Chapter 8 (Contemporary Cognitive Behavioral Therapies)

Third Generation of Behav Therapy

Combo of experiential, mindfulness, cognitive, + behav approaches

Target of Third Generation of Behav Therapy

Targets process of thoughts rather than the content to gain awareness + acceptance; Holism, wellness, + context are important

Overall Goal Third Generation of Behav Therapy

Finding peace + shifting perspective

What does Third Generation of Behav Therapy include?

Acceptance-based therapies, like:

• Dialectical Behavior Therapy (DBT)

• Acceptance + Behavior Therapy (ABT)

• Mindfulness-Based Cognitive Therapy (MBCT)

• Schema Therapy

Dialectical Behavior Therapy (DBT)

Balance b/w acceptance + change with a technique heavy + structure heavy approach; Can be applied to working with a wide variety of concerns including depression, complex trauma + relationships

What is DBT a type of?

Cognitive behavioral therapy

Linehan (DBT)

Dev DBT to treat ppl with borderline personality disorder; Had BPD herself which led her to dev this approach to help ppl with emotional regulation, mindfulness, + suicidal ideation/behav

Dialectics (DBT)

Art of investigating the relative truth of principles, opinions, + guidelines; Arriving at the truth by examining the argument + resolving the 2 into a rational synthesis → 2 things that appear opposing can actually work together

Helps clients to:

• Dev a broader perspective of their prob

• Learn to look for the dialectic pole

• Consider more options + possibilities

• Get “unstuck” + dev a sense of efficacy + competence

What do use of Dialectics help clients to do? (DBT)

• Dev a broader perspective of their prob

• Learn to look for the dialectic pole

• Consider more options + possibilities

• Get “unstuck” + dev a sense of efficacy + competence

Emotional Regulation (DBT)

The ability to respond to emotions in healthy ways → Can lead to healthier + more fulfilling lives

Why may ppl with BPD have emotional disreg? (DBT)

As a result of trauma, attachment wounds, genetics, etc

Overall Goal of DBT

Dev dialectic thinking + practice skills that result in emotional regulation, reduced suffering, + improved relationships

Therapeutic Relationship in DBT

Reciprocal + collaborative; Therapists are active

Stages of DBT

1. Reducing + eliminating life-threatening behavs

2. Experience emotions

3. Work to accomplish goals

4. Discover + engage in ways to feel complete

DBT Timeframe

1 year of 1 hour weekly individual therapy sessions + 2 hour weekly group therapy; Can be adapted to work with wide variety of populations

Emotional Regulation Skills (DBT)

First + most critical task; Promote clients’ ability to effectively understand + identify distressing emotions

DBT Techniques

Mindfulness (DBT)

Present moment awareness without judgement

Ex. Wise Mind + Radical Acceptance

DBT Techniques

Wise Mind

Represents the overlapping "middle path" where rational mind and emotional mind meet

Mindfulness; DBT Techniques; 3 States of Mind of Wise Mind Venn

Radical Acceptance

Complete + total acceptance of something or some situation

Mindfulness; DBT Techniques

Distress Tolerance

Assists with letting go or coping with distress; Includes self-soothing + distraction skills

Ex. The wise mind ACCEPTS acronym + IMPROVE acronym → coping strats to use during times of stress

DBT Techniques

Wise Mind ACCEPTS Acronym

Used to temporarily distract from and ride out intense, painful emotions without making the situation worse or acting on harmful impulses

A → Activities (focus on a task)

C → Contributing (do something nice for someone)

C → Comparisons (compare current situation to something hard you got through)

E → Emotions (do something that makes you feel opp)

P → Pushing Away (leaving room, etc)

T → Thoughts (engage in mental exercises or puzzles)

S → Sensations (safe intense physical sensations to ground)

Distress Tolerance; DBT Techniques

Wise Mind IMPROVE Acronym

A distress tolerance skill used to help you get through painful, high-intensity situations without making them worse or resorting to impulsive reactions

I → Imagery (imagine in a safe, relaxing place)

M → Meaning (find sense of purpose with pain/struggle)

P → Prayer (connect with higher power or self or universe)

R → Relaxation (breathing, calm physically)

O → One Thing in the Moment (full awareness to present)

V → Vacation (brief break from pressure)

E → Encouragement (pos self talk)

Distress Tolerance; DBT Techniques

Interpersonal Effectiveness

Skills req to make requests or convey wants to others, manage + resolve conflicts, est + maintain pos relationships + maintain self-respect

Ex. DEAR MAN GIVE FAST acronym

DBT Techniques

DEAR MAN GIVE FAST Acronym

Help you communicate clearly, get your needs met, keep relationships healthy, and protect your self-respect

D → Describe (state bare facts of situation)

E → Express (share feelings/opinions with i statements)

A → Assert (ask for what you want directly + say no)

R → Reinforce (explain pos effects, benefits, or conseq for getting or not getting what you need)

M → Mindful (keep focus on objective)

A → Appear Confident (strong posture, clear voice, etc)

N → Negotiate (be willing to give to get)

G → Gentle (be courteous)

I → Interested (listen actively + face other person)

V → Validate (acknowledge other person’s pov)

E → Easy Manner (keep relaxed presence)

F → Fair (be fair to yourself + other person)

A → Apologies (dont over apologize for having a need or having an opinion or saying no)

S → Stick to Values (dont compromise core values to please)

T → Truthful (dont exaggerate, make excuses, or lie)

Interpersonal Effectiveness; DBT Techniques

Who is DBT useful for?

Helpful for ppl with suicidal ideation, hospitalization, anxiety, + anger, substance abuse, disordered eating; Also effective with trauma, depression, bipolar, + personality disorders

What does DBT reduce symptoms of?

BPD, esp self-injurious + suicidal symptoms

Hayes (Acceptance + Commitment Therapy; ACT)

Developed Acceptance + Commitment Therapy; Focused on treatment of anxiety disorders with a contextual behav science focus

Focus of Acceptance + Commitment Therapy (ACT)

Acceptance of thoughts

Assumption of ACT

Assumes that avoidance of emotions + thoughts make probs worse; Acceptance + experiencing of thoughts + emotions leads to mental health

Experiential Avoidance (ACT)

Avoidance of distressing thoughts, emotions, interactions, + events which may lead to increased distress that serves as barriers to treatment

Goal is to instead observe + process distressing thoughts + experiences without attempting to control or change these inner experiences, distress becomes desensitized + easier to accept

Relational Frame Theory (ACT)

Behav theory of human lang + cognitions that helps ppl recog how they become entangled in thoughts + words + use those entangles in internal struggles against themselves

Goal is to engage in defusion; Once clients gain psych flexibility, they can engage in committed action

Defusion (ACT)

Stepping back + separating thoughts + lang; Goal of relational frame theory

Ex. Repeating thought over + over again instead of trying to change it

Committed Action (ACT)

Valued, enriched ways of living; What clients can do once they gain psych flexibility with relational frame theory

Overall Goals of ACT

Help clients accept cognitions + emotions that are outside of their control; Encourage clients to make a commitment to creating a life they value

Uses things like mindfulness, present-moment awareness, staying centered in body, + acceptance

Therapeutic Alliance in ACT

Bidirectional + therapists are empathetic, encouraging, compassionate, + reassuring

Are therapists in ACT respectful of cultural differences + spirituality?

Yes

What does ACT counselling initially focus on?

Initially focuses on acceptance of distress through psychoedu + metaphors; Clients then use skills + interventions including acceptance, diffusion, + mindfulness → then counseling gains are solidified + plan for relapse is dev

Hexaflex Model (ACT)

6 processes of healthy, flexible living including:

• Attention to present moment

• Acceptance

• Defusion

• Self-as-Context

• Values

• Committed Action

ACT Techniques

Awareness + Acceptance (ACT)

Clients are encouraged to engage in activities they used to enjoy but have withdrawn from; Clients are encouraged to be aware + accepting of thoughts + feelings rather than push them away

ACT Techniques

What is ACT useful/effective for?

Particularly helpful for anxiety (esp social anxiety); Effective for phobias, PTSD, panic, OCD, depression, psychosis, heroin addiction, substance abuse, chronic pain, + borderline personality disorder

How does ACT claim to reduce anxiety?

Anxiety can be reinforced through experiential avoidance so ACT aims to reduce by exposing ppl to their anxious thoughts, feelings, + fears

Kabat-Zinn (MBSR)

Dev mindfulness-based stress reduction (MBSR) + studied meditation with Buddhist teachers

Mindfulness-Based Stress Reduction (MBSR)

Focus is on mindfulness to decrease stress; Emphasizes mindfulness + cog process

Acceptance (MBSR)

A willingness to experience psychological events (thoughts, feelings, memories) without having to avoid them or let them unduly influence behav

The Being Mode (MBSR)

The opposite of the doing mode; Being mode is in direct experience, moment by moment, recognizing bodily sensation as they arise, without agendas or judgments, + letting go of thoughts

An openness to new experience rather than ruminating on how to solve a prob

Tenets of Mindfulness (MBSR)

What makes mindfulness work

• Observing inner experiences

• Acting with awareness

• Nonjudgement of inner experience

• Describing or labeling inner experience

• Nonreactivity

Overall Goal of Therapeutic Process in MBSR

Assist clients in moving away from obsessing + perseverating thoughts + feelings of their concern + instead teach them to be more present in the here + now

Therapists in MBSR

Listen deeply + stay in the present moment

Therapeutic Process in MBSR

Manualized + highly structured; 8 group sessions in 2-2.5 hours in length + one all day session with follow up sessions as needed

Weeks 1-4 → Developing skills, mindfulness training, present moment awareness, recog of thoughts, emotions, behavs, bodily sensations

Weeks 5-8 → Shifting towards recog of more challenging thoughts + feelings; Working on acceptance

Week 1-4 Therapeutic Process in MBSR

Developing skills, mindfulness training, present moment awareness, recog of thoughts, emotions, behavs, bodily sensations

Weeks 5-8 Therapeutic Process in MBSR

Shifting towards recog of more challenging thoughts + feelings; Working on acceptance

Conscious Thought Processing (MBSR)

Clients are encouraged to acknowledge thoughts + feelings that exist, + allow them to pass + not control them

MBSR Techniques

Mindfulness (MBSR)

Focused attention + open monitoring

MBSR Techniques

Decentering/Diffusion (MBSR)

Maintaining a degree of separation from inner experiences + viewing experiences as mental processes rather than facts

MBSR Techniques

Who is MBSR useful for?

Particularly helpful for depression + reducing relapse of depression; Can also be helpful for anxiety, bipolar, panic disorder, + adjustment disorders

Can also be effective for OCD, addiction, ADHD, + emotional dysregulation

Young (Schema)

Dev of schema therapy; Specialized in personality disorders, relationship issues, + self-esteem → believed that schemas dev in childhood (focuses more on ingrained probs)

What did Young believe about schemas?

Believed that schemas dev in childhood; Focuses more on ingrained probs

Schema Therapy

Integ of psychodynamic, interpersonal, attachment, + experiential techniques to target emotional + cog changes

Early Maladaptive Schemas (Schema)

Self-defeating emotional patterns from childhood; Can be thought of as a child’s needs left unmet

List of 5 Schema Domains (Schema)

1. Disconnection + Rej

2. Impaired Autonomy + Performance

3. Impaired Limits

4. Other Directedness

5. Overvigilance + Inhibition

Overall Goals of Therapeutic Process in Schema Therapy

To help ppl achieve + maintain a healthy adult mode of functioning + to help clients dev + sustain a healthy adult schema + stop engaging in maladaptive coping styles

Timeline of Schema Therapy

Generally longer in duration → typically 2 weekly indiv sessions over the course of 3 years

What is important in Schema Therapy?

Assessment is important + can be done through experiential exercises + schema inventories

Core of Schema Therapy

Therapeutic relationship → empathetic, warm, caring, + flexible; Balance b/w empathic attunement + caring confrontation

Limited Reparenting (Schema)

Using the power of the therapeutic alliance to provide connection, warmth, + nurturance → clients depend on therapists by regulating emotions

Schema Therapy Techniques

Empathic Confrontation (Schema)

Challenge clients’ maladaptive schemas in a warm + respectful manner

Schema Therapy Techniques

Cognitive Interventions (Schema)

Using hw assignments, challenging beliefs, + modifying maladaptive behavs → Challenging of schemas

Schema Therapy Techniques

Schema Flash Cards (Schema)

Examples of healthy ways clients can respond to activating schema triggers

Schema Therapy Techniques

What is Schema Therapy effective in treating ppl for?

BPD, ppl with relational probs, avoidant personality disorder, pain management, + sexual disorders

What can Schema Therapy be combined with?

With CBT to treat personality disorders, substance abuse, depression, anxiety, + eating disorders

Pros of 3rd Wave CBT

• Fits needs of culturally diverse clients bc of emphasis on values + context

• Mindfulness is effective for a wide variety of ppl

• ACT’s experimental focus may fit well with ppl who have a difficult time letting go

• Schema therapy proposed that early maladaptive schemas play a role in mental health

• DBT’s effects are long lasting

• Collab nature

Limits of 3rd Wave CBT

• Concern over spiritual aspects of mindfulness based approaches

• DBT may be too narrow + focused on BPD, however, it can be adapted to fit needs of other populations

• Demanding of therapists + extensive training is req

• Misunderstanding of theories can lead to misuse of approach

Behavioral Activation Therapy (BAT) Def

A 3rd wave approach that involves increasing pleasurable activities on a daily basis to help motivate ppl with depression who may experience low energy + who may have withdrawn from life → the positive activities serve as a pos reinforcer, builds self-efficacy + breaks the cycle of isolation + depression

Used early in depression treatment where clients lack energy or motivation

Strategies for Behavioral Activation

• Est a list of pleasant activities

• Scheduling

• Monitoring

• Charting activities

• Relaxation + skills training

• Recognizing aversive + avoidant behaviors

• Confronting cog distortions

Gilbert (Compassion)

Dev compassion-focused therapy

Compassion-Focused Therapy

Aims to help client feel safer + more capable; Teaches clients how to be more compassionate + kind to themselves → Specifically targets shame + self-criticism

Wells (Metacog)

Dev metacognitive therapy

Metacognitive Therapy

Cog approach that assumes clients lose control over their thoughts + emotions, which worsens emotional suffering; Metacog controls meta process + thinking

Explains stuff like tip of the tongue + addresses loss of control over thought patterns

Mindfulness Def

Teaches clients how to become aware of whats happening in the present moment without judgement

1st Step in Mindfulness

Use a psychoedu approach about what mindfulness is; Important to meet clients where they are at → introducing deep breathing in session may be the 1st step

What should happen in Mindfulness if someone has experience with it?

Introduce more complex mindfulness exercises may be helpful

• Body Scan

• Mindfulness Walk

• Awareness of Surrounding + Senses

Mindfulness + Indiv Differences

Should consider individual differences

Ex. Indiv with chronic pain may benefit from taking focus off pain

2nd Wave CBT

Focuses primarily on presenting symptoms + changing the content of dysfunctional thoughts

3rd Wave CBT

Targets the process of thinking, prioritizing wellness over dysfunction, a holistic perspective, finding peace/ease within the self, + shifting perspective without forcing immediate symptom reduction

What does DBT assume about BPD?

It results specifically from the interaction of emotional vulnerability + an invalidating environment; Strong painful emotions precede thoughts

3 States of Mind of Wise Mind Venn

1. Rational Mind

2. Emotional Mind

3. Wise Mind

Rational Mind

Logic, reasoning, planning, + obj prob solving

3 States of Mind of Wise Mind Venn

Emotional Mind

Mood, sensations, impulsivity, reactivity, + intense passion

3 States of Mind of Wise Mind Venn

4 Explicit Therapy Goals

1. Teaching new skills

2. Understanding + increasing client motivation

3. Helping clients accept what cannot be changed

4. Real world application + functionality

4 Stages of Treatment

1. Moving from out of control to in control

2. Moving from emotionally shut down to experience emotions fully without PTSD/dissociation symptoms

3. Building an ordinary life + solving ordinary probs of living

4. Moving from incompleteness to completeness + connection

3 Interpersonal Effective Domains

1. Objective Effectiveness

2. Relationship Effectiveness

3. Self-Respect Effectiveness

ACT Acronym

A → Accept + embrace thoughts + feelings

C → Choose a direction in life

T → Take steps towards action

What does Acceptance + Commitment Therapy (ACT Therapy) attribute psychopathology to?

Experiential avoidance; Psychological pain is viewed as a natural conseq to living, whereas psych rigidity (not pain itself) causes unnecessary suffering

Self-as-Context

The realization that indivs are not their thoughts, feelings, or memories; Altho these exist within a person, they are not the essence of who the person is

ACT Therapy

Doing Mode (MBCT)

The brain’s auto instinct to analyze, ruminate, + prob solve to elim unwanted neg feelings, which paradoxically reactivates depressive neural cycles

Being Mode (MBCT)

Moment-by-moment direct awareness of bodily sensations without agendas, judgements, or rumination

4 Self-Regulation Mechanisms of Mindfulness (MBCT)

1. Attention Regulation

2. Body Awareness

3. Emotion Regulation

4. Change in Perspective or Self

3 Schema Coping Resp (Schema)

1. Overcompensation

2. Avoidance

3. Surrender

5 BPD Schema Modes (Schema)

1. Abandoned/abused child

2. Angry/impulsive child

3. Detached protector

4. Punitive parent

5. Healthy adult

Schema Diary Forms (Schema)

A structured tool for clients to log triggering events, schemas, + adaptive reactions