Cognitive-Behavioral Theory: Foundations and Practice

1. Cognitive-Behavioral Theory:Foundations and Practice A general category of theories or a set of related theories that reflect the importance of both behavioral and cognitive approaches to counseling.

2. Quote: “ The best years of your life are the ones in which your problems are your own. You do not blame them on your mother, the ecology, or the president. You realize that you control your own destiny.” Albert Ellis

3. Cognitive-Behavioral Theories: Commonalities • A general category of theories or a set of related theories that reflect the importance of both behavioral and cognitive approaches to counseling. • Four common tenets across cognitive-behavioral theories • Collaborative Relationship Between Therapist and Client • Psychological distress is a function of disturbance in cognitive processes • Focus on changing cognitions to change affect and behavior • Treatment is educational and time-limited and focused on specific and structured target problems

4. Cognitive Behavioral Theorists • Albert Ellis (1913-2007) • Rational-Emotive Behavior Therapy (REBT) • Aaron Beck (1921- ) pic at left • Cognitive Therapy • Donald Meichenbaum • Cognitive Behavior Modification • Stress Innoculation Training and Self-Instruction Training • More than 20 different theories labeled cognitive or cognitive-behavioral Click pic to watch video of Ellis interview.

5. Rational Emotive Behavior Therapy (REBT) • Considered the parent of the CB approaches • Developed by psychologist Albert Ellis in 1955 • Roots in Greek philosopher Epictetus • “People are disturbed not by things, but by the view which they take of them” • Credits Adler with emphasis on teaching and persuasive methodology • People should accept themselves, even if they make mistakes yet at the same time learn to live more at peace with others!

6. Ellis believed….. • the empathic, therapeutic relationship may be “undesirable” because the temporary mood elevation brought on by empathy may prevent the client from doing “necessary work” to get better. Please click on picture to watch a video clip of Ellis introducing his theory and working with Gloria.

7. Basic Hypotheses • Our emotions stem mainly from our beliefs,evaluations, interpretations and reactions to life situations. “You feel the way you think” • Therapy is essentially a process of “reeducation” – a process of learning how to think more rationally about our experience. • Focus is on working with thinking and acting

8. View of Human Nature • Humans are born with a propensity for both rational and irrational thinking. • Humans are born with propensities toward self-actualization and self-destruction • Humans are “self-talking”, self-evaluating, and self-sustaining. • Humans often sabotage their movement toward self-actualization as a result of their tendency toward crooked thinking and through self-defeating patterns they have learned. • Humans do not need to be loved and respected even though they may strongly prefer it.

9. Emotional Disturbance • Blame is at the core of most emotional disturbance. • Exists when a person makes the mistake of irrationally thinking that simple preferences are dire needs. • During childhood we learn patterns of irrational, self-defeating thinking and we create these patterns ourselves. Examples include: • “I must have love or approval from all the significant people in my life.” • “I must perform important tasks competently and perfectly well.” • “If I don’t get what I want, it’s terrible and I can’t stand it.” • Occurs when we escalate our desires and preferences into “shoulds,”“musts,” and “oughts.”

10. To avoid emotional disturbance… • We are able to maintain emotional health by recognizing our preferences and by taking a rational view of our own imperfections

11. A-B-C Theory of Personality A (activating event) B (belief) C (emotional & behavioral) cons. D (disputing intervention) E (effect) F (new feeling)

12. A-B-C Theory of Personality • Individuals have goals that may be supported or thwarted by activating events (A). They then react, consciously or unconsciously, with their belief system (B), by which they respond to the activating event. The consequence (C) is the emotional and behavioral result of the reaction.

13. Further….. • D = Disputing intervention (detecting, debating, and discriminating • E = Effect of the disputing intervention (hopefully the successful challenge and dispute of irrational behavior) • F = new feeling (rational, logical,helpful)

14. Therapeutic Goals • Minimizing self-defeating behaviors and emotional disturbance • Acquiring a more realistic and workable philosophy of life • Reducing the tendency to blame self and others for what goes wrong in life. • Learning ways to deal with future difficulty

15. The Therapy Process • Step 1 – Building a “collaborative therapeutic alliance” • Step 2 – Goal setting • Step 3 Orientation of client to the therapeutic process • Step 4 Therapist disputing of irrational beliefs

16. Step 5 – Assignment of Homework • Progress check upon completion • Teaching new ways of thinking and acting • Reassignment • Step 6 – Progress review; Planning for dealing with future problems.

17. Techniques: CognitiveTypically directive and aimed at revising faulty cognitions • Disputing irrational beliefs: Challenging the “shoulds” and “musts”. • Cognitive homework: Clients are expected to make lists of their problems, look for their absolutionistic beliefs, and dispute these beliefs. • Changing one’s language: Replace “musts”, “oughts”, and “shoulds” can be replaced by preferences; increase personal power • Use of humor: Don’t take life so seriously!

18. Techniques: EmotiveDesigned to reduce the feelings that stand in the way of dealing with irrational patterns of thinking • Rational-Emotive Imagery: clients imagine themselves thinking, feeling, and behaving exactly the way they would like to behave in real life. • Role playing: To rehearse ways to change inappropriate feelings to appropriate ones. • Shame-attacking exercises: Clients work to feel unashamed even when others clearly disapprove • Use of force and vigor: Use forceful dialogues with themselves to express irrational beliefs and the powerfully dispute them.

19. Self-management Systematic desensitization Relaxation Modeling Homework assignments Reinforcement Extinction Shaping Any other techniques from Behavioral Theory Techniques: Behavioral“Acting differently can also lead to a change of irrational beliefs”

20. REBT is: highly directive persuasive confrontational Counselor is a teacher Cognitive Therapy is: more open-ended reflective more structured, more helpful Relationship is more collaborative Differences between CT & REBT

21. 1. Based on cognitive model of emotional disorders. 2. Brief and time-limited 3. Based on a sound therapeutic relationship 4. Collaborative effort between client and counselor 5. Uses the Socratic method 6. Structured and directive 7. Problem-oriented 8. Based on an educational method 9. Relies on inductive model 10. Uses homework as a central feature. Beck’s Cognitive Therapy: 10 Principles

22. Beck’s Cognitive Therapy • View of Human Nature • Same as REBT but more phenominological (idiosyncratic nature of thoughts) • Doing something will feel better than doing nothing.

23. Dysfunction & Goals of Therapy • Nature of Pathology • Views problematic thinking more as dysfunctional than irrational • Goals of Therapy • Assist client in identifying and confronting rules they live by that might be too absolute, broad or extreme

24. Therapeutic Relationship… • Warm personal relationship is essential, though not sufficient for therapeutic change • Labeling behavior that has meaning for someone as irrational sends up defenses

25. Role of the Counselor • Functions to guide the client toward personal discovery and skill development through deliberative corrective experiences (rather than direct teaching) • Use of Socratic questioning rather than disputing

26. Cognitive Therapy Process • Provide client with a cognitive rationale for counseling • Have client monitor thoughts that are distressful • Implement cognitive & behavioral techniques • Identify & challenge cognition that may be problematic • Examine beliefs and assumptions through reality testing • Teach clients coping skills to prevent relapse

27. Cognitive Therapy Techniques Cognitive Strategies: • Collaborative Empiricism • Socratic dialogue Behavioral Strategies: • Relaxation Therapy • Cognitive Modeling

28. Meichenbaum’s Cognitive Behavior Modification • Self-talk is at the heart of the way that a person functions. • Goal of therapy is cognitive restructuring (modify self-talk and cope more effectively) • Process includes: • Self-observation • Starting a new internal dialogue • Learning new skills

29. Self-instructional training (Cognitive Behavior Modification): clients learn to keep track of self-statements and to substitute more adaptive statements through homework & rehearsal) Stress inoculation training: consists of three phases--- 1. Conceptualization 2. Skills acquisition & rehearsal 3. Application & follow-through Meichenbaum’s theories

30. Behavior is learned Behavior is developed and maintained by external cues, reinforcers, or internal processes, such as cognition. Here-and-now orientation to problems Development is based upon each person’s learning history, unique experiences, and cognitive understanding of the world. Past problems are considered only as relating to present. Cognitive-Behavioral View of Human Nature:

31. Important constructs: • The Importance of Cognitions: Emphasis on the importance of cognitive workings; all cognitive interventions attempt to produce change by influencing thinking • The Importance of Learning: Asserts that abnormal behavior is learned and developed the same as normal behavior and can be changed through cognitive-behavioral approaches.

32. Important constructs (cont.) • The Importance of Operational Definitions: Problems are viewed operationally; problems are functionally related to internal and external antecedents and consequences • The Importance of Therapeutic Empathy: Some feel the techniques are more important than the relationship (like Ellis) Others feel here is a necessity for an empathic relationship.

33. 4 Questions to Establish Counseling Goals: 1. What are the problems that need to be addressed (presenting problems)? 2. How can progress in counseling be measured and monitored? 3. What are the environmental contingencies maintaining the behavior? 4. Which interventions are more likely to be effective (cognitive, behavioral, or both)?

34. REBT & Treatment • REBT has been applied to treatment of anxiety, depression, OCD, panic disorder, and agoraphobia. • There is some concern that the notion of “How you feel is based on what you think” may send a message to clients that they are responsible for their mental illness.

35. CBT Strengths • Empowerment of the client to create change • Clarity of models • Emphasis on teaching • Technical eclecticism • Beck has brought the “private experience back into the realm of scientific inquiry” • Demystification of the therapy process • Focus on self-help

36. Multicultural Issues & REBT • Therapist must listen carefully for cultural values and issues of client. • REBT emphasizes self-sufficiency as opposed to dependency on the support of others; many cultures promote interdependence rather than independence • Active nature of REBT techniques sometimes conflict with passive nature of some cultures

37. Gender & REBT • May be more appropriate for work with women because women are subject to more gender-role socialization messages that promote irrational beliefs. • Can be applicable to both genders because counselors can examine the irrational beliefs of any client, regardless of gender

38. Limitations of CBT • De-emphasis on client-counselor relationship • Rejection of transference • Rejection of unconscious realm • REBT: Power of the therapist to manipulate and judge a client

39. Limitations of CBT • Over simplistic with regard to psychopathology: based on the power of positive thinking • De-emphasis on the past • Underplaying the role of emotions as a direct agent for change

40. Limitations • Lack of attention to unconscious or internal factors which may affect behavior • Not very attentive to feelings • Insight and emphasis on the past are not emphasized.

41. Contributions/Advantages • Brief and time-limited • Action oriented • Puts newly acquired insights into action • Teaches clients to carry on their own “therapy” without counselor • Eclectic techniques that can be applied to individual client needs

42. Research and REBT • A review of 158 outcome studies found that REBT was significantly more effective than other therapies on various issues • There is some question about how well therapists in research actually represent “true” REBT; what they may be calling “REBT” may simply be an “integration” of cognitive and behavioral concepts.

43. To see cognitive behavioral theories in practice with clients, check out these video links: • Albert Ellis Doing REBT with Jeffery {Video file}. (2006). http://www.youtube.com/watch?v=A9tj8p5TfgI&feature=related • Cognitive Behavior Therapy {Video file}. (2006).http://www.youtube.com/watch?v=GqW8p9WPweQ

44. Ellis: The Man “I am a charismatic individual with characteristics which many people find distasteful.” (Ellis, 2001) Click on picture to Play audio clip about Ellis Perhaps one of the biggest limitations of REBT has been the negative influences of Ellis himself. In his opinion, professionals may oppose or slight REBT because they don’t like him. He admitted that his public manner and use of four-letter words is controversial and unconventional and that his use of the term rational may be aversive to empirically minded psychologists. Because it is irrational to demand that Ellis change his style, professionals must recognize that they can adhere to the basic principles of the theory without emulating Ellis’ less-than-nurturing style.