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Tom Minor

Fiona Kyle How has the cognitive model helped us understand mental disorders?

According to The Diagnostic Statistical Manual (DSM IV), the most authoritative reference on matters of definition and classification of mental illness, mental disorder is:

“A psychological syndrome associated with distress, impairment in an important area or areas of functioning, or significantly increased risk of death, disability, or loss of freedom…assumed to be the manifestation of a psychological or biological dysfunction.” (Colman, 2001)

Understanding mental disorders, however, is a far more complicated issue, one that cannot be solved with a simple definition. There is a whole branch of psychology that deals with the understanding of mental disorder, ‘Abnormal Psychology’; concerned with the diagnosis, classification, aetiology, treatment and prevention of mental disorder and disability. Within abnormal psychology there are many schools of thought devoted to gaining knowledge about mental illness, each with their own theories and studies, this discussion will focus on the ‘Cognitive Approach’. Clearly treatment methods, how good they are at ‘curing’ patients and the predictive ability of an approach are the best way to tell if an certain model is effective in understanding a disorder and its origins. As such this discussion will look at the cognitive theory and therapy of a disorder that has received huge interest from all psychological perspectives over the last 20 years; Depression. A brief mention will be made of a

rival approach, ‘Behaviourism’, looking at Obsessive-Compulsive Disorder, and then as a point of compromise, ‘Cognitive-Behavioural Therapy’ will be illustrated.

Cognitive approaches assume that humans are thinking beings and that our actions are determined by cognitive interpretations (Marshall & Mazie, 1987). Problems like depression result from the client’s illogical thinking about themselves, the world they live in and their future. Depression as a mood disorder involves severe alterations in mood and for much more prolongued periods of time than the transitory depression that most people suffer at some point in their life. The mood disturbances are intense and persistent, to the point of being maladaptive, leading to serious problems in relationships and work performance. The point of cognitive therapy is to change the maladaptive schema that, lead to the distorted thinking characteristic in many disorders, including depression (Carson, Butcher & Mineka, 2000).

Aaron Beck’s (1967) ‘Cognitive Theory of Depression’ has had a massive impact on treatment methods for people suffering the disorder. He came up with the ‘Negative Cognitive Triad’, a model of how depressed people think negatively about themselves, their experiences in the world surrounding them and their future. These negative thoughts are maintained by a number of biases and distortions such as, dichotomous or all or none reasoning, where people think in extremes; another is over-generalisation, which is a tendency to draw sweeping conclusions from a single (and often unimportant) event. In support of this theory, Haaga et al. (1991) found that depressed people were more likely to draw negative conclusions that went beyond the information presented in a scenario, than non-depressed people. They also underestimated positive feedback. Depressed people also show biased recall of

negative information and not just for autobiographical material but emotive words as well (Mathews & MacLeod, 1994; Mineka & Nugent, 1995). Underlying all of these mechanisms are ‘depressogenic schemas’ or ‘dysfunctional beliefs’ that are rigid, extreme, counterproductive and which predispose the person to depression (Beck, 1967; Sacco & Beck, 1995). This explanation of Beck’s approach to depression illustrates how complicated the cognitive model can be, it is sometimes easier to use a diagram to describe the theory and in this case it works well as an overview. Beck’s Cognitive Model of Depression:


BELIEFS ACTIVATED NEGATIVE AUTOMATIC THOUGHTS SYMPTOMS OF DEPRESSION BEHAVIOURAL SOMATIC MOTIVATIONAL COGNITIVE AFFECTIVE In this diagram (adapted from Fennell, 1989), some kinds of early experience lead to dysfunctional beliefs (leaving the person vulnerable to depression). The critical incidents or stressors serve to activate these beliefs, which trigger the automatic negative thoughts, thus producing the depressive symptoms, which can be physical,

cognitive, emotive, motivational or behavioural. These symptoms further fuel more depressive (automatic) thoughts and continue what Teasdale (1988) calls the ‘vicious cycle of depression’.

In addition to his model, Beck (1983) identified two types of people with certain personality characteristics that make them particularly prone to suffering from depression: highly ‘sociotropic’ people who are excessively concerned with interpersonal dependency and are overly sensitive to interpersonal rejection or loss; highly ‘autonomous’ people, who are immoderately worried about achievement issues, highly self-critical and very sensitive to failure. The evidence for these vulnerable personality types seems to be strongest with regard to predicting a relapse into depression rather than first onset (Coyne & Whiffen, 1995). Being able to predict who is likely to suffer from a disorder is a strong piece of understanding and in this way the cognitive model is great tool; trying to get to the underlying thought processes that precede illness helps to confirm why people become mentally disturbed in the first place and therefore aids the direction for treatment.

The behavioural viewpoint looks less at the underlying cognitions that lead to behaviour and more at the role of learning in human maladaptive behaviours. A failure to learn necessary adaptive competencies and learning ineffective or maladaptive responses is thought to be the cause of disorder. Therapy is centred on changing specific behaviours and emotional responses by eliminating undesirable reactions and learning new desirable ones using conditioning. Behavioural treatments specifically use: guided exposure, systematic desensitisation, aversion techniques, modelling, token economies, reinforcement and many more to extinguish or counter-

condition the maladaptive reactions synonymous with mental disorder. In fathoming the behavioural model there is a clearer picture to be seen when a particular disorder is considered. Obsessive Compulsive Disorder (OCD) is a prime example that serves as a good comparison considering the high rate of co-morbidity it has with depression (Carson et al., 2000).

OCD is the occurrence of unwanted and intrusive, obsessive thoughts or distressing images, accompanied by compulsive behaviours. These behaviours are used to neutralise the obsessive thoughts/images or to prevent a perceived dreaded situation happening. The compulsive behaviours are often not realistically connected with the thoughts they are designed to cancel out (American Psychiatric Association, 1994). For OCD to be considered a mental disorder it must cause marked distress and consume excessive time, interfering with social or occupational functioning. Mowrer’s, (1947) two-process theory of avoidance learning explains mental disorder, including OCD, as a neutral stimuli being associated with an aversive stimuli, which therefore elicits anxiety. This happened through classical conditioning and as such the maladaptive behaviour reinforces the cause (anxiety). Once these responses are learnt they are very difficult to extinguish (Mineka & Zinbaug, 1996; Salkovskis & Kirk, 1997). The behavioural treatment of this disorder includes exposure to the feared stimulus (the intrusive thoughts) and prevention of the response ritual, allowing participants to see that their anxiety will naturally subside (Rachman & Shafian, 1998). This therapy appreciates the factors that maintain the obsessive-compulsive behaviours but doesn’t have the predictive ability of the cognitive approach, nor the understanding of what underlies the disorder other than the fact that it is learning gone awry. Behavioural therapy of this type is very effective, however, with 50-70%

reduction in symptoms (Steketee, 1993). Cognitive factors have been implicated in OCD and checking compulsions have been linked to poor memory, contributing to repetitive nature of the rituals (Sher, Frost & Otis, 1983). There is also increasing evidence that there are deficits in the non-verbal memory of OCD sufferers (Trivedi, 1996), plus low confidence in their memory ability (Gibbs, 1996; Trivedi, 1996).

A cognitive approach to treating depression was investigated by Marshall and Mazie (1987). The focus was on group therapy and a follow up was conducted to see if any gains were maintained after therapy ceased. Initially, clients were made aware of the connection between their patterns of thinking and their emotional responses. Identifying these automatic negative thoughts or ‘logical errors’ was facilitated with the use of daily records, and therapy included time with the therapist to work on substituting these negative thoughts with positive alternatives to challenge their validity. The goal of these “Feeling Better” sessions, as they were so called, was for clients to gain an understanding of their depressive cycle. Their progress was monitored with the ‘Beck Depressive Inventory’ (BDI), a self-report measure of depression and through this process clients become less depressed. The fact that the people suffering from depression were considered ‘clients’, rather than ‘cases’, ‘participants’ or ‘patients’, indicates the collaborative nature of this therapy. Results were significant, and scores on the BDI were lower at the end of treatment than at the start, thus proving that the cognitive approach was effective in decreasing depression. However, the improvements that were maintained for most clients could be due to other factors. Factors, such as, the social support that individuals received between the start and end of therapy or the clients’ focus of attention being changed and directed at less depressing things. There is still a strong case to support that the extensive and

well thought out research into this mental disorder through the cognitive approach has helped the understanding of how to treat it. In fact the cognitive perspective and the insights it has given to the role of cognition within mental disorders has led to an extremely effective and widely used form of treatment that combines the practical behavioural principles with the cognitive model, a compromise between the two; ‘Cognitive-Behavioural Therapy’ (CBT).

CBT focuses on how thoughts and information processing can be distorted and lead to maladaptive behaviour and emotions. Attention is paid to the mechanisms that maintain disorders and because of this, CBT is very successful, can be used to treat many disorders and a number of more specific treatment methods have arisen from it. ‘Rational Emotive Behaviour Therapy’ (Ellis, 1989) is one such treatment but is mentioned only as a testament to the advances in understanding mental disorders that the cognitive model has instigated. Without Beck’s first offerings into the internal devices that underline the experience of depression, people suffering a mental disorder might still be prescribed a cocktail of different drugs each with their own adverse side effects and any chance of quality of life would be severely diminished. It is hoped that this discussion has highlighted the way in which the cognitive approach has not only helped but lead the way to a better and more co-operative understanding of mental disorders.

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How has the cognitive model helped us to understand mental disorder