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 50’s 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) > 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 – con’d. • 3. (my opinion) Chapter’s 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. Horney’s 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 > 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. – Meds> 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

8. 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.

9. 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

10. The Practice of Therapy con’d. • 3. con’d.: - 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

11. The Practice of Therapy – con’d. • 3. con’d – - 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

12. The Practice of Therapy – con’d. • 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.

13. The Practice of Therapy – con’d. • 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).

14. The Practice of Therapy – con’d. • 6. Noncompliance (resistance): - #1-14 (occur in permutations and combinations): - Failure to validate patient’s experience; - Limited coping capacity; - Lack of therapist skill; - Environmental or social stressors interfere with change; - Patient’s 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 patient’s “justifying” or “imperative” beliefs; - Failure to develop a problem list or share a rationale.

15. 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 can’t 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;

16. Treatment Applicability – con’d. 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 I’ll 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