Cognitive-Behavioral Therapy

1. Introduction to CBT Cognitive-Behavioral Therapy

2. Cognitive Behavioral Therapy is based on the observation that cognition, emotion, and behavior are reciprocally related. Let’s take a look at what we know about each of these.Let’s take a look at what we know about each of these.

3. Emotion James-Lange Theory of Emotion Action or response precedes emotion I run, therefore I must be afraid. Canon-Bard Theory of Emotion Emotion precedes action. I am afraid, therefore I run. The dilemmas with these two theories arise when one considers factors such as muscle tension, perspiration, and other physiological aspects of sympathetic nervous system arousal. The dilemmas with these two theories arise when one considers factors such as muscle tension, perspiration, and other physiological aspects of sympathetic nervous system arousal.

4. Singer-Schacter Theory of Emotion According to the 2-factor theory, there are two contributors to emotion: Physiological Responses and Cognitive Labels, and these occur concurrently. The Cognitive Label is critically important, and depends, among other things, on the situation (lactic infusion studies related to social cues to meaning of arousal… what one thinks one should feel) According to the 2-factor theory, there are two contributors to emotion: Physiological Responses and Cognitive Labels, and these occur concurrently. The Cognitive Label is critically important, and depends, among other things, on the situation (lactic infusion studies related to social cues to meaning of arousal… what one thinks one should feel)

5. Emotion #3 Emotion cannot be accessed directly, but it can be elicited in therapy. Experiences that are accompanied by the arousal of strong emotion have more powerful effects on cognitive and behavioral patterns. Memory (learning) is mood congruent. A recurrence of mood triggers recall of learning. A reminder of learning situation triggers the original mood.

6. Emotional Symptoms Emotional excess Overreactions or unpredictable emotions Excessive or overly extravagant expression of emotion Emotionally labile Emotional insufficiency Difficulty in displaying emotion Difficulty in “reading” emotion in others Difficulty in verbal expression of emotion Lack of self-control, poor frustration tolerance

7. Judgment is the emotionally (socially) relevant use of knowledge. Judgment takes place in the frontal cortex.

8. Behavior Classical Conditioning The repeated pairing of a stimulus with a (formerly) neutral response, resulting in the stimulus coming to trigger the neutral response. (Pavlovian) Aversion therapy Desensitization Flooding Stimulus control Alters antecedent conditions to affect behavior Example: food -> salivation, changed to food -> gagging Blueberries triggering nausea Bed triggering sleepiness (UCS –> UCR)Example: food -> salivation, changed to food -> gagging Blueberries triggering nausea Bed triggering sleepiness (UCS –> UCR)

9. Behavior #2 Operant Conditioning Modifies “voluntary behavior” Positive Reinforcement: a behavior is followed by a reward. Increases behavioral frequency. Negative Reinforcement: a behavior is followed by the removal of an aversive stimulus. Increases behavioral frequency. Positive Punishment: a behavior is followed by an aversive stimulus. Decreases behavioral frequency. Negative Punishment: a behavior is followed by the removal of a favorable stimulus. Praise, reward, feeling good Taking aspirin removes pain, saying “uncle” results in the bully not twisting your arm, being submissive results in not being hollered at Punishment by negative – spanking, hitting Punishment by response cost – removing a privilege, taking away a toy, etc. Praise, reward, feeling good Taking aspirin removes pain, saying “uncle” results in the bully not twisting your arm, being submissive results in not being hollered at Punishment by negative – spanking, hitting Punishment by response cost – removing a privilege, taking away a toy, etc.

10. Behavior #3 Operant conditioning = instrumental learning (Skinnerian) Extinction Differential Reinforcement of Other Behavior (DRO) Avoidance learning (E.g., electric shock to reduce arousal in presence of child pornography)

11. Behavior #4 A behavior that is rewarded every time is acquired or learned quickly. Fading the reward schedule to intermittent makes the behavior less vulnerable to instances of non-reward. The behavior persists for a relatively long period of time, even if not rewarded.

12. Effectiveness of consequences depends on: Immediacy Consistency (reinforcement schedule) Potency (cost-benefit ratio) Satiation (felt need for the stimulus or response)

13. The Premack Principle A desirable or often-engaged in behavior or situation can serve as a reinforcer for another (new) behavior. Example: If you always brush your teeth and need to develop a habit of taking medicine, pair the medicine routine with the teeth-brushing routine.

14. Social Conditioning Complex social behavior increases and decreases in frequency in response to social reinforcement and social “response cost” or punishment. Example: A pat on the back or a thank you from the boss reinforces excellent work habits better than an increase in salary.

15. Behavioral Difficulties Behavioral excess Behavioral insufficiency Lack of skill (lack of “know-how”) Restricted range of coping strategies (“know-what”) Behavioral inconsistency (“know-when”) Insufficient stimulus control (difficulty with initiating or maintaining behavior) Insufficient contingency control (failure to reward self)

16. Behavioral Difficulties #2 Disorders of Executive Control Planning Organization Time Management Task Management Delay of Gratification / Poor Impulse Control (inhibition of behavior) Goal Directedness (initiation of behavior) Remember that behavior needs to be judged in the context of developmental stage and ability.Remember that behavior needs to be judged in the context of developmental stage and ability.

17. Cognition Human cognition tends to be categorical and hierarchical. (We sort and categorize.) This is biologically determined – it’s how the brain works. Sorting and categorizing makes learning possible, through a process of assimilation and accommodation. Categorizing and comparing allows us to arrive at efficient rules for sorting the vast amount of information that confronts us every waking moment.

18. Cognition #2 Early-acquired cognitive rules form basic schema that tell us what information is important for survival: what data to actively seek, what data is relevant and noteworthy, and what can be safely ignored

19. Cognitive Schema Early acquired schema (probably prior to age 8 or so) form our basic assumptions about ourselves and the world and the relationship between those two. They form our Core Beliefs or Basic Beliefs. Schema tend to be partial constructs, usually operating outside our awareness. They tend to be fragmentary, visceral, iconic vs. verbal. They are presumed true, unquestioned. “Everybody knows…” “That’s just the way it is…”“Everybody knows…” “That’s just the way it is…”

20. Characteristics of Basic Schema They are absolutes. They are unquestioningly taken as Truths. They are consistent across time and situation. They function below the level of awareness. They tend to be non-verbal, visceral & iconic. They tend to be partial constructs. They are highly resistant to change. They are evident only indirectly in patterns of cognition, emotion, & behavior.

21. Cognitive Schema may be…

22. Self-Schema Beliefs about Self are acquired from: Stories told about the child within his/her hearing Stories told directly to the child about themselves Reflections of and reactions to the child’s behavior by significant others Stories erroneously adopted (false memories) Events that happened to others Events in books or on television Personal experience Interpretations of early life events Experiences of success and failure Research demonstrates that before babies can talk, they can understand what is said about them in their presence – minimally the feeling tone. Receptive language develops before expressive language. Cultures vary in the attention they give to and interpretation of children’s behavior – e.g. the reaction to fantasy or magical thinking differs between cultures. “You were always…” “You’re such a…” “You’re just a …” Consider organ inferiority, birth order, mastery (beliefs about one’s competence) vs. competence (actual skill), Research demonstrates that before babies can talk, they can understand what is said about them in their presence – minimally the feeling tone. Receptive language develops before expressive language. Cultures vary in the attention they give to and interpretation of children’s behavior – e.g. the reaction to fantasy or magical thinking differs between cultures. “You were always…” “You’re such a…” “You’re just a …” Consider organ inferiority, birth order, mastery (beliefs about one’s competence) vs. competence (actual skill),

23. Self-Schema ExamplesThe Self may be experienced as…

24. Schema about the World - general The nature of God God is/isn’t; Is vengeful, just, merciful; Is personal/impersonal; Is relevant/irrelevant; Takes an active part/observes but does not interfere; Has a personal relationship with us/is available only through the mediation of a shaman or intermediary

25. Schema about the World – general - 2 The nature of Man Man is savage, noble, erring, divine; Is trustworthy/untrustworthy; Is innocent/sinful; villainous/heroic; Is powerful/powerless; Has agency and free will/has a predestined fate.

26. Schema about the World – general - 3 The nature of the World The world is mysterious/knowable; Is fair/unfair/impartial; Is dangerous/benign; Is meaningful/meaningless;

27. Schema about the World – 4 Gender roles Men should/are/will… Women should/are/will… Power Family roles Birth order & role within the family Relative value of boys and girls Generational relationships Power dynamics Role of father, mother, children, boundary diffusion Matriarchal/Patriarchal Rules about family membership, diffuseness of boundary around the family Nature of success

28. Schema about the World – 5 Ethnicity/Culture/Subculture Foods, clothing; Definition of family; Parent/child relationship; Nature of respect; Individual-family-group balance Achievement & striving Goal of development Relationship with dominant culture Relationship with authority

29. Schema about the World – 6 Country/Region - examples What’s edible? The South shall rise again. Texas-sized Revolutionists, freedom-fighters The “show me” state Northeastern taciturnity The Second City, a city of farmers More nuts per square inch… Sophisticated; Big Apple

30. Schema about the Future The future is… Controllable/uncontrollable Bright/dim Changeable/unchangeable Likely to be worse, better, the same Frightening/unfrightening

31. Schema result in behavioral imperatives: I am… The world is… Therefore I must…

32. Schema provide us with a cognitive map that Explains the past (where we’ve been) Makes sense of the present (where we are) Predicts the future (where we are likely to go next) They tell us what signposts to look out for and what to do along the way. They form a basis for our personalities, making our cognition, emotion, and behavior consistent across time and situation.

33. Schema contribute to cognitive error. Schema are generalizations. They do not reflect differences between first learning experiences and the present situation. They resist influence by new data. Schema filter out some information, while over-valuing other information. Schema are highly resistant to change. They are over-valued ideas that operate outside of awareness and are unquestioned under normal circumstances. We resist, ignore, fail to notice, or disbelieve data that runs counter to our basic beliefs. We differentially note data that confirms basic beliefs.

34. Cognitive Errors Fundamental attribution error: The tendency to overemphasize dispositional or personality-based explanations for others’ behavior while dismissing situational explanations. The opposite typically occurs when explaining one’s own (negative) behaviors. Availability heuristic – the most salient (aggravating, desired) examples are most easily brought to mind, and are then taken as typical or representative.

35. Cognitive Error is inevitable. It occurs simply because of the way the brain works. It is desirable – if we did not sort and categorize, we could not learn.It is beatable under certain circumstances – we can learn to notice, catch, interrupt, and do something else with our tendency toward error.

36. Types of Cognitive Error Minimization/Maximization Over-generalization Mind-reading Dichotomization Catastrophizing Selective Abstraction Disqualifying the Positive Fortune Telling Emotional Reasoning “Shoulds” and “Musts” Labeling Personalization

37. Underlying Assumptions Basic or Conditional (if-then) Beliefs Usually operate outside of awareness, but can be brought to awareness with much more ease than basic schema.

38. Automatic Thoughts Immediate, unpremeditated, “knee jerk” cognitive interpretations of events. Directly shape emotion and strongly influence behavior. Exaggerated, distorted, mistaken, or unrealistic ATs play a role in psychological distress.

39. Other Contributors Vaihinger – “as if” Phenomenology – Immanual Kant & Husserl – the construction of knowledge as a rule-bound, creative act Karen Horney – Tyranny of the Shoulds Kelly – the Psychology of Personal Constructs & fixed role therapy Social Learning Theory – observation of models

40. Assumptions of CBT Albert Ellis Most All Beck, then most Arnold Lazarus CT highlights the role of philosophy and self-persuasion in personal change. Supposes that we have a choice how to think and feel about things, as well as how we act. Cognition, Emotion, and Behavior mutually influence each other Disorders are characterized by (not caused by) dysfunctional thinking. Disorders are characterized by insufficient range of coping responses.

41. So CBT assesses and seeks to intervene in three areas:

42. Cognitive, emotional and behavioral patterns may cause, contribute to, maintain, contribute to resistance in changing, or cause relapses in symptoms. SITUATIONAL VARIABLES can also cause, contribute to, maintain, resist changes in, or cause relapses in symptoms. It is always important to understand the physical, biological, developmental, and social-emotional context in which the problem occurs.

43. Goals of CBT/CT Interrupt self-perpetuating cycles of cognitive error, disturbed mood, and ineffective behavior. The client becomes less disturbed. Symptoms recede. First-order change. Modify beliefs and assumptions that predispose the client to the problems. The client becomes less disturbable. Ellis’s “elegant solution” or “second-order change”. Provide the client with more effective ways to manage the situations that provoke their distress or difficulties. The client is able to manage similar and dissimilar stressors more effectively; the client is more skilled.

44. Assessment ala CBT Nature of the problem Onset (learning history, but later), duration, course Context: Stimulus variables Consequences (reinforcers and costs) The client’s explanation & understanding of the problem Previous attempts to solve the problem and relative success of these Client’s goals

45. Assessment ala CBT/CT Baseline data Current incidents Daily Thought Record Journaling Counting instances Collateral data Critical Incidents - history Cognition, emotion, behavior Situational variables – who, what, when, where

46. Thought Record – part 1

47. Assessment ala CBT/CT cont’d. Formal Assessment Tools Beck Depression Inventory Beck Anxiety Scale Beck Hopelessness Scale Burns Anxiety Inventory Dysfunctional Attitudes Scale Fear Survey Schedule And MANY more… Use appropriately; use sparingly; use repeatedly.

48. Assessment ala DSM-IV-TR

49. Collaborative Empiricism Collaborative Goal Setting: Client’s goals – realistically and objectively defined Therapist’s goals based on practicality, theory, conceptualization Mutually agreed upon Goals should be empirical: Objective – verifiable by other than subjective methods Observable – outside of “the black box” Measurable – able to be counted, recorded, scored, scaled, Guided Discovery Socratic questioning Stochastic questioning Jointly identified inter-session tasks (“homework”)