new ones, may frequently occur in therapy. It is also important to note that the normal decline in fluid intelligence suggests that the therapist may need to guide the older adult to certain conclusions, rather than giving suggestions and expecting the client to infer them.

Emotional changes that come with maturity may also affect the presentation of problems, requiring an adjustment of cognitive interventions. Research on emotion suggests that young adults experience pure and intense emotions, whereas older adults experience both sad and happy emotions in response to the same environmental or cognitive stimulus. Instead of replacing a negative, distorted thought with a more neutral or positive thought, it may be more strategic to have the older client focus on both the positive and negative emotions experienced.

A tendency for older adults to reminisce may make it difficult to focus on the present in CBT. Keeping an exclusively present-oriented focus when working with older adults who want and need to talk about the past is likely to be counterproductive. It is important to allow time for reminiscence, which may be perceived as reinforcement for other therapeutic work.

Cohort differences. In working with older adults, it is important to be aware of cohort differences that may influence the process of therapy. Cohort differences refer to an individual's membership in a birth-year group and the socialization process that shapes the abilities, beliefs, attitudes, and personality aspects of individuals born in a specific cohort. The attributes of a cohort are believed to be stable as the cohort ages, and thus differentiate it from those born earlier and later. For example, later-born cohorts (people who are now younger) have more years of formal education, are superior in reasoning ability and spatial orientation, and are more extroverted. Consequently, it may be necessary to change the wording of scales or assignments to adjust to different education levels of earlier cohorts and to adapt to cohort-specific values or examples in order to increase comfort with written assignments given in CBT. Thus, younger therapists working with older adults need to learn what it was like to grow up before the therapist was born because cohort differences in education level, intellectual skills, and personality may influence the process of therapy.

Social environment. Knowledge of the social context of older adults is crucial for appropriate interventions within both classic behavioral and social learning models of therapy because reinforcement contingencies that create or maintain maladaptive behavior or negative affect often arise from the environmental context. Staff in nursing homes, for example, may reward older adults for passively conforming to scheduled routines, a passivity that may result in reduced activity levels, lowered sense of control, and worsened mood. In order to improve the client's mood, the environment will need to be changed or staff will need to be consulted about possible environmental changes in the client's highly structured residential setting.

Cognitive-behavioral interventions for late-life problems

Many older adults who seek help in therapy deal with problems that threaten their well-being, including chronic illness, disability, and the death of loved ones. These problems are not unique to late life, but they are likely to occur more frequently at older ages. Furthermore, the usual difficulties of life, such as disappointments in love, arguments with family, and failure to achieve goals, can also take place in late life. Finally, many persons who struggle with depression, anxiety, substance abuse, or psychosis in their younger years continue to do so in their later years.

Chronic illness and disability. Conducting CBT with distressed older adults often means working with a population that is chronically ill, physically disabled, or both, and that struggles to adjust to these problems. In working with this population, it is important to learn about chronic illnesses and their psychological impact, control of chronic pain, adherence to medical treatment, rehabilitation strategies, and assessment of behavioral signs of medication reactions.

A frequent element of treating chronically ill or disabled elders is addressing concurrent depression, since up to 59 percent of this population experiences depression. Although there have been few studies examining the effectiveness of cognitive-behavioral therapy with medically ill older adults, results are encouraging for both outpatient and inpatient populations. Rybarczyk et al. (1992) have identified five important issues in applying CBT to chronically ill older adults: (1) solving practical barriers impeding participation, (2) acknowledging that depression is a separate and reversible problem, (3) limiting excess disability, (4) counteracting the loss of important social roles and autonomy, and (5) challenging the thought of being a "burden." For instance, in challenging the belief of being a burden on a family caregiver, the therapist may help the client to recall things he or she has done for the family caregiver in the past, thereby providing the client with a greater sense of equity in the relationship. Breaking down the issues facing the chronically ill older adult is helpful to the therapist in developing a strategy using both cognitive-behavioral techniques and practical considerations.

In addition to treating depression in medically ill or disabled elders, cognitive and behavioral techniques are also effective in managing pain associated with rheumatoid arthritis and delayed healing from injuries. Cognitive pain-management methods include distracting oneself from the pain, reinterpreting pain sensations, using pleasant imagery, using calming self-statements, and increasing daily pleasurable activities.

Depression. As mentioned previously, depression is prevalent in older adults who are chronically ill, disabled, or grieving; although the prevalence of depression in older adults is less than in young adults. Cognitive and behavioral approaches are effective in relieving depression in older adults. In treating depression, CBT focuses on teaching new coping strategies to deal with problems and on challenging those thoughts that interfere with effective coping. The client's participation in daily events that affect mood may also be addressed in therapy. By using a chart to monitor the frequency of these events, the therapist enables the client to see the relationship between pleasant events and moods, so that the frequency of pleasant events can be increased while the frequency of unpleasant events is reduced during the course of therapy. The therapist may also use the dysfunctional-thought record, a technique showing self-talk and negative interpretation of events, to enable the client to recognize distorted thoughts and replace negative and irrational thoughts with more adaptive ones.

Anxiety. Anxiety is fairly common in late life, but it is an understudied problem. Results from various studies indicate that brief courses (less than twenty sessions) of cognitive-behavioral therapy may be effective in treating late-life anxiety. In cognitive therapy, distorted thoughts that may exacerbate anxiety, such as "My heart is beating faster, which means I am about to have a heart attack" are challenged (Wetherell, 1998). Other cognitive restructuring techniques consist of making more accurate risk estimates; "decatastrophizing" by determining ways to cope with the feared situation; stopping thoughts by noticing and eliminating anxiety-provoking thoughts; and replacing automatic, anxious thoughts with positive thoughts. Relaxation training is often combined with diaphragmatic breathing and cognitive restructuring. For a review of treatment of anxiety in older adults, see Wetherell (1998).

Alcohol abuse. Even though alcoholism rates are lower for older adults than for younger adults, older problem drinkers often drink in response to loneliness, depression, and poor social-support networks. Consequently, CBT for the treatment of alcoholism in older adults focuses on improving the client's life in various ways in addition to just abstaining from drinking. Studies indicate that CBT models are effective in treating alcoholism in older adults, although further research is needed because not all studies have included a control group.

Stopping drinking completely, or at least achieving a period of abstinence followed by very limited and controlled drinking is a mandatory goal in treatment. Analysis of the drinking behavior itself also takes place to figure out the maladaptive purpose underlying the drinking behavior. Coping skills and behavior alternatives are then developed and practiced in therapy to handle situations in which the urge to drink arises. Irrational thoughts associated with the drinking are also challenged during therapy to increase the mood and self-esteem of the client, which in turn helps to control drinking behavior.

Conclusion

CBT may be effectively adapted for use with older adults by applying minor modifications to clinical techniques, since the principles of cognitive and behavioral theory are assumed to be similar for older and younger adults. Deciding which modifications to make, and how to conduct them, relies on a complete understanding of the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. Applying CBT to older clients entails several challenges, including learning about the social environment of older adults, working with clients whose experiences may be different from and prior to those of the therapist, and dealing with the interplay of physical and psychological problems on a frequent basis. Those who take on the challenge are likely to discover that their ideas about therapy and about aging will be transformed by working with older clients.

Bob G. Knight Gia S. Robinson

See also Alcoholism; Anxiety; Behavior Management, Bereavement, Depression; Geriatric Psychiatry; Intelligence; Psychotherapy.

BIBLIOGRAPHY

Arean, P., and Miranda, J. "The Treatment of Depression in Elderly Primary Care Patients: A Naturalistic Study." Journal of Clinical Geropsychology 2 (1996): 153–160.

Baltes, M. M. "Dependency in Old Age: Gains and Losses." Current Directions in Psychological Science 4 (1995) 14–18.

Carstensen, L. L.; Edelstein. B. A.; and Dornbrand, L., eds. The Practical Handbook of Clinical Gerontology. Thousand Oaks, Calif.: Sage Publications, 1996.

Cook, A. J. "Cognitive-Behavioral Pain Management for Elderly Nursing Home Residents." Journal of Gerontology: Psychological Sciences 53B (1998): P51–P59.

Duffy, M. Handbook of Counseling and Psychotherapy with Older Adults. New York: John Wiley, 1999.

Finch, E.; Ramsay, R.; and Katona, C. "Depression and Physical Illness in the Elderly." Clinics in Geriatric Medicine 8 (1992): 275–287.

Gallagher-Thompson, D., and Thompson, L. W. "Applying Cognitive-Behavioral Therapy to the Psychological Problems of Later Life." In A Guide to Psychotherapy and Aging. Edited by S. Zaret and B. G. Knight. Washington, D.C.: American Psychological Association, 1996: Pages 61–82.

Gatz, M.; Fiske, A.; Fox, L. S.; Kaskie, B.; Kasl-Godley, J.; McCallum, T.; and Wetherell, J. "Empirically-Validated Psychological Treatments for Older Adults." Journal of Mental Health and Aging 4 (1998): 9–46.

Knight, B. G. Psychotherapy with Older Adults, 2d ed. Thousand Oaks, Calif.: Sage Publications, 1996.

Knight, B. G., and Satre, D. D. "Cognitive-Behavioral Psychotherapy with Older Adults." Clinical Psychology: Science and Practice 6 (1999): 188–203.

Lichtenberg, P. A. A Guide to Psychological Practice in Geriatric Long-Term Care. New York: Haworth Press, 1994.

Lopez, M. A., and Mermelstein, R. J. "A Cognitive-Behavioral Program to Improve Geriatric Rehabilitation Outcome." The Gerontologist 35 (1995): 696–700.

Rybarczyk, B.; Gallagher-Thompson, D.; Rodman, J.; Zeiss, A.; Gantz, F. E.; and Yesavage, J. "Applying Cognitive-Behavioral Psychotherapy to the Chronically Ill Elderly: Treatment Issues and Case Illustration." International Psychogeriatrics 4 (1992): 127–140.

Schonfeld, L., and Dupree, L. W. "Treatment Approaches for Older Problem Drinkers." The International Journal of the Addictions 30 (1995): 1819–1842.

Teri, L.; Curtis, J.; Gallagher-Thompson, D.; and Thompson, L. W. "Cognitive-Behavior Therapy with Depressed Older Adults." In Diagnosis and Treatment of Depression in Late Life. Edited by L. S. Schneider, C. F. Reynolds, B. Liebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Press, 1994. Pages 279–292.

Wetherell, J. L. "Treatment of Anxiety in Older Adults." Psychotherapy 35 (1998): 444–458.

Widner, S., and Zeichner, A. "Psychological Interventions for the Elderly Chronic Pain Patient." Clinical Gerontologist 13 (1993): 3–18.

Zarit, S. H., and Knight, B. G., eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, D.C.: American Psychological Association, 1996.

Zeiss, A. M., and Steffen, A. "Behavioral and Cognitive-Behavioral Treatments: An Overview of Social Learning." In A Guide to Psychotherapy and Aging. Edited by S. Zarit and B. G. Knight. Washington, D.C.: American Psychological Association, 1996. Pages 35–60.

Cognitive-Behavioral Therapy

Definition

Cognitive-behavioral therapy is an action-oriented form of psychosocial therapy that assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and "negative" emotions. (Maladaptive behavior is behavior that is counter-productive or interferes with everyday living.) The treatment focuses on changing an individual's thoughts (cognitive patterns) in order to change his or her behavior and emotional state.

Purpose

Theoretically, cognitive-behavioral therapy can be employed in any situation in which there is a pattern of unwanted behavior accompanied by distress and impairment. It is a recommended treatment option for a number of mental disorders, including affective (mood) disorders, personality disorders, social phobia, obsessive-compulsive disorder (OCD), eating disorders, substance abuse, anxiety or panic disorder, agoraphobia, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). It is also frequently used as a tool to deal with chronic pain for patients with illnesses such as rheumatoid arthritis, back problems, and cancer. Patients with sleep disorders may also find cognitive-behavioral therapy a useful treatment for insomnia.

Precautions

Cognitive-behavioral therapy may not be suitable for some patients. Those who do not have a specific behavioral issue they wish to address and whose goals for therapy are to gain insight into the past may be better served by psychodynamic therapy. Patients must also be willing to take a very active role in the treatment process.

Cognitive-behavioral intervention may be inappropriate for some severely psychotic patients and for cognitively impaired patients (for example, patients with organic brain disease or a traumatic brain injury), depending on their level of functioning.

Description

Cognitive-behavioral therapy combines the individual goals of cognitive therapy and behavioral therapy.

Pioneered by psychologists Aaron Beck and Albert Ellis in the 1960s, cognitive therapy assumes that maladaptive behaviors and disturbed mood or emotions are the result of inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual reacts to his or her own distorted viewpoint of the situation. For example, a person may conclude that he is "worthless" simply because he failed an exam or did not get a date. Cognitive therapists attempt to make their patients aware of these distorted thinking patterns, or cognitive distortions, and change them (a process termed cognitive restructuring).

Behavioral therapy, or behavior modification, trains individuals to replace undesirable behaviors with healthier behavioral patterns. Unlike psychodynamic therapies, it does not focus on uncovering or understanding the unconscious motivations that may be behind the maladaptive behavior. In other words, strictly behavioral therapists do not try to find out why their patients behave the way they do, they just teach them to change the behavior.

Cognitive-behavioral therapy integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. The therapist works with the patient to identify both the thoughts and the behaviors that are causing distress, and to change those thoughts in order to readjust the behavior. In some cases, the patient may have certain fundamental core beliefs, called schemas, which are flawed and require modification. For example, a patient suffering from depression may be avoiding social contact with others, and suffering considerable emotional distress because of his isolation. When questioned why, the patient reveals to his therapist that he is afraid of rejection, of what others may do or say to him. Upon further exploration with his therapist, they discover that his real fear is not rejection, but the belief that he is hopelessly uninteresting and unlovable. His therapist then tests the reality of that assertion by having the patient name friends and family who love him and enjoy his company. By showing the patient that others value him, the therapist both exposes the irrationality of the patient's belief and provides him with a new model of thought to change his old behavior pattern. In this case, the person learns to think, "I am an interesting and lovable person; therefore I should not have difficulty making new friends in social situations." If enough "irrational cognitions" are changed, this patient may experience considerable relief from his depression.

A number of different techniques may be employed in cognitive-behavioral therapy to help patients uncover and examine their thoughts and change their behaviors. They include:

• Behavioral homework assignments. Cognitive-behavioral therapists frequently request that their patients complete homework assignments between therapy sessions. These may consist of real-life "behavioral experiments" where patients are encouraged to try out new responses to situations discussed in therapy sessions.
• Cognitive rehearsal. The patient imagines a difficult situation and the therapist guides him through the step-by-step process of facing and successfully dealing with it. The patient then works on practicing, or rehearsing, these steps mentally. Ideally, when the situation arises in real life, the patient will draw on the rehearsed behavior to address it.
• Journal. Patients are asked to keep a detailed diary recounting their thoughts, feelings, and actions when specific situations arise. The journal helps to make the patient aware of his or her maladaptive thoughts and to show their consequences on behavior. In later stages of therapy, it may serve to demonstrate and reinforce positive behaviors.
• Modeling. The therapist and patient engage in role-playing exercises in which the therapist acts out appropriate behaviors or responses to situations.
• Conditioning. The therapist uses reinforcement to encourage a particular behavior. For example, a child with ADHD gets a gold star every time he stays focused on tasks and accomplishes certain daily chores. The gold star reinforces and increases the desired behavior by identifying it with something positive. Reinforcement can also be used to extinguish unwanted behaviors by imposing negative consequences.
• Systematic desensitization. Patients imagine a situation they fear, while the therapist employs techniques to help the patient relax, helping the person cope with their fear reaction and eventually eliminate the anxiety altogether. For example, a patient in treatment for agoraphobia, or fear of open or public places, will relax and then picture herself on the sidewalk outside of her house. In her next session, she may relax herself and then imagine a visit to a crowded shopping mall. The imagery of the anxiety-producing situations gets progressively more intense until, eventually, the therapist and patient approach the anxiety-causing situation in real-life (a "graded exposure"), perhaps by visiting a mall. Exposure may be increased to the point of "flooding," providing maximum exposure to the real situation. By repeatedly pairing a desired response (relaxation) with a fear-producing situation (open, public spaces), the patient gradually becomes desensitized to the old response of fear and learns to react with feelings of relaxation.
• Validity testing. Patients are asked to test the validity of the automatic thoughts and schemas they encounter. The therapist may ask the patient to defend or produce evidence that a schema is true. If the patient is unable to meet the challenge, the faulty nature of the schema is exposed.

Initial treatment sessions are typically spent explaining the basic tenets of cognitive-behavioral therapy to the patient and establishing a positive working relationship between therapist and patient. Cognitive-behavioral therapy is a collaborative, action-oriented therapy effort. As such, it empowers the patient by giving him an active role in the therapy process and discourages any overdependence on the therapist that may occur in other therapeutic relationships. Therapy is typically administered in an outpatient setting in either an individual or group session. Therapists include psychologists (Ph.D., Psy.D., Ed.D. or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. with specialization in psychiatry) and should be trained in cognitive-behavioral techniques, although some brief cognitive-behavioral interventions may be suggested by a primary physician/caregiver. Treatment is relatively short in comparison to some other forms of psychotherapy, usually lasting no longer than 16 weeks. Many insurance plans provide reimbursement for cognitive-behavioral therapy services. Because coverage is dependent on the disorder or illness the therapy is treating, patients should check with their individual plans.

Rational-emotive behavior therapy

Rational-emotive behavior therapy (REBT) is a popular variation of cognitive-behavioral therapy developed in 1955 by psychologist Albert Ellis. REBT is based on the belief that a person's past experiences shape their belief system and thinking patterns. People form illogical, irrational thinking patterns that become the cause of both their negative emotions and of further irrational ideas. REBT focuses on helping patients discover these irrational beliefs that guide their behavior and replace them with rational beliefs and thoughts in order to relieve their emotional distress.

There are 10 basic irrational assumptions that trigger maladaptive emotions and behaviors:

• It is a necessity for an adult to be loved and approved of by almost everyone for virtually everything.

• A person must be thoroughly competent, adequate, and successful in all respects.
• Certain people are bad, wicked, or villainous and should be punished for their sins.
• It is catastrophic when things are not going the way one would like.
• Human unhappiness is externally caused. People have little or no ability to control their sorrows or to rid themselves of negative feelings.
• It is right to be terribly preoccupied with and upset about something that may be dangerous or fearsome.
• It is easier to avoid facing many of life's difficulties and responsibilities than it is to undertake more rewarding forms of self-discipline.
• The past is all-important. Because something once strongly affected someone's life, it should continue to do so indefinitely.
• People and things should be different from the way they are. It is catastrophic if perfect solutions to the grim realities of life are not immediately found.
• Maximal human happiness can be achieved by inertia and inaction or by living passively and without commitment.

Meichenbaum's self-instructional approach

Psychologist Donald Meichenbaum pioneered the self-instructional, or "self-talk," approach to cognitive-behavioral therapy in the 1970s. This approach focuses on changing what people say to themselves, both internally and out loud. It is based on the belief that an individual's actions follow directly from this self-talk. This type of therapy emphasizes teaching patients coping skills that they can use in a variety of situations to help themselves. The technique used to accomplish this is self-instructional inner dialogue, a method of talking through a problem or situation as it occurs.

Preparation

Patients may seek therapy independently, or be referred for treatment by a primary physician, psychologist, or psychiatrist. Because the patient and therapist work closely together to achieve specific therapeutic objectives, it is important that their working relationship is comfortable and their goals are compatible. Prior to beginning treatment, the patient and therapist should meet for a consultation session, or mutual interview. The consultation gives the therapist the opportunity to make an initial assessment of the patient and recommend a course of treatment and goals for therapy. It also gives the patient an opportunity to find out important details about the therapist's approach to treatment, professional credentials, and any other issues of interest.

In some managed-care clinical settings, an intake interview or evaluation is required before a patient begins therapy. The intake interview is used to evaluate the patient and assign him or her to a therapist. It may be conducted by a psychiatric nurse, counselor, or social worker.

KEY TERMS

Automatic thoughts— Thoughts that automatically come to mind when a particular situation occurs. Cognitive-behavioral therapy seeks to challenge automatic thoughts.

Cognitive restructuring— The process of replacing maladaptive thought patterns with constructive thoughts and beliefs.

Maladaptive— Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Psychodynamic therapy— A therapeutic approach that assumes dysfunctional or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.

Relaxation technique— A technique used to relieve stress. Exercise, biofeedback, hypnosis, and meditation are all effective relaxation tools. Relaxation techniques are used in cognitive-behavioral therapy to teach patients new ways of coping with stressful situations.

Schemas— Fundamental core beliefs or assumptions that are part of the perceptual filter people use to view the world. Cognitive-behavioral therapy seeks to change maladaptive schemas.

Normal results

Many patients who undergo cognitive-behavioral therapy successfully learn how to replace their maladaptive thoughts and behaviors with positive ones that facilitate individual growth and happiness. Cognitive-behavioral therapy may be used in conjunction with pharmaceutical and other treatment interventions, so overall success rates are difficult to gauge. However, success rates of 65% or more have been reported with cognitive-behavioral therapy alone as a treatment for panic attacks and agoraphobia. Relapse has been reported in some patient populations, perhaps due to the brief nature of the therapy, but follow-up sessions can put patients back on track.

Resources

ORGANIZATIONS

Albert Ellis Institute. 45 East 65th St., New York, NY 10021. (800) 323-4738. 〈http://www.rebt.org〉.

Beck Institute. GSB Building, City Line and Belmont Avenues, Suite 700, Bala Cynwyd, PA 19004-1610. (610) 664-3020. 〈http://www.beckinstitute.org〉.

National Association of Cognitive-Behavioral Therapists. P.O. Box 2195, Weirton, WV 26062. (800) 853-1135. 〈http://www.nacbt.org〉.

Cognitive-Behavioral Therapy

Definition

Purpose

Precautions

Description

Preparation

Results

Resources

Definition

Cognitive therapy is a psychosocial (both psychological and social) therapy that assumes that faulty thought patterns (called cognitive patterns) cause mal-adaptive behavior and emotional responses. The treatment focuses on changing thoughts to solve psychological and personality problems. Behavior therapy is also a goal-oriented, therapeutic approach, and it treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training. Cognitive-behavioral therapy (CBT) integrates features of behavior modification into the traditional cognitive restructuring approach.

Purpose

CBT attempts to change clients’ unhealthy behavior or thought processes through cognitive restructuring (examining assumptions behind the thought patterns) and through the use of behavior therapy techniques.

CBT is a treatment option for a number of mental disorders, including depression, dissociative identity disorder, eating disorders, generalized anxiety disorder, hypochondriasis, insomnia, obsessive-compulsive disorder , and panic disorder without agoraphobia.

Precautions

CBT may not be appropriate for all patients. Patients with significant cognitive impairments (patients with traumatic brain injury or organic brain disease, for example) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.

Description

Origins of the two approaches

Psychologist Aaron Beck developed cognitive therapy in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted view of the situation. Cognitive therapy strives to change these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.

Behavior therapy focuses on observable behavior and its modification in the present, in sharp contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past. Behavior therapy was developed during the 1950s by researchers and therapists who were critical of the prevailing psychodynamic treatment methods. The therapy drew on a variety of theories and research, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), the work of American B. F. Skinner (1904-1990), and the work of psychiatrist Joseph Wolpe (1915-1997). Pavlov became famous for experiments in which dogs were trained to salivate at the sound of a bell, and Skinner pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. Wolpe is probably best known for his work in the areas of desensitization and assertiveness training. By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Since the 1980s, many therapists have begun to use CBT to change clients’ unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.

The combined approach

In CBT, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, that are flawed and are having a negative impact on the patient’s behavior and functioning.

For example, a patient with depression may develop a social phobia because he is convinced that he is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends who care for him and enjoy his company. By showing the patient that others value him, the therapist exposes the irrationality of the patient’s assumption and also provides a new model of thought for the patient to change his previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.

CBT is usually administered in an outpatient setting (clinic or doctor’s office) by a specially trained therapist. Therapy may be in either individual or group sessions. Therapists are psychologists (PhD, PsyD, EdD, or MA degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (MA or MS degree), or psychiatrists (MD trained in psychiatry).

Techniques

Therapists use several different techniques in the course of CBT to help patients examine and change thoughts and behaviors. These include:

• Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
• Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to cope successfully with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to manage it.
• Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
• Writing in a journal. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behaviors that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
• Homework. To encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling, review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
• Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.
• Systematic positive reinforcement. Human behavior is routinely motivated and rewarded by positive reinforcement, and a more specialized version of this phenomenon (systematic positive reinforcement) is used by behavior-oriented therapists. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of tokens that may be accumulated and later exchanged for certain privileges. Just as providing reinforcement strengthens behaviors, withholding it weakens them. Eradicating undesirable behavior by deliberately withholding reinforcement is another popular treatment method called extinction. For example, a child who habitually shouts to attract attention may be ignored unless he or she speaks in a conversational tone.
• Aversive conditioning. This technique employs the principles of classical conditioning to lessen the appeal of a behavior that is difficult to change because it is either very habitual or temporarily rewarding. The client is exposed to an unpleasant stimulus while engaged in or thinking about the behavior in question. Eventually the behavior itself becomes associated with unpleasant rather than pleasant feelings. One treatment method used with alcoholics is the administration of a nausea-inducing drug together with an alcoholic beverage to produce an aversion to the taste and smell of alcohol by having it become associated with nausea. Studies investigating use of these aversive conditioning approaches have not identified a high level of therapeutic effectiveness. According to the American Psychiatric Association, aversion therapy should be practiced only in very specialized centers. In counter-conditioning, a maladaptive response is weakened by the strengthening of a response that is incompatible with it. A well-known type of counterconditioning is systematic desensitization, which counteracts the anxiety connected with a particular behavior or situation by inducing a relaxed response to it instead. This method is often used in the treatment of people who are afraid of flying.

Preparation

Because CBT is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in CBT should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist’s professional credentials, his/her approach to treatment, and other relevant issues.

In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.

Results

Because CBT is employed for such a broad spectrum of illnesses and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. However, several studies have indicated that CBT:

• may reduce the rate of rehospitalization and improve social and occupational functioning for bipolar disorder patients, when combined with pharmacotherapy (treatment with medication)
• is an effective treatment for patients with bulimia nervosa
• can help generalized anxiety patients manage their worry, when combined with relaxation exercises
• is helpful in treating hypochondriasis
• may be effective for treating depression, especially when combined with pharmacotherapy, and may also prevent depression in at-risk children
• is one of the first-line treatments for obsessive-compulsive disorder
• that focuses on education and provides some exposure and coping skills is effective for treating panic disorder without agoraphobia
• is effective for helping to treat insomnia, and its effects may be sustained longer than the effects of medications alone

See alsoAversion therapy; Behavior modification; Cognitive problem-solving skills training; Cognitive retraining techniques; Covert sensitization; Exposure treatment; Rational emotive therapy; Systematic desensitization.

Resources

BOOKS

Alford, B. A., and A. T. Beck. The Integrative Power of Cognitive Therapy. New York: Guilford, 1997.

Beck, A. T. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.

Craighead, Linda W. Cognitive and Behavioral Interventions: An Empirical Approach to Mental Health Problems. Boston: Allyn and Bacon, 1994.

Nathan, Peter E., and Jack M. Gorman. A Guide to Treatments that Work, 2nd ed. New York: Oxford University Press, 2002.

Weishaar, Marjorie. “Cognitive Therapy.” Encyclopedia of Mental Health, Ed. Howard S. Friedman. San Diego: Academic Press, 1998.

Wolpe, Joseph. The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, 1996.

PERIODICALS

Rupke, Stuart J., David Blecke, and Marjorie Renfrow. “Cognitive Therapy for Depression.” American Family Physician 73 (2006): 83-85. Also available online at: <http://www.aafp.org/afp/20060101/83.html>.

OTHER

American Academy of Family Physicians. “Cognitive Therapy.” Available online at: <http://familydoctor.org/882.xml>.

Kleber, Herbert D., and others. Practice Guideline for Treatment of Patients with Substance Use Disorders, 2nd ed. (2006). Available online through the American Psychiatric Association at: <http://www.psych.org/psych_pract/treatg/pg/SUD2ePG_04-28-06.pdf>.

National Alliance on Mental Illness. “Cognitive-Behavioral Therapy.” Available online at: <http://www.nami.org/Template.cfm?Section = About_Treatments_and_Supports&template¼/ContentManagement/Content Display.cfm&ContentID¼7952>.

Paula Ford-Martin, MS
Emily Jane Willingham, PhD

Cognitive-behavioral therapy

Definition

Cognitive therapy is a psychosocial (both psychological and social) therapy that assumes that faulty thought patterns (called cognitive patterns) cause maladaptive behavior and emotional responses. The treatment focuses on changing thoughts in order to solve psychological and personality problems. Behavior therapy is also a goal-oriented, therapeutic approach, and it treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training. Cognitive-behavioral therapy (CBT) integrates features of behavior modification into the traditional cognitive restructuring approach.

Purpose

Cognitive-behavioral therapy attempts to change clients' unhealthy behavior through cognitive restructuring (examining assumptions behind the thought patterns) and through the use of behavior therapy techniques.

Cognitive-behavioral therapy is a treatment option for a number of mental disorders, including depression, dissociative identity disorder , eating disorders, generalized anxiety disorder , hypochondriasis , insomnia , obsessive-compulsive disorder , and panic disorder without agoraphobia .

Precautions

Cognitive-behavioral therapy may not be appropriate for all patients. Patients with significant cognitive impairments (patients with traumatic brain injury or organic brain disease, for example) and individuals who are not willing to take an active role in the treatment process are not usually good candidates.

Description

Origins of the two approaches

Psychologist Aaron Beck developed cognitive therapy in the 1960s. The treatment is based on the principle that maladaptive behavior (ineffective, self-defeating behavior) is triggered by inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual automatically reacts to his or her own distorted view of the situation. Cognitive therapy strives to change these thought patterns (also known as cognitive distortions), by examining the rationality and validity of the assumptions behind them. This process is termed cognitive restructuring.

Behavior therapy focuses on observable behavior and its modification in the present, in sharp contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past. Behavior therapy was developed during the 1950s by researchers and therapists who were critical of the prevailing psychodynamic treatment methods. The therapy drew on a variety of theories and research, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), the work of American B. F. Skinner (1904-1990), and the work of psychiatrist Joesph Wolpe (1915-1997). Pavlov became famous for experiments in which dogs were trained to salivate at the sound of a bell, and Skinner pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. Wolpe is probably best known for his work in the areas of desensitization and assertiveness training . By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Since the 1980s, many therapists have begun to use cognitive-behavioral therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.

The combined approach

In cognitive-behavioral therapy, the therapist works with the patient to identify the thoughts that are causing distress, and employs behavioral therapy techniques to alter the resulting behavior. Patients may have certain fundamental core beliefs, known as schemas, that are flawed and are having a negative impact on the patient's behavior and functioning.

For example, a patient suffering from depression may develop a social phobia because he is convinced that he is uninteresting and impossible to love. A cognitive-behavioral therapist would test this assumption by asking the patient to name family and friends who care for him and enjoy his company. By showing the patient that others value him, the therapist exposes the irrationality of the patient's assumption and also provides a new model of thought for the patient to change his previous behavior pattern (i.e., I am an interesting and likeable person, therefore I should not have any problem making new social acquaintances). Additional behavioral techniques such as conditioning (the use of positive and/or negative reinforcements to encourage desired behavior) and systematic desensitization (gradual exposure to anxiety-producing situations in order to extinguish the fear response) may then be used to gradually reintroduce the patient to social situations.

Cognitive-behavioral therapy is usually administered in an outpatient setting (clinic or doctor's office) by a specially trained therapist. Therapy may be in either individual or group sessions. Therapists are psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. trained in psychiatry).

Techniques

Therapists use several different techniques in the course of cognitive-behavioral therapy to help patients examine and change thoughts and behaviors. These include:

• Validity testing. The therapist asks the patient to defend his or her thoughts and beliefs. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed.
• Cognitive rehearsal. The patient is asked to imagine a difficult situation he or she has encountered in the past, and then works with the therapist to practice how to cope successfully with the problem. When the patient is confronted with a similar situation again, the rehearsed behavior will be drawn on to manage it.
• Guided discovery. The therapist asks the patient a series of questions designed to guide the patient towards the discovery of his or her cognitive distortions.
• Writing in a journal. Patients keep a detailed written diary of situations that arise in everyday life, the thoughts and emotions surrounding them, and the behaviors that accompany them. The therapist and patient then review the journal together to discover maladaptive thought patterns and how these thoughts impact behavior.
• Homework. In order to encourage self-discovery and reinforce insights made in therapy, the therapist may ask the patient to do homework assignments. These may include note-taking during the session, journaling, review of an audiotape of the patient session, or reading books or articles appropriate to the therapy. They may also be more behaviorally focused, applying a newly learned strategy or coping mechanism to a situation, and then recording the results for the next therapy session.
• Modeling. Role-playing exercises allow the therapist to act out appropriate reactions to different situations. The patient can then model this behavior.
• Systematic positive reinforcement. Human behavior is routinely motivated and rewarded by positive reinforcement , and a more specialized version of this phenomenon (systematic positive reinforcement) is used by behavior-oriented therapists. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of tokens that may be accumulated and later exchanged for certain privileges. Just as providing reinforcement strengthens behaviors, withholding it weakens them. Eradicating undesirable behavior by deliberately withholding reinforcement is another popular treatment method called extinction. For example, a child who habitually shouts to attract attention may be ignored unless he or she speaks in a conversational tone.
• Aversive conditioning. This technique employs the principles of classical conditioning to lessen the appeal of a behavior that is difficult to change because it is either very habitual or temporarily rewarding. The client is exposed to an unpleasant stimulus while engaged in or thinking about the behavior in question. Eventually the behavior itself becomes associated with unpleasant rather than pleasant feelings. One treatment method used with alcoholics is the administration of a nausea-inducing drug together with an alcoholic beverage to produce an aversion to the taste and smell of alcohol by having it become associated with nausea. In counterconditioning, a maladaptive response is weakened by the strengthening of a response that is incompatible with it. A well-known type of counterconditioning is systematic desensitization , which counteracts the anxiety connected with a particular behavior or situation by inducing a relaxed response to it instead. This method is often used in the treatment of people who are afraid of flying.

Preparation

Because cognitive-behavioral therapy is a collaborative effort between therapist and patient, a comfortable working relationship is critical to successful treatment. Individuals interested in CBT should schedule a consultation session with their prospective therapist before starting treatment. The consultation session is similar to an interview session, and it allows both patient and therapist to get to know one another. During the consultation, the therapist gathers information to make an initial assessment of the patient and to recommend both direction and goals for treatment. The patient has the opportunity to learn about the therapist's professional credentials, his/her approach to treatment, and other relevant issues.

In some managed-care settings, an intake interview is required before a patient can meet with a therapist. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist.

Results

Because cognitive-behavioral therapy is employed for such a broad spectrum of illnesses, and is often used in conjunction with medications and other treatment interventions, it is difficult to measure overall success rates for the therapy. However, several studies have indicated that CBT:

• may reduce the rate of rehospitalization and improve social and occupational functioning for bipolar disorder patients, when combined with pharmacotherapy (treatment with medication)
• is an effective treatment for patients with bulimia nervosa
• can help generalized anxiety patients manage their worry, when combined with relaxation exercises
• is helpful in treating hypochondriasis
• may be effective for treating depression, especially when combined with pharmacotherapy, and may also prevent depression in at-risk children
• is one of the first-line treatments for obsessive-compulsive disorder
• that focuses on education and provides some exposure and coping skills is effective for treating panic disorder without agoraphobia
• is effective for helping to treat insomnia, and its effects may be sustained longer than the effects of medications alone

See also Aversion therapy; Behavior modification; Cognitive problem-solving skills training; Cognitive retraining techniques; Covert sensitization; Exposure treatment; Rational emotive therapy

Resources

BOOKS

Alford, B. A., and A. T. Beck. The integrative power of cognitive therapy. New York: Guilford, 1997.

Beck, A. T. Prisoners of hate: the cognitive basis of anger, hostility, and violence. New York: HarperCollins Publishers, 1999.

Craighead, Linda W. Cognitive and Behavioral Interventions: An Empirical Approach to Mental Health Problems. Boston: Allyn and Bacon, 1994.

Nathan, Peter E., and Jack M. Gorman. A Guide to Treatments that Work. 2nd edition. New York: Oxford University Press, 2002.

Weishaar, Marjorie. "Cognitive Therapy." In Encyclopedia of Mental Health, edited by Howard S. Friedman. San Diego, CA: Academic Press, 1998.

Wolpe, Joseph. The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, 1996.

Paula Ford-Martin, M.A.

Cognitive Retraining

Definition

Purpose

Precautions

Description

Preparation

Aftercare

Risks

Typical results

Resources

Definition

Cognitive retraining is a therapeutic strategy that seeks to improve or restore a person’s cognitive skills. These skills include paying attention, remembering, organizing, reasoning and understanding, problem solving, decision making, and higher level cognitive abilities. These skills are all interrelated. Cognitive retraining is one aspect of cognitive rehabilitation, a comprehensive approach to restoring such skills after brain injury or other disability.

Purpose

The purpose of cognitive retraining is the reduction of cognitive problems associated with brain injury, other disabilities or disorders, and/or aging. The overall purpose of the therapy is to decrease the everyday problems faced by individuals with cognitive difficulties, thereby improving the quality of their lives.

Precautions

The extent to which a person with a brain injury can recover from or compensate for cognitive problems varies with the person and their injury. Therapy must be tailored to each individual‘s needs and abilities. Some cognitive retraining techniques require higher levels of skill, and therefore would be more suitable for persons who have made some progress in their recovery. In addition, a person‘s moods and emotions have an effect on their cognitive skills. Someone who is depressed, for example, may need psychotherapy and/or medication before he or she can engage in and benefit from cognitive retraining. Some persons with brain injuries may find it difficult to transfer a skill learned in one setting, such as a clinic, to another setting, such as their home. Although a specific individual may show some improvement on training tasks, his or her cognitive skills may not be considered improved or restored unless there is some evidence that the skills have been transferred to everyday settings and can be maintained over time.

Description

The techniques of cognitive retraining are best known for their use with persons who have had a brain injury. However, cognitive retraining has also been used to treat dementia, schizophrenia, attention-deficit disorder, learning disabilities, obsessive-compulsive disorder, and cognitive changes associated with aging. Professionals from a variety of fields, such as psychology, psychiatry, occupational therapy, and speech-language pathology, may be involved in cognitive retraining.

Cognitive retraining includes a considerable amount of repetitive practice that targets the skills of interest. In fact, repetition is essential for the newly retrained skills to become automatic. Regular feedback is another important element of cognitive retraining, as is the use of rewards, such as money. Retraining usually begins with simpler skills and proceeds to more complicated skills. The therapist may address cognitive skills while the person is practicing real-life tasks, in an effort to improve their performance of these tasks. In fact, practicing skills in the ways and settings they will be used in real life is critical to the success of retraining efforts. The length of time for cognitive training varies according to the type and extent of the injury and the type of retraining skills used. For example, retraining memory may take months or years. In contrast, it may take only a few days or weeks to retrain someone to organize his or her home or workplace.

The use of computerization for cognitive retraining has become an increasingly common practice. In particular, researchers have focused on developing a “mixed-reality” system, producing a virtual reality environment for the person undergoing rehabilitation. This system, called in one study a “Human Experience Modeler,” places the patient in a context similar to reality—such as home or work—except that the stimuli can be controlled and the patient’s experiences captured with automated feedback provided. These approaches have shown some promising success in pilot studies.

Types of cognitive retraining

• Attention and concentration retraining. This type of cognitive retraining aims to improve several abilities, including focusing attention, dividing attention, maintaining attention while reducing the effects of boredom and fatigue, and resisting distraction. Attention has been considered the foundation of other more complicated cognitive skills, and therefore an important skill for cognitive retraining. This area of cognitive retraining has been widely researched, and has been shown to improve patients’ abilities in various tasks related to attention.
• Memory retraining. Memory retraining involves teaching the patient several strategies that can be used to recall certain types of information. For example, rhymes may be used as a memory aid. A series of numbers, such as a phone number with an area code, may be broken down into smaller groups. A person may be taught to go through each letter of the alphabet until he or she remembers someone’s name. Both memory and organization problems are common and often disabling after head injury.
• Organizational skills retraining. This approach is used when the person has difficulty keeping track of or finding items, doing tasks in a set order, and/or doing something in a timely manner. Strategies may include having one identified place for an item (“a place for everything and everything in its place”). In addition, the person can be taught to keep the items that are used most frequently closer to him or her (the front or the lower shelves of a cabinet, drawer, closet, or desk, for example). Items that are often used together (such as comb and brush, toothbrush and toothpaste) are placed beside each other. Items may be put into categories (allocating decorations to a specific holiday, such as the Fourth of July or Thanksgiving, for example). These strategies help individuals function better in their home or work environment.
• Reasoning. Reasoning refers to the ability to connect and organize information in a logical, rational way.

Reasoning retraining techniques include: listing the facts or reality of a situation; excluding irrelevant facts or details; putting the steps to solve a problem in a logical order; and avoiding irrational thinking, such as jumping to conclusions based on incomplete information, or focusing on the negative aspects of the situation and ignoring the positive. When the person can connect relevant information in a logical way, they are better able to understand or comprehend it.

• Problem solving. Problem-solving retraining aims to help people define a problem; come up with possible solutions to it; discuss the solution(s) with others and listen to their advice; review the various possible solutions from many perspectives; and evaluate whether the problem was solved after going through these steps. This sequence may be repeated several times until the problem is solved. This process is referred to as “SOLVE,” from the first letter of the name of each step: Specify; Options; Listen; Vary; and Evaluate. The “SOLVE” technique is more appropriate for use with individuals at a higher level of functioning.
• Decision making. Decision-making retraining is used when a person must choose among a number of options. The goal of this retraining is to help him or her consider the decision thoroughly before taking any action. The considerations may range from such practical matters as money, people, rules and policies, to personality issues.
• Executive skills. Executive skills retraining refers to teaching individuals how to monitor themselves, control their thinking and actions, think in advance, set goals, manage time, act in socially acceptable ways, and transfer skills to new situations. These are higher-level cognitive skills. Charts and videotapes may be used to monitor behavior, and a variety of questions, tasks, and games may be used in retraining these skills.

Preparation

Cognitive retraining usually takes place in a quiet room without distractions. It is also important for the person to feel relaxed and calm while they are being retrained in cognitive skills. Engaging in cognitive retraining is not recommended when someone is emotional distressed, e.g., after the recent loss of a loved one. The therapist usually evaluates the person’s level of cognitive skills and the extent of their cognitive problems before retraining begins. This evaluation provides a way to monitor improvement by comparing the patient’s skill levels during and after retraining to his or her skill levels before retraining. Cognitive

KEY TERMS

Cognitive —Pertaining to the mental processes of memory, perception, judgment, and reasoning.

Executive skills —Higher-level cognitive skills that are used when a person makes and carries out plans, organizes and performs complex tasks, etc.

retraining requires patience and persistence on the part of everyone involved.

Aftercare

The therapist will try to promote the transfer of skills learned using cognitive retraining techniques to the settings of the patient’s everyday life. Training may be continued until the patient’s skills are improved, transferred to, and maintained in real world activities.

Risks

It is important for the therapist, patient, and the patient’s friends or family members not to assume that improvement on training exercises and tests automatically leads to transfer of the skills to real-life settings.

Typical results

Cognitive retraining may be considered successful if performance on a behavior related to a particular cognitive skill has improved. It is ultimately successful if it helps the injured person improve his or her functioning and meet his or her needs in real-life situations and settings.

See alsoAttention-deficit/hyperactivity disorder; Dementia; Learning disabilities; Schizophrenia.

Resources

BOOKS

Mateer, Catherine A., and Sarah Raskin. “Cognitive Rehabilitation.” Rehabilitation of the Adult and Child with Traumatic Brain Injury, 3rd ed. M. Rosenthal, E. R. Griffith, J. S. Kreutzer, and B. Pentland, eds. Philadelphia: F. A. Davis, 1999.

Parente, Rick, and D. Herrmann. Retraining Cognition: Techniques and Applications. Gaithersburg, MD: Aspen, 1996.

Ylvisaker, Mark, and Timothy J. Feeney. Collaborative Brain Injury Intervention. San Diego: Singular, 1998.

PERIODICALS

Buhlmann, Ulrike, and others. “Cognitive Retraining for Organizational Impairment in Obsessive-Compulsive Disorder.” Psychiatry Research 144 (2006): 109–16.

Fidopiastis, C.M., and others. “Human Experience Modeler: Context-Driven Cognitive Retraining to Facilitate Transfer of Learning.” Cyber Psychology and Behavior 9 (2006): 183–87.

OTHER

American Brain Tumor Association. “Becoming Well Again through Cognitive Retraining.” (2006) Available online at: <http://www.abta.org/wellagain2.php>.

Joneis Thomas, PhD
Emily Jane Willingham, PhD