SOWK6190/SOWK6127 Cognitive Behavioural Therapy and Cognitive Behavioural Intervention

1. SOWK6190/SOWK6127Cognitive Behavioural Therapy and Cognitive Behavioural Intervention Week 2 - The scientific foundations of cognitive-behavioral therapy & the relationship between cognition and emotion Dr. Paul Wong, D.Psyc.(Clinical)

2. Philosophy of CBT “It is not things themselves that disturb men, but their judgments about these things”. Epitectus http://en.wikipedia.org/wiki/Epictetus

3. The Basic Foundation of CBT • Behavioural therapy: • based on both the classical (Pavlovian), operant conditioning models (Skinnerian), and social learning approach (Bandura). • Cognitive therapy and Rational Emotive Behaviour Therapy: • Aaron Beck and Albert Ellis both suggested that THINKING played a large mediating role in behavioural and emotional reactions to the world.

4. Behavioural Therapy Focus on present rather than past Observable vs. unconscious Short term treatment, clear goals, and rapid change

6. Therapy and classical conditioning Systematic desensitization – replacing an old conditioned response with a new one by changing the unconditioned stimulus Aversion therapy – an undesirable behaviour is paired with an aversive stimulus to reduce the frequency of the behaviour, e.g., Antabuse Flooding – rapidly and intensely exposed to the fear provoking situation

7. http://www.squidoo.com/learningbehaviormodification

8. Therapy and operant conditioning Modeling – learning through the observation and imitation of others. Token economy – the use of objects called “tokens” to reinforce behaviour Contingency contract – a formal written contract between therapist and client in which goals for behavioural change, reinforcements, and penalties are clearly stated.

9. Rational Emotive Behavior Therapy • Human beings tend to construct absolute “musts” about their desires, such as “I must be loved”, this tendency is referred to as “must-urbation”. • Ellis came up with 11 irrational beliefs

10. Irrational beliefs • It is a dire necessity for adult humans to be loved or approved by virtually every significant other person in their community. 2. One absolutely must be competent, adequate and achieving in all important respects or else one is an inadequate, worthless person. 3. People absolutely must act considerately and fairly and they are damnable villains if they do not. They are their bad acts. 4. It is awful and terrible when things are not the way one would very much like them to be. 5. Emotional disturbance is mainly externally caused and people have little or no ability to increase or decrease their dysfunctional feelings and behaviors.

11. 6. If something is or may be dangerous or fearsome, then one should be constantly and excessively concerned about it and should keep dwelling on the possibility of it occurring. 7. One cannot and must not face life's responsibilities and difficulties and it is easier to avoid them. 8. One must be quite dependent on others and need them and you cannot mainly run one's own life. 9. One's past history is an all-important determiner of one's present behavior and because something once strongly affected one's life, it should indefinitely have a similar effect. 10. Other people's disturbances are horrible and one must feel upset about them. 11. There is invariably a right, precise and perfect solution to human problems and it is awful if this perfect solution is not found.

12. Rational beliefs • It is not possible for everyone to love and approve of us; indeed, we can not be assured that any one particular person will continue to like us. What one person likes another hates. When we try too hard to please everyone, we lose our identity, we are not self-directed, secure or interesting. It is better to cultivate our own values, social skills, and compatible friendships, rather than worry about pleasing everyone.  • No one can be perfect. We all have weaknesses and faults. Perfectionism creates anxiety and guarantees failure.  Perfectionistic needs may motivate us but they may take away the joy of living and alienate people if we demand they be perfect too. We (and others) can only expect us to do what we can (as of this time) and learn in the process. • No matter how evil an act, there are reasons for it. If we put ourselves in the other person's situation and mental condition, we would see it from his/her point of view and understand. Even if the person were emotionally disturbed, it would be "understandable" (i.e. "lawful" from a deterministic point of view). Being tolerant of past behavior does not mean we will refuse to help the person change who has done wrong. Likewise, our own mean behavior should be understood by ourselves and others. When people feel mistreated, they can discuss the wrong done to them and decide how to make it right. That would be better than blaming each other and becoming madder and madder so both become losers. • The universe was not created for our pleasure. Children are commonly told, "You can't have everything you want." Many adults continue to have that "I want it all my way" attitude. The idea is silly, no matter who has it. There is nothing wrong, however, with saying, "I don't like the way that situation worked out. I'm going to do something to change it." If changes aren't possible, accept it and forget it. An ancient idea is to accept whatever is. • As ancient philosopher Epictetus said, it is not external events but our views, our self-talk, our beliefs about those events that upset us. So, challenge your irrational ideas. You may be able to change external events in the future and you certainly can change your thinking.  Remember no one can make you feel anyway; you are responsible for your own feelings. 

13. There is a great difference between dreadful ruminations about what awful things might happen and thinking how to prevent, minimize, or cope with real potential problems. The former is useless, depressing, exhausting, and may even be self-fulfilling. The latter is wise and reassuring. Keep in mind that many of our fears never come true. Desirable outcomes are due to the laws of behavior, not due to our useless "worry." Unwanted outcomes are also lawful, and not because we didn't "worry."  • As with procrastination, avoidance of unpleasant tasks, and denial of problems or responsibilities frequently yields immediate relief but, later on, results in serious problems. The lifestyle that makes us most proud is not having an easy life but facing and solving tough problems.  • People are dependent on others, e.g. for food, work, etc., but no one needs to be dependent on one specific person. In fact, it is foolish to become so dependent that the loss of one special person would leave you helpless and devastated. • You can't change the past but you can learn from it and change yourself (and maybe even the circumstances). You can teach an old dog new tricks. Self-help is for everyone every moment. • It is niceto be concerned, sympathetic, and helpful. It is not helpful and may be harmful to become overly distraught and highly worried about other people's problems. They are responsible, if they are able adults, for their feelings, for their wrong-doing, and for finding their own solutions. Often there is little you can do but be empathic. Avoid insisting on rescuing people who haven't asked you for help. • A helpless, hopeless "I-can't-change" attitude is not in keeping with modern-day self-help and therapeutic methods. There are many ways to change unwanted feelings.  On the other hand, there is merit in "being able to flow with your feelings" in certain circumstances. Being unable to feel or express certain emotions is a serious handicap but correctable.  Being dominated by one's emotions--a slave to your emotions--is also a serious but correctable problem. As long as our emotions are sometimes destructive and irrational, it is crazy to unthinkingly "follow our feelings."

14. Cognitive Therapy Human emotion is the direct result of what people think, tell oneself, assume or believe People have the capacity to change their cognitive, emotive and behavioural processes The therapy is a collaborative processof empirical investigation, reality testing, and problem-solving between therapist and patient. The patient’s maladaptive interpretations and conclusions are treated as testable hypothesis.

15. Cognitive therapy • Identify cognitions relevant to the presenting problem • Recognize connections among cognitions, affects, and behaviors • Examine the evidence for and against key beliefs • Encourage the client to try out alternative conceptualizations • Teach the client to carry out the cognitive process independently

16. Helpless core beliefs I am helpless.I am powerless.I am out of control.I am weak.I am vulnerable.I am needy.I am trapped.I am inadequate.I am ineffective.I am incompetent.I am a failure.I am disrespected.I am defective (i.e., I do not measureup to others).I am not good enough (in terms of achievement). Unlovable core beliefs I am unlovable.I am unlikable.I am undesirable.I am unattractive.I am unwanted.I am uncared for.lam bad.I am unworthy.I am different.I am defective (i.e., so others will notlove me).I am not good enough (to be loved by others).I am bound to be rejected.I am bound to be abandoned.I am bound to be alone. Core beliefs

18. CT vs. REBT • Power of the therapist • REBT is highly directive, persuasive, and confrontative • CT uses a Socratic dialogue by posing open-ended questions to clients with the aim of getting them to reflect on personal issues and arrive at their own conclusions • http://www.fenichel.com/Beck-Ellis2002.shtml

19. CT vs. REBT • Nature of problematic thinking: • REBT persuades clients that certain of their beliefs are irrational, deliberately getting clients to seek out their dogmatism and absolutic thinking. • CT does not tell clients there are irrational rather they are problematic because they interfere with normal cognitive processing. • Beck takes a more functional view of biased beliefs as opposed to seeing them as philosophically incongruent with reality.

20. CT vs. REBT • Therapeutic relationship: • REBT views the therapist largely as a teacher and does not think that a warm personal relationship is essential. • CT emphasizes more on a collaborative therapeutic relationship.

21. Basic conceptual framework • CBT has several defining elements: • Active. The client must be involved in the therapeutic process as a core and key participant. • Motivational. The therapist needs to take responsibility for helping to motivate the client toward a change in behavior, affect, or thinking. • Directive. The therapist must be able to develop a treatment plan and then to help the client to understand, contribute to, and see the treatment plan as a template for change. • Structured. The overall therapy follows a structure that approximates the treatment plan. The individual session is structured so that every session has an identified beginning, middle, and end.

22. Collaborative. Both the client and the therapist work together. • Psycho-educational. The therapist works as a change agent. Many of the problems that bring people to therapy involve skill deficits. The therapist may have to teach by direct instruction, modeling, role playing, guided practice or in vivo experience. • Problem-oriented. CBT focuses on discrete problems rather than vague and amorphous goals of feeling good, getting better, or increasing self-esteem. • Solution-focused. The therapist works with the client on generating solutions, not simply gaining insight into the problems. The CBT therapist uses the Socratic dialogue to move the client toward a more problem-solving focus. • Dynamic. CBT is to help clients to identify, understand, and modify their schema. • Time-limited. Each therapy session should, ideally, stand alone.

23. CBT is based on several principles • Cognitions affect behaviour and emotion (the way we think affects what we do and how we feel) • Certain experiences can evoke cognitions, explanations, and attributions about the situation • Cognitions may be made aware, monitored,and altered • Desired emotional and behavioural change cab be achieved through cognitive change.

24. Conceptual shift for CBT (from earlier models) • The presenting symptom is viewed as a target for change, rather than a symptom of intrapsychiatric conflict or as a result of unresolved conflicts; • The shift for CBT is away from seeing the therapist as a priest, shaman, or healer. The role of therapist doing CBT is more of a consultant, a resource, and a catalyst for change; • CBT is a coping model as opposed to a mastery/cure model; • CBT prefers an intervention that is least intrusive, least aggressive, least expensive, with the greatest demonstrated effectiveness; • Planning, focus, and direction are the watchwords of the CBT model; and • Specific outcomes are needed for CBT.

25. Components of CBT • Cognitive interventions • Behavioural interventions • Emotive/Affective interventions

26. 1) Cognitive interventions • Goals: • Help clients examine, challenge/dispute the current beliefs and thinking that causes them to have self-identified undesirable reactions; and • Then to aid them in developing new, more useful and helpful ways of thinking so as to further their goals.

27. Cognitive interventions • “Self-help” form: clients are asked to write down the activating situation, their emotional and behavioural responses, and what they were thinking. • Disputing/Challenging Beliefs: once a dysfunctional belief has been identified the therapist sets about helping the client challenging it in terms of functions, evidence, logic, meaning, and alternative beliefs. • Referenting: write down the disadvantages and advantages of keeping these dysfunctional beliefs. • Role reversal: switch role of the client and the therapist • Recording therapy sessions: having clients listen to their therapy session provides them that one degree of separation that sometimes allows them to develop more insights and understanding about themselves. • Reframing: Challenge their original thoughts.

28. 2) Behavioural interventions • Role playing during the sessions; • Skills training include social skills, assertiveness skills, anger management skills, relaxation skills etc. • Modeling – ask clients to identify someone in their life who they believe has a better way of handling a specific situation that they have identified they want to work on. • In Vivo Desensitization – creating a “hierarchy of pain” to deal with an anxiety-provoking situation. • Graded task assignments – Client break large and overwhelming tasks into smaller pieces that feel more manageable with each step helping their client move toward their ultimate goal; and • Behavioural experiment – Clients are asked to do something between sessions.

29. 3) Emotive/Affective Interventions • Coping statements – write their own coping statements prior to the bad-feeling-provoking situations; and • Encouragement and unconditionalacceptance by therapist

30. Using CBT with Chinese • Chinese are practical-minded prefer the problem and solution-focused nature of CBT over abstract self exploration and unconscious dynamics • Chinese are used to directive teaching in socialization, prefer clear instructions and imperatives to non-directive explorative approach • Chinese obedience orientation to authority figures favours expert and active role of therapist • Chinese are reserved in emotional expression. CBT focuses on rationality rendering Chinese clients more secure in therapy process. • The time limited approach fits the practice situation in HK.

31. Patients who do not respond well to CBT • Severely disturbed • High level of cognitive dysfunction • Severely personality disordered • Do not have ready access to won feelings and thoughts • Do not readily identify target problems • Cannot readily form a collaborative relationship with therapist • Not motivated to do homework assignments

32. Criticisms of CBT • Relatively underplaying client’s expression of feelings and emotional re-experiencing of painful events; • Lack of emphasis on the unconscious factors and ego defenses; • Focusing only on the present, ignoring the past and importance of childhood experiences; • Lack of emphasis on the therapeutic relationship; and • REBT is too confrontative, many clients may not accept this forceful style of therapy, more likely that therapist may impose values on clients.

33. Homework Please go to this website and take a look of the article: http://www.bmj.com/content/324/7332/288.1.full