Socializing the Patient to Treatment

Another critical part of the early phases of cognitive therapy is to begin to teach the patient to think like a cognitive therapist. This is done in both explicit and subtle ways. For example, the therapist will use the cognitive model to explain the patient’s problems back to him or her and thereby provide a cognitive case formulation. The formulation is not presented as a fact—the therapist and patient develop this model together over time—but as an explicit reference to the model and its predictions. Another explicit part of the socialization process is the introduction and use of different concepts and terms. For example, in common language, people often confuse terms related to cognition and emotion. However, the cognitive model posits that emotions generally follow from cognitive appraisals, and so clearly differentiating the words we use to describe how we think and feel and stating them in a manner that is consistent with the model helps the patient to learn how to use cognitive therapy techniques. In many cases, the therapist will spend time explaining different aspects of the cognitive model and even teaching terminology that will allow the patient to express himself or herself in a way that fits the model.

A number of terms are used in cognitive therapy that are not part of everyday language, such as schema, cognitive distortion, attribution, cognitive error, or the many terms used to describe the various types of distortions (e.g., maximization, minimization, fortune telling, catastrophization). The cognitive therapist should therefore use these terms judiciously and introduce them only when they are useful, and then define them and ensure that the patient understands them.

Socialization into the cognitive model takes place in subtle ways. When the patient presents different problems, the cognitive therapist will use language and explain the problem in cognitive terms. The therapist might say things like, “So what were you thinking just before you became angry?” This question implicitly reinforces the model that cognitions precede and predict emotional responses. As another example, after an effective cognitive restructuring exercise, the therapist might say something like, “So when you looked at this situation more objectively, it was not as scary as it had first seemed?” Such a question reinforces the idea that effective evidence gathering can undermine negative distortions, although not in an explicit manner. Indeed, many of the questions that therapists use in cognitive therapy have both an explicit element as well as a more subtle educative aspect. This type of “Socratic questioning” is similar to a series of leading questions in that the therapist wants the patient to come to some understanding through these questions, but they are open enough in their format that the therapist also learns about the patient through the responses. Socratic questioning is an interactional style that is used throughout cognitive therapy, and there is a general bias in cognitive therapy toward helping the patient arrive at his or her own solutions to the problems that are presented in therapy to facilitate the growth of self-efficacy and agency in the patient. However, questioning is not used in a dogmatic way. If the patient is truly stuck on an issue, the therapist may well provide information or guidance or may suggest how the patient can obtain help from other experts.