Cognitive And Interpersonal Therapy Research Paper

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Cognitive and interpersonal therapies are each structured psychological treatments. They differ consider-ably in their rationale and therapeutic procedures, but both have been subject to research since their inception. In recent years, each has been demonstrated to offer effective symptomatic help for a range of specific mental disorders. This has facilitated their adoption in publicly or insurance funded health services, where major changes have been taking place in the pattern of therapeutic provision and in the training of mental health professionals. In English-speaking countries, where psychiatrists trained in psychological treatments were, even 10 years ago, more likely to offer psychoanalytic psychotherapy than any other kind, provision of cognitive or inter-personal therapy is increasingly common. Cognitive therapy is also provided frequently by clinical psychologists. This research paper will provide a brief overview of their respective rationales, methods, and current applications. It concludes with some speculations on future developments.

1. Cognitive Psychotherapy

1.1 Overview

All forms of cognitive therapy (CT) work from the premise that common mental disorders are consequent to and/or maintained by faulty thinking (rather than the reverse). Cognitive therapists, therefore, set out to identify cognitions associated with a target problem (such as depressed mood or hypochondriacal behavior) then use this analysis as the basis for an explicit therapeutic plan. Treatments addressing these cognitions can adopt a number of techniques, depending upon the problem addressed, the formulation of an individual case, and the specific form of cognitive psychotherapy favored by individual practitioners.

1.2 Rationale

Although cognitive therapy has only gained currency since 1970, its basic aims are not new. Attempts to restore mental health by arguing sufferers out of their false beliefs underpinned much ‘moral therapy’ in eighteenth-century asylums. As a modern movement, CT emerged from behavior therapy (qv). This had its theoretical rationale in learning theory (qv), derived from experimental manipulation of contingent responses in laboratory animals. Behavioral treatments had sought behavioral change through functional analysis of target symptoms. Behavioral theory paid little attention to the ‘black box’ of the mind and any mediating role it played between environmental stimulus and behavioral response. Cognitive therapy developed in reaction to this denial of the importance of thought, but was helped by clinical evidence that thinking could actively obstruct the progress of behavioral treatment unless it was explicitly attended to. The behavioral and cognitive approaches to psychological treatment have retained many common features, including emphasis on explicit formulation, and an empirical and collaborative approach. Behavioral and cognitive techniques may be combined within a treatment, and the close relationship between the two is reflected in the designation of ‘cognitive-behavior therapy’ or ‘CBT’ for much work that remains essentially cognitive.

Cognitive therapists have used a variety of models to account for how cognitive processes contribute m psychopathology. While these can be impressive in their orderliness and ingenuity, and can be of great heuristic value in practice, they nearly always derive from clinical experience. At the same time, independent support for such models has been sought from experimental psychology. Few cognitive findings in emotional disorders remain robust when stringently tested, although a good deal of evidence exists that selective preference for negative memories is common in people with depressed mood, and irrational expectations of future danger is more common in people prone to anxiety (Williams et al. 1990).

The development of cognitive therapy has gone through a succession of stages of increasing theoretical complexity. These have accompanied a tendency, shared with other maturing psychotherapies, to follow early successes with relatively straightforward cases by attempts to deal with those that are more resistant to simple measures. While the theoretical ramifications of this are beyond the scope of the research paper, it is helpful to distinguish between two kinds of cognition that have been seen as pathogenic—‘surface’ and ‘deep.’ Surface cognitions are available to introspection, transient, and situation specific. Deep cognitions are less easy to access, enduring and more global in scope.

The most influential package of models informing therapeutic practice derive from Beck and co-workers (Beck 1989). As applied to common disorders in which the main features are anxiety symptoms or depression, cognitive changes lead to evident differences in appraisal of a ‘cognitive triad’ of three interlinked areas. These are someone’s automatic attitudes concerning their world, themselves, and what is likely to happen. Beck terms surface cognitions of these kinds ‘automatic thoughts.’ While their content is colored by the particulars of an individual’s experience and personal values, some themes have been demonstrated as common to people having a particular kind of emotional disorder. For instance, when anxiety is marked, automatic thoughts about future danger are common; with depression, personal helplessness, and perceived inability to change their personal circumstances; with hostility, thoughts that the world is a bad or very unreliable place. Beck identifies two other kinds of cognitive pathology that accompany these developments. One is a set of ways in which cognitive processes frequently are distorted. These ensure that appraisals based on automatic thinking are likely to be con-firmed. Examples include making of arbitrary or personal inferences, selective abstraction and over-generalization from experience, and all or nothing (‘dichotomous’) thinking. At the level of deep cognitions, Beck recognizes the presence of ‘schemas’ as constellations of assumptions and beliefs which, being more latent but enduring cognitions that can be reactivated by events, are associated with predisposition to emotional disorders. The main functional relationships between these elements are summarized in Fig. 1.

While a good deal of reasoning in cognitive therapy represents extensions or amendments to this frame-work, a significant conceptual departure came with revision of the concept of the ‘schema.’ Used to refer to a variety of kinds of deep cognition, the term’s adoption by Young (1994) to refer to ‘early mal-adaptive schemas’ (EMS) has had important practical implications. An EMS is not only latent and enduring, but presumed to result from experiences early in life. It is rigid in restricting the scope of thinking and likely to be associated with very strong affect if challenged. Because of this emotional valence, EMSs can appear to be quasi-autonomous, acting to preserve themselves (schema maintenance). There can be a preference for executive functions that either fail to activate the schema (schema avoidance) or that disguise it behind displays of contrary traits (schema compensation). EMSs resistance to change means they cannot be inferred straightforwardly from behavior or simple enquiries.

1.3 Methods

In general, therapeutic strategies aim to counteract cognitive distortions by teaching patients skills by which they can recognize and revise problematic cognitions, as well as working to challenge specific current cognitions and to establish a more adaptive way of thinking. Essentially, this will involve techniques for the identification of surface and deep cognitions and their sequelae that are not otherwise amenable to simple introspection, and for the modification of beliefs and cognitive distortions so encountered. Although this account will concentrate on interventions directed at cognitions, both of these tasks are carried out in practice through the pre-scription of behavioral experiments and exercises. For instance, when working with people subject to panic attacks who fear they may die from a heart attack during a panic episode, the assumption that physical symptoms such as dizziness, breathlessness, and awareness of accelerated heartbeat indicate collapse and death are imminent is addressed by a behavioral procedure. In order to break the link between these experiences and expectations, a patient agrees to hyperventilate under controlled conditions until these sensations are induced. The strength of their beliefs concerning the consequences of the hyperventilation exercise would be rated and recorded at its outset and its conclusion, as part of a therapeutic examination of the validity of the expectations in the light of a disconfirmatory experience. This example illustrates the general principle that, even when using a behavioural manipulation, a cognitive therapist would insist it subserves a cognitive goal, and that attention is paid to its cognitive impact throughout.

Measures to identify automatic thoughts include analysis of situations in which a target problem occurs. This is unlikely to be successful through generalized recall: specific instances need to be examined in detail. These might be recounted in the session; lived through between sessions after a patient is instructed on how to maintain a detailed and contemporaneous record of associated negative thoughts; or reconstructed as a patient has a shift of affect in a session. Other techniques such as role-plays or induction of imagery may be employed in sessions to stimulate automatic thoughts. Measures intended to facilitate reattribution expose not only the irrationality of automatic thoughts but their incompatibility with experience. The importance of active testing in modifying them, alongside regular and explicit reappraisal of the validity of the thoughts, has already been referred to. Patients and therapists are likely to collaborate in drawing up a set of alternative explanations whose fit with the facts of experience can then also be tested.

As experience of cognitive techniques has developed, there has been a progressive shift of interest away from factors leading simply to inaccurate appraisal of situations, to those by which faulty cognitions, and problems associated with them, are maintained (Salkovskis 1991). These may be automatic thoughts associated with plans of action that perpetuate a problem by protecting a faulty cognition from challenge (safety behaviors) or attentional shifts that have a similar impact through distraction. Interventions that address these maintaining factors directly can allow cognitive techniques to be effective where attention to errors in appraisal alone would not.

Deep cognitions in the form of schemas are not only more difficult to identify than surface cognitions, but harder to attempt to change therapeutically. Identification needs a more probing and hypothetical approach in the course of guided discovery by use of techniques such as the ‘vertical arrow.’ This is a reiterative questioning of patients’ suppositions about the implications of a negative idea being the case, until a fundamental and general belief about themselves emerges. Attempts to change schemas would normally only be made when there had been some progress with emotional symptoms. As the previous description of the kinds of concealment and resistance associated with EMSs implies, schema-focused work is likely to be more complicated and prolonged than work with automatic thoughts. Because schemas may embody templates for how someone relates to others, and be associated with manifest relationship problems, therapeutic work with them is likely to resemble psycho-dynamic psychotherapy (qv) more closely than other forms of cognitive therapy (Safran and Segal 1990).

1.4 Applications

Unlike psychoanalytic psychotherapies, cognitive psychotherapy has developed through its application to conditions in which symptoms or problematic habits are associated with specific patterns of thinking. Its growth since 1970 has been accompanied by progressive developments in psychiatric nosology. The diagnostic and statistical manuals of the American Psychiatric Association chart diagnostic developments which have involved the progressive refinement of diagnoses based on anxiety, depression, psychosis, and distortions of personality, with the effective invention of categories to encompass the so-called somatoform, dissociative, adjustment, and eating dis-orders (APA 1968, 1980, 1994). These have facilitated understanding of common cognitive patterns associated with these and development of specific treatment techniques. Use of cognitive therapy in depression and anxiety disorders are best established, while diagnostic sub-classifications that have clarified the characteristics of bipolar depressive disorder and panic disorder have been followed by specific cognitive techniques for their management. The category of personality disorders has not only been refined through this period, but, with the advent of multiaxial classification, been designated as an independent axis for summary clinical descripton (axis II). Given that the basic difference between disorders of personality from the symptom focused categories of axis I lies in their early onset and relative stability, models of their cognitive pathology have emphasized ‘deep’ cognitions over surface ones, and more recently the early maladaptive schema model of Young. Efforts to link specific personality types with consistent schema formations continue. A further development of particular significance to psychiatrists has been the application of cognitive therapy to schizophrenia. These have included treatments for specific symptoms (delusions and hallucinations) as well as measures to live with the impact of illness and enhance coping capacities (Chadwick et al. 1996).

The vast majority of cognitive therapy is provided as individual therapy. However, group treatments have been pioneered for specific disorders including depressive, anxiety, and eating disorders. Beck has advocated its use with couples experiencing conflict.

More recently, attempts have been made to differentiate between psychological therapies with reference to the strength of independent evidence concerning their clinical effectiveness. An empirically supported treatment is one which is clearly defined and, for a given clinical problem, is consistently more efficacious than placebo treatments on the evidence of controlled clinical trials. On this basis, cognitive therapies have emerged as empirically supported in adults for anxiety disorders (including panic disorder, generalized anxiety disorder, and social phobia); unipolar depression; anorexia nervosa and bulemia nervosa (Roth and Fonagy 1996).

1.5 Comment

The remarkable growth of cognitive therapy has been facilitated by a number of external developments: the growth of clinical psychology as a profession whose members receive training in cognitive theory and techniques within their core curriculum; compatibility between cognitive models of psychopathology and classifications adopted for diagnosis, care management, and/organization of the evidence base; and an intellectual Zeitgeist that favors explanations based on information processing or neurocognitive paradigms. The relative rapidity of the clinical effects of CT has invited comparisons of their efficacy with those of pharmacological treatments, while their longer term impact is not always clear. They enjoy a high level of acceptability that reflects their collaborative and trans-parent style. However, the emphasis on monitoring, rating, and homework exercises can be seen as excessively demanding by some patients, and the relative lack of attention to the historical origins of difficulties is not to all patients’ taste. Practical methods are relatively easily learned and taught, although growing evidence concerning the added value of intensive training and supervision for clinical outcomes suggests this ease is deceptive. Important developments in the theoretical base and practice of cognitive therapies continue to be made. Some of these, in indicating the importance of formative experience, of the relation-ship with the therapist and patterns of relating, and of increasingly inaccessible (‘unconscious’) cognitive structures underlying behavior, are narrowing the gap between cognitive and psychodynamic models of psychotherapy in practice.

2. Interpersonal Therapy

2.1 Overview

Interpersonal therapy (IPT) is an increasingly common model of brief psychotherapy that was developed as a specific treatment for depression in the 1970s. Findings from research into the interpersonal precipitants of depression were used in designing an intervention that could bring symptomatic relief through improvements in interpersonal functioning (Klerman et al. 1984). Different therapeutic strategies are used, depending upon which of four basic kinds of inter-personal problem is paramount in an individual case. IPT is now being adapted to other disorders and settings (Klerman and Weissman 1993).

2.2 Rationale

IPTs basic rationale is that depressed mood is usually secondary to deterioration in interpersonal relation-ships, and can be reversed by deliberate attention to the quality of current relationships. Historically, it was developed in deliberate contrast to psychodynamic therapies, in which the importance of interpersonal relationships within the therapy itself as well as in a patient’s life are paramount. A key difference has been that psychodynamic psychotherapies not only pay considerable attention to the formative influence of past relationships, but they focus on (maladaptive) patterns of relating that are seen as characteristic of a person. Interpersonal therapy pays attention to cur-rent relationships for their own sake. It does not conceptualise underlying patterns, although it would expect someone’s style of relating to improve through reinforcement of positive changes achieved in the relationships targeted in therapy. Although the ‘inter-personal psychiatry’ of Sullivan (1953) is frequently quoted as an antecedent of IPT, its focus on in-session interactions and on enduring patterns of relating is inconsistent with this new therapy, despite their mutual emphasis on the importance of good inter-personal relationships for personal mental health.

IPT has used theoretical developments in a number of fields, from attachment theory to life events re-search, to highlight the association of onset of depression with loss through grief or major life changes, conflict, and isolation. Its model identifies whether a person’s most pressing need is resolution of grief, role transitions, interpersonal disputes, or interpersonal deficits.

The model was designed to be researchable from the outset, its method being summarized in a manual (Klerman et al. 1984) to promote consistent application in practice. Studies have not only addressed its efficacy for specific conditions (see below) but the impact of process on outcome. An important literature has therefore also developed concerning the impact of training on the practice of psychotherapy (Rounsaville et al. 1988).

2.3 Method

As a time-limited therapy, IPT was pioneered over 12 sessions per treatment, now often 16. A typical treatment is subdivided into initial, treatment, and termination phases. During the initial phase, the patient is educated to see their difficulties as the consequence of having a depressive illness, and to allow themselves to occupy a sick role. (This means they should not feel responsible for this state of affairs, and allow others to take on some of their normal duties so they can concentrate on recovery.) A detailed inventory is drawn up with the therapist summarizing all current relationships, however insignificant. This not only provides a map of potential areas of difficulty, but of sources of potential support and opportunities for the development of relationships in future. Detailed questioning in the first phase allows a treatment focus to be identified which reflect four distinct forms of interpersonal need: grief (where the loss of a significant other through death has not been overcome); role disputes (where conflict in a key relationship, perhaps in the form of an impasse rather than overt fighting, cannot be resolved); role transitions (where adaptation to a different situation, commonly following loss events, is required). In some residual cases, where a patient’s interpersonal situation is particularly impoverished through an inability to establish relationships, a fourth category of inter-personal deficits applies.

Different therapeutic techniques are likely to be required in each of these instances, the model being sufficiently flexible to accommodate these. Examples would be assisted mourning with grief, and attention to communication in interpersonal disputes. In all cases, there is careful attention to affect and considerable emphasis on its successful expression throughout treatment.

Therapy concludes with explicit attention to termination, both in anticipating and working through loss of the therapy and in planning for continuing progress along the lines tried out during the therapy.

2.4 Applications

IPTs use in the treatment of major depression was highlighted by a large randomized controlled trial sponsored by the US National Institute of Mental Health (Elkin et al. 1989). This remains one of the largest comparative trials of psychological and pharmacological treatments ever conducted, providing information on the relative benefits from two psycho-therapies (CT and IPT), imipramine and a drug placebo. The results were encouraging for IPT, showing it to be as effective as CT in relieving symptoms overall, while having the lowest attrition, and significantly better results than CT among the most severely depressed patients.

Since its original application in studies of clinical depression, IPT’s use has been broadened to incorporate depressed populations with special needs; patients with distinct mental disorders and adaptations of the therapeutic process to fit different working contexts (cf. Klerman and Weissman 1990). Depression in adolescents and the elderly, as well as the chronic low grade depression known as dysthymic disorder, have all been shown to benefit from treatment (Markowitz 1998). Modifications of therapeutic technique can be involved, for instance greater involvement of significant others in the treatment process with adolescents, and use of less frequent maintenance sessions after the phase of regular sessions in dysthymia. Adjustment of content is likely to be involved with use of IPT with other disorders. A great deal of exploratory work in the field of substance misuse has so far failed to show significant benefits. An area of greater promise has been in the treatment of bulimia nervosa, where lasting clinical improvements comparable to those from CT have been achieved (Agras et al. 2000).

The principal adaptations to the model to suit different contexts have been its shortening to six brief sessions for use with subclinical populations in primary care settings (cf. Klerman and Weissman 1990). Attempts to develop a group model of IPT for treatment of social phobia are promising but at an early stage.

3. Conclusion

Although cognitive and interpersonal therapeutic packages are relatively new, each has elaborated principles of good psychiatric management—respectively, the importance of a patient’s attitude or social relationships to their health and recovery—that are widely recognized. Their rapid growth reflects their proven efficacy for specific disorders, the relative ease with which they can be learned and disseminated, and the promise of brief psychological treatment for clinical conditions that account for a large proportion of psychiatric practice. Both are widely used alongside physical treatments such as psychotropic medication. Developments are likely to include continuing influence of basic research in psychology and the neurosciences on the refinement of therapeutic models and methods, and increasing rapprochement with other therapeutic models as integrative models of treatment are developed for more complex and treatment-resistant conditions.

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