Cognitive-Behavioral Therapy

1. Cognitive-Behavioral Therapy Introduction to CBT

2. Cognitive Behavioral Therapy is based on the observation that cognition, emotion, and behavior are reciprocally related.

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.

4. Singer-Schacter Theory of Emotion

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

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.

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)

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.

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… Compelling Active Latent Non-Compelling

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

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 Severity Symptoms from DSM

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”)