Cognitive Approaches

1Not the event, but the view of it

Nearly two thousand years ago the Stoic philosopher Epictetus taught that "Men are disturbed not by things, but by the views which they take of things" (Enchiridion, in Elizabeth Carter's 1758 translation). Two students fail the same chemistry mock exam. Gatete thinks, "I'm stupid. I'll never pass," feels hopeless and stops revising. Ingabire thinks, "I didn't prepare organic chemistry properly. I can fix that before the real exam," feels disappointed and makes a plan. Same event, different thoughts, very different feelings and actions. Cognitive approaches to counselling are built on this observation. (Gatete and Ingabire are illustrative.)

21. Ellis's Rational Emotive Behaviour Therapy (REBT)

Albert Ellis developed REBT from 1955. Its core is the ABC model, extended to D and E for therapy:

Ellis argued that most distress comes from turning preferences into absolute demands, three "musts" in particular: I must do well; other people must treat me well; life must be easy. He disputed them in three ways: empirical (where is the evidence?), logical (does it follow?) and pragmatic (does it help?). REBT is direct and challenging, sometimes confrontational.

32. Beck's cognitive therapy

Aaron Beck developed cognitive therapy for depression in the 1960s. He described three levels of thinking: automatic thoughts, intermediate beliefs (rules and assumptions, such as "If I'm not top of the class, I'm a failure") and core beliefs. In depression these form the negative cognitive triad (Unit 7) and are kept going by common distortions:

Unlike Ellis, Beck worked through collaborative empiricism: client and counsellor act like a research team, treating thoughts as hypotheses to test. Techniques include Socratic questioning (guided questions that help the client examine a thought), thought records (writing down situation, thought, feeling, evidence for and against, and a balanced alternative), and behavioural experiments (testing a prediction in real life, for example "If I ask a question, the class will laugh").

Figure 1. The cognitive behavioural triangle. A helpful alternative thought ("I didn't prepare organic chemistry; I can fix that") would bring disappointment instead of hopelessness, and lead to revising rather than giving up.

43. CBT and the "third wave"

Most counsellors now combine Beck's and Ellis's ideas with behavioural techniques as CBT, the most researched form of psychological therapy, with evidence for depression, anxiety disorders, PTSD, OCD, insomnia and more. Newer "third-wave" approaches change the relationship to thoughts rather than their content. Mindfulness-based cognitive therapy (MBCT) teaches people with recurrent depression to notice thoughts without being carried away by them; a pooled analysis of nine trials (Kuyken and others, 2016) found it reduced the risk of relapse. Acceptance and commitment therapy (ACT, Steven Hayes) teaches acceptance of difficult thoughts and feelings while acting on one's values.

54. Cognitive approaches in African communities

In Harare, Zimbabwe, psychiatrist Dixon Chibanda founded the Friendship Bench: trained lay health workers, many of them older women called "grandmothers", deliver structured problem-solving therapy on wooden benches outside clinics. In a cluster-randomised trial with 573 participants (Chibanda and others, 2016), people who received it had fewer symptoms of depression and anxiety after six months than those given enhanced usual care. The WHO's Problem Management Plus, a brief programme delivered by trained non-specialists, reduced distress in a trial in Kenya (Bryant and others, 2017). Such adaptations show how cognitive and problem-solving methods can reach people where specialists are few.

65. Evaluation

• Strengths: the strongest evidence base of any approach; structured, time-limited and skills-based, so clients can keep using the skills; can be adapted for lay workers, groups, books and apps.
• Limits of the evidence: for depression, CBT works about as well as other well-delivered therapies, and some analyses suggest its effects have become smaller in newer trials (Johnsen and Friborg, 2015).
• Circumstances matter: some negative thoughts are realistic responses to poverty, violence or discrimination; treating them only as "distortions" risks blaming the client. Good practice also tackles practical problems.
• Culture and literacy: written homework and an emphasis on individual thoughts may not fit every client; successful adaptations use pictures, stories, family involvement and local idioms.