Cognitive Therapy

1
Cognitive Therapy

• PSYC E-2488
• 12/3 and 10/07

2
Exercise 25 minutes

• Break up into groups of 3-4 members/group
• Pick an experience that evokes a strong emotional
  reaction among all members
• Talk among yourselves to build a sufficiently
  dysphoric image that you can share as a group and
  each individually focus on comfortably
• Pick one of the following psychological processes
  (each group must take a different process)
• - Mindfulness
• - Progressive Relaxation
• - Examining and changing negative cognitions
• - EMDR
• Practice the technique for 10 minutes
• Refocus on the dysphoric image
• Write down your thoughts and feelings
• Discuss them as a group

3
Historical Background

• Introduction
• 1. Cognitive Revolution
• - 1956 MIT Symposium on Information processing
• Seminal works published in the 50s by Jerome
  Bruner (? Narrative/stories), Chomsky (Language
  structures and thought), George Kelly (Personal
  construct therapy), Benjamin Whorf (Language,
  thought, and reality), and Herbert Simon and
  Newell
• Psychodynamic therapists (see Karen Horney
  neurotic needs) connect with dynamic core
  implicit beliefs and interpersonal schemata and,
  Behaviorists directive, active, brief, empirical.
  And goal focused.
• Ellis and Beck (both analysts)
• Trans-cultural adoption (Sweden and China) with
  differences in values about implicit beliefs.
• Clinical warmth, empathy and positive regard are
  widely accepted as trans-theoretical traits that
  are important in therapy
• Historical Background
• 1. Epictetus
• 2. Michael Mahoney (late) a. Active and
  proactive nature of knowing, learning and
  perception b. Abstract (tacit) gt Concrete
  (explicit) processes in all sentient and sapient
  experience and, c. Learning, knowing, and memory
  are ongoing attempts to organize/re-organize
  experience in their adaptive environmental
  context.

4
Historical Background cond.

• 3. (my opinion) Chapters authors attempts to
  differentiate psychodynamic and
  cognitive-constructivist models on the basis of
  being goal directed, adaptive, purposive, and
  active, personally meaningful and self-organizing
  reflects partial knowledge of full spectrum of
  psychodynamic history and theory.
• 4. Contemporary CBT reflects influence of Frankl,
  Adler, Arieti, Freud, and Tolman.
• - Eschews Drive reduction metaphor and idea of
  defensive functioning and shares the idea of the
  role that psychology has ascribed to cognitive
  processes in etiology of psychopathology
• - Early contributors are Lazarus, Goldfried,
  Ellis, Beck, Mischel, Mahoney, Meichenbaum, and
  George Kelly
• (accelerated in the 1970s)
• - A (antecedents) B (eliefs/behaviors) C
  (onsequences)
• - BASIC ID (Lazarus)

5
Assumptions of Cognitive Therapy

• 1. It is a school of thought
• 2. Basic assumptions
• - How individuals understand events and
  circumstances determines how they feel and
  behave
• - Interpretation of events is active and
  ongoing
• - Individuals develop idiosyncratic belief
  systems that guide their behavior and determine
  what is stressful
• - Stressors contribute to maladaptive cognitive
  functioning and activate dysfunctional
  strategies
• - Cognitive specificity hypothesis suggests
  that clinical syndromes and states reflect
  specific content in belief systems and cognitive
  processes
• 3. Foundation of CT is the belief or meaning
  system Both CS and automatic (stream of
  consciousness)
• 4. Cognitive processes, emotions, and behavior
  are intertwined in biological and social
  functioning modes and affective schema are
  current ways of thinking about older concepts.

6
The Basic Cognitive Therapy Model

• 1. The Cognitive Triad Virtually all patients
  have a view of themselves, the world, and their
  future which is reflected in the distortions of
  beliefs reflecting normal concerns (e.g.,
  depressed individuals are negative anxious
  individuals see the world as threatening)
• 2. Schemata Originated with Kant and Piaget.
• - Organized, tacit cognitive structures stored
  in memory generalizations from specific
  experiences and prototypes for focusing and
  deriving/giving meaning to incoming experience
• - They influence attention, encoding, retrieval,
  and inference
• - They serve as prototypes for experiences and,
  abstract events for assimilation and
  accommodation to novel experience
• - We have self-schemata developed in childhood
  that had/have an adaptive function
• Cognitive Distortions (see K. Horneys neurotic
  needs) Dichotomous thinking, mind reading,
  emotional reasoning, personalization,
  overgeneralization, catastrophizing, Should
  statements, and selective abstraction

7
Evidence for Cognitive Models of Depression

• 1. Early studies showed benefit gt waiting list,
  no therapy, BT, pharmacotherapy (?s raised), but
  used self report of mood and less severely
  depressed patients
• 2. NIMH (1989-CDCRP) Elkin et al. Medsgt CT, CT
  not appreciatively better than placebo for
  severely depressed not lasting benefits like
  other therapies.
• 3. Complex on closer look Uneven quality of CT
  administration at several sites and, more
  experienced therapists got better results with
  more severely depressed, that equaled the
  progress of those on meds.
• 4. Effect may be a function of therapists
  experience.
• 5. Relapse rates lower, esp. with booster sessions

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Cognitive Therapy for Other Disorders

• 1. Useful in understanding and treating PTSD,
  e.g., with respect to ways in which traumatic
  experiences can disrupt cognitive processes or
  schemata and may activate pathological fear
  structures
• 2. Treatments based on model use a variety of
  approaches to change mental impact of trauma
  discussion of event impact, in vivo exposure,
  cognitive restructuring (a variety of
  techniques), relaxation training and anxiety mgt.
  
• 3. CBT helps and is superior to waiting list and
  supportive therapy. List of techniques is useful,
  relative to list and supportive therapy groups.

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The Practice of Therapy

• 1. The Therapeutic Relationship in CT
• 2. Assessment and Treatment Planning
• Assessment Techniques
• Assessment of Vulnerability Factors
• 3. Specific Interventions
• Cognitive Techniques
• Idiosyncratic Meaning
• Questioning the evidence
• Rational Responding
• Examining options and alternatives

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The Practice of Therapy cond.

• 3. cond.
• - Decatastrophizing
• - Fantasized Consequences
• - Advantages and Disadvantages
• - Turning Adversity to Advantage
• - Guided Association/Discovery
• - Use of Exaggeration or Paradox
• - Scaling
• - Externalization of Voices
• - Self-instruction
• - Thought Stopping
• - Distraction
• - Direct Disputation
• - Labeling of Distortions

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The Practice of Therapy cond.

• 3. cond
• - Developing Replacement Imagery
• - Bibliotherapy
• - Behavioral Techniques
• - Activity Scheduling
• - Mastery, Pleasure, and Social Ratings
• - Social Skills or Assertiveness Training
• - Guided Task Assignments
• - Behavioral Rehearsal/Role Playing
• - In Vivo Exposure
• - Relaxation Training
• - Homework

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The Practice of Therapy cond.

• 4. Common Errors in Conducting CT
• - Inadequate socialization of patient to
  model
• - Failure to develop sufficient problem list
  and share it with the
  patient
• - Not assigning appropriate homework and
  following up
• - Premature emphasis on identifying
  schemata
• - Therapist impatience and overly
  directive
• - Premature introduction of rational
  techniques before adequate formulation is
  completed
• - Lack of attention to developing
  rapport and a working relationship with
  non-specific factors
• - Not attending to the
  counter-transference.

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The Practice of Therapy cond.

• 5. Termination
• - When patient report, assessments, feedback
  from others, shows durable higher level
  adaptive functioning, termination can be
  considered
• - Final phase includes consolidation of gains
  and relapse prevention
• - 12-15 sessions often effective for completion
  of treatment
• - 2-3 years of treatment can be productive if
  underlying schema are examined
• - Termination is accomplished gradually by
  increasing time between sessions, making
  provisions for emergency sessions and examining
  feelings about ending the process (esp. in
  patients for whom loss and separation have been
  issues).

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The Practice of Therapy cond.

• 6. Noncompliance (resistance)
• - 1-14 (occur in permutations and
  combinations)
• - Failure to validate patients experience
• - Limited coping capacity
• - Lack of therapist skill
• - Environmental or social stressors interfere
  with change
• - Patients fear of failure
• - Fear of negative consequences of changing
• - Congruencies between patient and therapist
  distortions
• - Poor socialization to the model
• - Secondary gain fro dysfunctional behavior
• - Lack of working alliance
• - Poor timing of interventions
• - Failure to help patient maintain a
  consistent, stable view of themselves (schema
  protection)
• - Failure to address patients
  justifying or imperative beliefs
• - Failure to develop a problem
  list or share a rationale.

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Treatment Applicability

• 1. Cognitive Specificity Hypothesis
• - Emotional states and clinical disorders can
  be distinguished on the basis of their
  characteristics concerns and behaviors that
  mediate the disorders and can be seen as focus of
  treatment
• - Cognitive Triad, perceptual and memory
  biases, negativistic attributional style and
  problem solving deficits
• - Depressed Significantly flawed, incompetent,
  future bleak, others are uncaring, negativistic
  expectations
• - Anxious World is threatening and they cant
  cope with it
• - CT focuses on providing a patient with a
  rationale and techniques to change their
  specific core constellation of beliefs,
  attributions, expectations, and skill deficits

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Treatment Applicability cond.

• 2. Treatment of Anxiety
• - Model suggests how cognitive, social, and
  behavioral factors interact to produce problem
  they face.
• - Existing memories, beliefs,
  schemata, and assumptions contribute to taking
  an adaptive response to perceived threat and
  distorting it
• - Treatment consists of re-examining
  cognitive underpinnings, developing appropriate
  coping skills,
• enhancing perception of personal efficacy,
  de-catastrophizing perceived threats, and
  discouraging avoidance and withdrawal.
• 3. Personality Disorders An enduring pattern of
  dysfunctions in thought, perception and
  interpersonal relatedness, that are relatively
  inflexible and occur across situations
• Consistent over time
• Have constellations of cognitive concerns and
  processes
• Dependent PD continually seeks relationships with
  others, fears loss of them, and feels depressed
  and anxious when deprived of others support
• Schizoid World and others are dangerous and Ill
  avoid them
• Beliefs once had functional reality, are tacit
  and hard to examine, patient often seeks help for
  other issues
• Focus of treatment is on underlying schemata and
  is more comprehensive and long-term