Exhibit 4.1 Principles of Cognitive Therapy

Focus on current adaptation and present problems

Time-limited treatment

Structured therapy

Key role of activity and homework

Focus on the therapeutic relationship

Collaborative empiricism

Psychoeducation

Technical eclecticism

Treatment as prevention

Focus on Current Adaptation and Present Problems

Cognitive therapy represents a pragmatic philosophy toward psychotherapy. Patients seek the services of a psychotherapist when they have problems to solve. More to the point, they come for such services when their own efforts to solve these problems have failed. In the first instance, then, cognitive therapy is a system for solving problems (D. J. G. Dobson & Dobson, 2009).

Problem solving can be described as a process that involves a series of interactive steps. The steps include identifying and naming the problem, generating alternative ways to solve the problem, choosing the most likely successful strategy, implementing the chosen strategy, assessing the outcome(s) of the strategy, and then either stopping the process (if the strategy is successful) or else cycling back to the beginning to reconsider the problem and choose a new strategy (D’Zurilla & Nezu, 2007). Problem solving also rests on a generally positive attitude toward problems. Specifically, one needs to believe that the problem can be solved and that the effort is worthwhile. This “problem-solving orientation” (Nezu, Nezu, & Lombardo, 2004) sometimes needs to be cultivated; although patients may wish or hope that their problems will remit, they are sometimes not committed fully to the course of action that might be recommended or required for the desired outcome.

Even if a patient comes to treatment with a strong and positive orientation toward solving a problem, it is almost certainly the case that he or she has failed in his or her own efforts to do so. This failure can be demoralizing, and some time to address this sense of failure and helplessness in treatment may be required before new efforts can be attempted. In some cases, a type of motivational interviewing is needed to encourage patients to see the potential advantages of making an effort. However, failure can also indicate a skills deficit or a lack of ability on the part of the patient to approach the problem effectively. In such cases, therapy may need to include education or training in potential strategies that can then be utilized. In other cases, patients may have a desire to change and even a sense of how to accomplish change, but they may face external pressures or challenges that preclude the use of the intended plan. The external forces may include pragmatic problems such as a lack of funds or physical impairment or social impediments such as unsupportive families or partners. In such cases, these impediments may need to be addressed before the main change process can be approached.

In ideal circumstances, the patient comes to therapy with a specific list of problems, and the therapist can quickly identify strategies that the patient has not previously tried, one of which turns out to be effective. Unfortunately, this simplistic process rarely occurs. In some cases, the patient presents with a number of severe, chronic, or severe and chronic problems. Indeed, in many cases patients wait until the problem is too severe to tolerate or until several attempts to address the problem have failed before they seek help. Sometimes the delay in seeking help exacerbates the problem.

One of the first tasks a cognitive therapist will undertake is to list the presenting problems. The list is developed into a specific set of potential treatment targets. With the patient, the therapist prioritizes the problems from the most to the least significant. The therapist may take some time to understand the patient’s perception of the problem list, as this is one of the first opportunities to understand the patient’s worldview and sense of agency. The development of the problem list also provides the first opportunity for the therapist to communicate to the patient a desire to hear about concerns and problems and to demonstrate a willingness to work with the patient on these issues.

Sometimes the patient presents a set of problems that do not fit into a cognitive therapy formulation. For example, one patient may want to focus on understanding her problematical childhood. Another may seem fixated on blaming others for his unsatisfactory job performance or life situation. In such cases, the cognitive therapist will attempt to reorient the patient to problems that can be addressed with cognitive therapy methods. So, for example, the patient with the problematic childhood will be asked about the effect of her childhood on her current relationships and view of herself. The angry and blaming patient will be asked what role he has in his own problems, since he can control only his own behavior. Such questions help to show the patient that the problem is heard but focus the patient on current problems.

The therapist and the patient may have a difference of opinion about problem priorities. For example, a patient may want to talk about her childhood, whereas the therapist believes that her current unemployment is more urgent. In such cases, the cognitive therapist will typically express this difference of viewpoint and then take the patient’s direction. This response is made in the belief that if the more important problem is not addressed, it will still be present when the therapist and patient finally get to it. Furthermore, cognitive therapists believe that responsiveness to the patient’s perceived needs will build therapeutic rapport. Exceptions to this general rule can be made if the patient or someone in his or her life might be placed at risk in the event that an issue is not attended to or there is a legal or ethical imperative requiring priority attention. In such cases, the patient should be provided with the rationale for the therapist’s decisions and actions so that even if the patient does not concur with the decision, he or she at least understands the therapist’s actions.

Finally, in some instances it might not be possible to agree on treatment goals. For example, agreement may be impossible if the therapist determines that there are safety issues but the patient is unwilling to address them. In such instances, it is appropriate for the therapist and patient to agree to disagree. The most ethical course of action may well be to refer the patient to another therapist.

A problem-focused therapy implies a concomitant responsibility to assess the patient’s problems over time. Therefore, cognitive therapists often make use of standardized tests of psychological maladjustment to monitor reduction in symptoms. Cognitive therapists also rely on self-reported behaviors, activity charts, self-monitoring forms, global ratings of change, and other reported change indices to ensure that the problems being treated are in fact responding to the interventions. In some cases, goal-attainment scaling (Kiresuk, Stelmachers, & Schultz, 1982) can also be profitably used to determine progress in achieving goals.