Cognitive Therapy

The variety of techniques for eliciting thoughts and feelings during the session is very large and we can do little more than highlight one or two aspects in this summary. Direct questioning is one approach, and we have illustrated this in talking of the way in which a therapist attempts to engage the patient at the beginning of therapy. The above descriptions also illustrate another approach: using times when the patient appears upset to ask what went through their mind just then. This was a technique that Salkovskis used at the beginning of the therapy session he describes. But a technique which emerges very clearly in some of the case descriptions in this book is the introduction of behavioural experiments within the session to simulate real-life circumstances. For example, Greenberg uses the hyperventilation technique to examine the patient's thoughts and feelings about their own bodily symptoms. After hyperventilation for two minutes the patient reported discomfort: sweating, drowsiness, stinging, apprehension. He also reported the fear that he was going to faint. This in turn reminds him of the feeling that he gets outside the therapeutic situation in which he finds himself asking the question, 'Can I get help?' or 'I'm all alone here, could I get to...?' and 'If I died what would happen?' and 'Well, who would care?'

In Channon and Wardle's description of their patient with an eating disorder (Chapter 6), they demonstrate the use of a behavioural experiment (eating a small piece of chocolate) to elicit automatic dysfunctional thoughts. The patient was asked to list her thoughts at four stages: (1) before the food is presented; (2) in the presence of food, before eating; (3) during eating, and (4) after eating. The statements that the patient made were at first fairly specifically related to the chocolate itself: 'Chocolate is unhealthy'; or fairly closely related to the patient's own lack of impulse control: 'If I have one bit I'll go on and on eating'. But these thoughts were able to form the basis of further exploration so that the therapist could ask what the patient meant when she said that chocolate was unhealthy. Once again, the patient's attitude seems unremarkable: 'Everyone knows that chocolate is fattening'. It is not clear that there is very much that is dysfunctional here until the therapist gently pushes a little harder and finds that the patient believes that simply having eaten the small piece of chocolate will make her fat because it just sits in her stomach. The therapist asks about the consequences of this and the person replies, 'It'll just stay there and I'll have a great big stomach and get fat.' Note the therapist's reply to this (once again in the form of a question, and once again using the vocabulary of cognitive therapy so that the point is introduced gently): 'Is that a very frightening idea for you?' Patient: 'Yes--I'd hate myself and look ugly.'

In Moorey's description of the treatment of drug abuse (Chapter 7) we find another example of using exposure to a specific situation to assess the dysfunctional aspects. Tables 7.3 and 7.4 in his chapter reproduce the stimuli that were used in an exposure situation within the session. A picture of a doctor's surgery, a tourniquet and a spoon, an empty syringe, a syringe and needle, syringe and needle containing physeptone, drawing up drug from an ampoule, finally sitting with syringe and needle against the arm. Note how this situation differed from the sort of exposure that might be used in behavioural therapy without a cognitive component. In Moorey's case, the exposure was presented as an experiment in which the subject tested out her prediction that in the presence of the stimulus her craving would not reduce. In fact the craving did reduce over time and the therapist was able to point out the extent to which the patient was using active strategies in coping with her craving. As the craving reduced so the automatic thoughts that were recorded changed in nature from 'I'd enjoy a fix' and 'The heroin looks familiar and comforting' at the point at which craving was at the highest, to 'I can't wait to throw this heroin away' at a point when the craving had reduced.

Cole (Chapter 8) gives several examples of the use of imaginal cognitive rehearsal of specific offence situations to elicit the thoughts and feelings of people undergoing cognitive therapy for offending behaviour. A client awaiting trial for indecent assault on male teenagers was helped to recall one of the incidents. The therapist asks what he noticed about a particular imagined young male. When the client replied, 'He's smiling at me', the therapist asked how he was feeling right now. The client replies, 'Sort of friendly and affectionate.' The therapist is then able to ask what it meant that he was smiling at him? The client replies, 'Children are attracted to me. They come straight towards me. I'm popular.' Cole uses this material to derive as comprehensive a hypothesis as possible about the setting conditions in which the offending behaviour occurs and what is maintaining it. Making these issues explicit to the client can then lead to mutual decisions as to what behavioural experiments can be done to test out (within or between sessions) the factors which are involved in their behaviour.

Dealing with dysfunctional attitudes

Making explicit dysfunctional attitudes is a theme common to all the cognitive therapy strategies which have been illustrated in this book. These are sometimes directly related to the 'symptoms'. For example, the exhibitionist mentioned by Cole who said, 'I am over-sexed. I have stronger feelings than other boys so I have to do something about it.' But Cole also points out how closely related this is to a feeling of dependency. This means that the client not only believes that he cannot overcome his propensity to continue with offence behaviour but also believes he cannot cope in life without the help of others. His feeling of need of help may exceed the resources he needs to enable him to stop. This can jeopardise the formation of reasonable goals and maintenance of change as a result of therapy.

A similar self-schema