CBT: Some Basic Historical Concepts 708: Cognitive Assessment & Psychotherapy

Cognitive-Behavioral Therapy & Three Fundamental Propositions Cognitive activity affects behavior Cognitive activity may be monitored and altered Desired behavior change may be effected through cognitive change There is overwhelming evidence that cognitive appraisals of events can affect the response to those events; and the content of these appraisals can be modified Implicit in this statement is the assumption that we may gain access to cognitive activity, and that cognitions are knowable and assessable --there can be biases in cognitive reports; further validation of cognitive reports is required --most cognitive assessment strategies emphasize the content of cognitions and the assessment of cognitive results rather than the cognitive process While cognitive-behavioral theorists accept that overt reinforcement contingencies can alter behavior, they are likely to emphasize that there are alternative methods for behavior change, in particular cognitive change --e.g., Bandura – self-efficacy: perceived ability to approach a fearful object strongly predicts actual behavior

What is CBT? Internal covert processes – “thinking” or “cognition” Cognitive events mediate behavior change Emotional and physiological changes are also indicators of change Some recognize three major classes Coping skills therapies Cognitive restructuring methods Problem-solving therapies 2) Behavior change does not have to involve elaborate cognitive mechanisms (i.e., exposure) 3) Especially if this is a major aspect of the presenting problem in therapy (e.g., anxiety disorders) 4) Coping skills therapies are primarily used for problems that are external to the client; develop a repertoire of skills designed to assist the client in coping with a variety of stressful situations 4) Cognitive restructuring techniques are used more when the disturbance is created from within the person; assume that emotional distress is the consequence of maladaptive thoughts 4) Problem-solving therapies may be characterized as a combination of both; emphasize the development of general strategies for dealing with a broad range of personal problems, and stress the importance of an active collaboration between client and therapist in the planning of the treatment program

Historical Bases of CBT Most philosophical foundations of CBT can be seen in “constructivism” “Reality is a socially constructed phenomenon that exists as a function of the observer who creates it, and is embodied in dynamic and subjective knowledge.” Basis of Beck’s approach to treatment Kant: “If thou are pained by any external thing, it is not this thing that disturbs thee, but thine own judgment about it.” Beck: modify thought to modify behavior

Historical Bases of CBT Psychodynamic Therapy Aaron Beck & Albert Ellis – early training in psychodynamic therapy Not satisfied with client outcomes Rejected psychoanalytic emphasis on unconscious processes, review of historical material, and the need for long-term therapy (relied on insight from the transference-countertransference relationship) Research showed poor efficacy “There still is no acceptable evidence to support the view that psychoanalysis is an effective treatment” (Rachman & Wilson, 1980, p. 76).

Historical Bases of CBT Behavior Therapy 1960s-1970s: behaviorism alone does not account for all of human behavior “Pure” behavioral treatments were found to not be enough (for change) Some disorders may be more cognitive/internal in nature Behavioral models later expanded to incorporate “covert” behaviors (i.e., thoughts) Initially perceived passively – i.e., eventual acknowledgement of existence, but not of much clinical utility See Social Learning Theory 2) Methodological behaviorism (thoughts don’t exist) vs. radical behaviorism (skinner – thoughts exist, but can’t do much with them, so don’t bother) 2) Classical and operant conditioning principles of behaviorism

Historical Bases of CBT Social-Cognitive Theory “Protest” movement to psychodynamic therapy and behavior therapy {The other protest movement was phenomenological-humanistic therapy} Kelly (1955) and personal construct theory Focuses on how the person sees events and self on her own dimensions We construe our own behavior – categorizing, interpreting, labeling, and judging ourselves and the world around us The same behavior or event is construed distinctly by different people To understand the individual, one has to understand her constructs

Historical Bases of CBT Social-Cognitive Theory Kelly (1955) and constructive alternativism A person’s construction system can vary/change based on experience When people cannot change events, they can construe their constructs differently Stated differently: An interpretation of an event is open to alternative constructions, which may lead to different courses of action If people cannot construe (i.e., change) their constructs, when in contradiction to certain events/experiences, great distress may be experienced “Events do not tell us what to do… we ourselves create the only meaning they will ever convey during our lifetime” (Kelly, 1955, p. 29)

Historical Bases of CBT Social-Cognitive Theory Mischel (1973) proposed the social cognitive reconceptualization of personality Person-situation interaction – behavior is the function of the interaction between personality traits and situational forces Social-cognitive person variables – characterize the differences between people in how they interpret social stimuli and situations as they interact with them Each of these variables provides distinctive information about the individual, and collectively they interact to influence the behaviors that are generated in the particular situation

Social-Cognitive Person Variables Encodings – constructs; appraisals; categories for the self, people, events Expectancies and beliefs – self, social world, outcomes for behavior in particular situations Emotions – “hot cognitions” and physiological reactions Goals and values – desirable/aversive outcomes, self-efficacy, intrinsic motivation Competencies and self-regulatory plans – strategies for organizing action and affecting outcomes; cognitive reappraisals

Historical Bases of CBT Social-Cognitive Theory Bandura (1977) and and observational learning (modeling) Learning occurs without the learner’s receiving direct external reinforcement, or even without the learner ever performing the learned response Humans learn from what others say and do, and what they see, hear, and read, whether it is intended to be taught or not Reciprocal determinism Self-efficacy

Historical Bases of CBT “Cognitive revolution” – cognitivism Behaviors  social learning  Thoughts Cognition refers to awareness and thinking as well as to specific mental acts such as perceiving, attending to, interpreting, remembering, believing, deciding, and anticipating General cognitive psychology and “applied cognitive psychology” challenged behavioral theorists Rejected the notion that mental processes and states were unscientific Extension of information-processing models to clinical constructs Theoretical and empirical support for dysfunctional thoughts as causal precursors to dysfunctional behavior {sensory input into mental representations}

Historical Bases of CBT Establishment of several key proponents of CBT – “zeitgeist” Beck, Ellis, Meichenbaum First CBT book: “Cognition and Behavior Modification” (Michael Mahoney, 1974) First CBT journal “Cognitive Therapy and Research” (1977) Growing clinical efficacy of CBT interventions Fits well into the medical model and the scientific method

Historical Bases of CBT Some key components of CBT Recognizes problems that go beyond specific behaviors Helps people interpret and construe experiences constructively Focuses on interactions between events, thoughts, emotions, and behaviors Although past events can be relevant, focus is on the here-and-now Client is an active participant in therapy (i.e., not passive) Therapy is not meant to last for a very long time Ideally, clients should eventually be able to generalize skills and independently solve problems after therapy

Major Models of CBT Rational Emotive Behavior Therapy (REBT) Cognitive Therapy Self-Instructional Training Stress Inoculation Training Self-Control Treatments Problem-Solving Therapy

Rational Emotive Behavior Therapy “Premiere” example of the CBT approach Albert Ellis (1960s) Discouraged by the limitations of the analytic method REBT – thinking and emotion are significantly interrelated ABC Model A = activating experiences or events B = belief system (irrational) C = consequences

Rational Emotive Behavior Therapy Goal = identify and challenge the irrational beliefs at the root of emotional disturbance Individuals possess innate and acquired tendencies to think and behave irrationally Must constantly monitor and challenge their basic belief systems “logico-empirical method of scientific questioning, challenging, and debating”

Cognitive Therapy Aaron Beck (1960s) Questioned psychoanalytic formulations of the neuroses, especially for depression Noticed that his patients showed systematic distortions in their thinking process “Cognitive Therapy and the Emotional Disorders” (1976) “Cognitive Therapy of Depression” (1979)

Cognitive Therapy Distorted thinking and unrealistic cognitive appraisals of events  negatively affect feelings and behavior Reciprocal relation between affect and cognition Schemas – cognitive structures that organize and process incoming information Thought patterns developed over the lifespan with accumulate experiences e.g., “negative cognitive triad” of depression 1) The way an individual structures reality determines his or her affective state --principal goal of cognitive therapy is to replace the client’s presumed distorted appraisals of life events with more realistic and adaptive appraisals 1) Reciprocal – results in a possible escalation of emotional and cognitive impairment 2) Schemas – maladjusted individuals result in distorted perceptions, faulty problem-solving, and psychological disorders 2) Cognitive Triad – self, world, future

Cognitive Therapy Therapeutic process has a collaborative and psychoeducational approach (1) monitor automatic thoughts (2) recognize relations among cognition, affect, and behavior (3) test the validity of automatic thoughts (4) substitute more realistic cognitions for distorted thoughts (5) identify and alter underlying beliefs, assumptions, or schemas that predispose individuals to engage in faulty thinking patterns

Self-Instructional Training Donald Meichenbaum (early 1970s) Behaviorist Research investigating operant treatment procedure for schizophrenia patients trained to emit “healthy talk” Appeared less distracted and demonstrated superior task performance on multiple measures Began research program that focused on the role of cognitive factors in behavior modification

Self-Instructional Training Meichenbaum greatly influenced by Vygotsky Developmental relation among language, thought, and behavior Gradual external regulation by others to self-regulation from internalization of verbal commands Recall: zone of proximal development & scaffolding Self-instructional training (SIT) program initially designed for impulsive children

Self-Instructional Training Six global skills (1) problem definition (2) problem approach (3) attention focusing (4) coping statements (5) error-correcting options (6) self-reinforcement SIT – significant literature has accumulated on the utility of SIT for a variety of psychological disorders

Stress Inoculation Training Meichenbaum (1970s) Learn to cope with small amounts of stress Treatment maintenance and generalization Follows immunization model If learn coping from mild levels of stress then “inoculated” against uncontrollable levels of stress

Self-Control Treatments Marvin Goldfried (early 1970s) Systematic desensitization (1) description of the therapeutic rationale in terms of skills training (2) use of relaxation as generalized coping strategy (3) use of multiple theme hierarchies (4) training in “relaxing away” scene-induced anxiety (i.e., exposure) Does not terminate the imaginal scene at indication of distress

Problem-Solving Therapy D’Zurilla & Goldfried (early 1970s) Self-control training for client to function as own therapist Makes available a variety of effective response alternatives for coping with a problem situation and increases the likelihood of selecting the most effective response available The flexibility and pragmatism of these approaches continue to attract the attention of clinicians in search of comprehensive treatment programs.