Chapter 10: Cognitive Behavior Therapy

The various cognitive behavioral approaches share the following attributes:

• A collaborative relationship between client and therapist

• The premise that psychological distress is often maintained by cognitive processes (if we change the way we think, we change the way we see thinks)

• A focus on changing cognitions to produce desired changes in affect and behavior

• A present-centered, time-limited focus

• An active and directive stance by the therapist

• An educational treatment focusing on specific and structured target problems

Albert Ellis’s Rational Emotive Behavior Therapy (REBT)

• Assumes that cognitions, emotions, and behaviors interact and have a reciprocal cause-and-effect relationship.

• The point of entry is the cognition, but for Carl Rogers it is emotion—that’s why empathy is a major thing

• Is highly cognitive and directive.

• Teaches that our emotions stem mainly from our beliefs that influence the evaluations, interpretations, and reactions to life situations.

• Clients learn to identify the interplay of their thoughts, feelings, and behaviors and to identify and dispute irrational beliefs maintained by self-indoctrination.

• Clients learn to replace detrimental ways of thinking with effective and rational cognitions.

  • If I can be rational, I don’t have to be so worked out about that

Albert Ellis

Rational Emotive Behavior Therapy (REBT)

View of Emotional Disturbance

• Clients learn irrational beliefs and re-create it throughout their lifetime.

• Clients learn to stop blaming themselves and learn to fully and unconditionally accept themselves.

• Clients have strong tendencies to transform their desires and preferences into “shoulds,” “musts,” and “oughts.”

  • Dispute the “I must” by finding a piece of evidence (ex. I must be pretty for people to like me) → this is irrational → do you know of anyone who is pretty that is also disliked?

  • The “I must” is the irrational belief that will keep us stressed and feeling doomed, it will affect our feeling

clinical procedures

• Rely on experimental findings of psychological research

• Based on principles of learning that are systematically applied

• Focus is on the client’s current problems and on assessing behavior through observation or self-monitoring.

  • Does not work with what happened to with what happened when you were 5 years old. We do not have to go to the past to fix

  • CBT is usually the therapy of choice because of its experimental which has added to its effectiveness→ once I have disputed the irrational thinking, the person feels better → this is very concrete

ABC Framework

• A is the existence of an activating.

• C is the emotional and behavioral consequence or reaction of the individual.

• B is the person’s belief about A, largely creates C, the emotional reaction.

  • B is the middle, the black box

Therapeutic Goals

• To help clients differentiate between realistic and unrealistic goals and between self-defeating and life-enhancing goals

• To assist clients in the process of achieving the following:

  • Unconditional self-acceptance (USA)

    • Do not put a condition that you must have, for you to be successful or for you to be good

  • Unconditional other-acceptance (UOA)

    • My boss is a control freak, but this part of the job. I hate it when he micro-manages me but he is my boss and doesn’t have to be different for me to accept him as a boss.

  • Unconditional life-acceptance (ULA)

USA

Unconditional self-acceptance

• Do not put a condition that you must have, for you to be successful or for you to be good

UOA

Unconditional other-acceptance 

• My boss is a control freak, but this part of the job. I hate it when he micro-manages me but he is my boss and doesn’t have to be different for me to accept him as a boss.

ULA

Unconditional life-acceptance

Cognitive Techniques

Therapists practicing REBT use the following techniques:

• Disputing irrational beliefs

• Doing cognitive homework

• Bibiliotherapy

  • Reading material

• Changing one’s language

  • Instead of saying “I must” can you say “I want to” We are not desperate, you do not need it to be successful or happy

• Psychoeducational methods

  • Disputing irrational belief

Emotive Techniques

• Therapists practicing REBT use the following techniques:

  • Rational emotive imagery

  • Using humor

  • Role playing

  • Shame-attacking exercises

  • Standard behavior therapy procedures

Application to Group Counseling

• Group members can do the following:

• Learn how their beliefs influence what they feel and what they do

• Explore ways to change self-defeating thoughts in various concrete situations

• Learn to minimize symptoms through a profound change in their philosophy

Application to Group Counseling

• Group REBT affords many opportunities for the following:

• Practice assertiveness skills

• Take risks by practicing different behaviors

• Challenge self-defeating thinking

• Learn from the experiences of others

• Interact therapeutically and socially with each other in after-group sessions

Aaron Beck

Cognitive Therapy

Aaron Beck’s Cognitive Therapy

• Tailored for specific diagnoses such as anxiety, panic, eating disorders, and phobias.

• Treatments are standardized and based on empirical research.

• Homework allows lessons learned in group to generalize to the client’s daily environment.

• Reason why people get depression: Angry with someone else and turn it inside

  • Depressed people actually want to feel better, they are not punishing themselves

  • Depression is a way of thinking

    • Very self-punishing, the way they see themselves

    • It is your thinking that makes you feel depressed

Following are the three theoretical assumptions of Cognitive Therapy (CT):

1. People’s thought processes are accessible to introspection.

2. People’s beliefs have highly personal meanings.

3. People can discover these meanings themselves rather than being taught or having them interpreted by the therapist.

Not so essential for the counselor to challenge and trying to find the rational belief – it is introspectional

Aaron Beck’s Cognitive Therapy

• Pattern that triggers depression is the following:

1. Clients hold negative views of themselves.

• “I am a lousy person.”

2. Selective abstraction

• Client interprets life events through a negative filter.

• “The world is a negative place where bad things are bound to happen to me.”

• Look at something that is circumstantial and make it personal

3. Client holds a gloomy vision of the future.

• “The world is bleak and it isn’t going to improve.”

• There is no future, nothing can be done to feel better

Selective abstraction

a cognitive distortion in which a person focuses on a single negative detail of a complex situation while ignoring all other positive or neutral aspects

• Client interprets life events through a negative filter.

Beck identifies the following are the seven cognitive distortions:

1. Arbitrary inferences

2. Selective abstraction

3. Overgeneralization

4. Magnification and minimization

5. Personalization

6. Labeling and mislabeling

7. Dichotomous thinking: black and white thinking → it is irrational → this or that → create a lot of non-acceptance of the self and non-acceptance of others

Arbitrary inferences

Selective abstraction

Overgeneralization

Magnification and minimization

Labeling and mislabeling

Dichotomous thinking

Basic Principles of Cognitive Theory

• Psychological problems are an exaggeration of adaptive responses resulting from commonplace cognitive distortions.

• It is an insight-focused therapy with an emphasis on changing negative thoughts and maladaptive beliefs.

• Clients’ distorted beliefs are the result of cognitive errors.

• Through Socratic dialogue/reflective questioning, clients test the validity of their cognitions (collaborative empiricism).

• Change results from reevaluating faulty beliefs based on contradictory evidence that clients have gathered.

• Clients’ distorted beliefs are the result of cognitive errors rather than being driven solely by irrational beliefs.

  • Black and white is not a belief, it is a cognitive thinking

collaborative empiricism

Client-Therapist Relationship

• Cognitive therapists are continuously active and deliberately interactive with clients, helping clients reframe their conclusions.

• He or she functions as a catalyst and a guide who helps clients understand how their beliefs and attitudes influence the way they feel and act.

• Homework facilitates more rapid and enduring gains.

length and course of CT

varies greatly and is determined by the therapy protocols used for specific diagnoses.

• CT for depression: lasts 16 to 20 sessions and begins with behavioral activation

  • You have to change the person’s behavior

• CT for panic disorder: lasts 6 to 12 sessions and targets catastrophic beliefs about internal physical and mental sensations

3 types of activity:

1. Activity that gives us some level of Enjoyment

2. Activity that gives us some level of Accomplishment/Achievement

3. Activity that gives us some level of Social interaction

Behavior Activation Diary

Christine Padesky and Kathleen Mooney

Strengths-Based Cognitive Behavior Therapy (S-B CBT)

Christine Padesky and Kathleen Mooney’s Strengths-Based Cognitive Behavior Therapy

• Developed by Christine Padesky and Kathleen Mooney, S-B CBT is a variant of Aaron Beck’s cognitive therapy.

• It involves identifying and integrating client strengths at each phase of therapy.

• Active incorporation of client strengths encourages clients to engage more fully in therapy and often provides avenues for change that otherwise would be missed.

Basic Principle of Strengths-Based CBT

• SB-CBT is empirically based.

  • Therapists should be knowledgeable about evidence-based approaches pertaining to client issues discussed in therapy.

  • Clients are asked to make observations and describe the details of their life experiences, so what is developed in therapy is based in the real data of clients’ lives.

  • Therapists and clients collaborate in testing beliefs and experimenting with new behaviors to see if they help achieve desired goals.

Applications of Strengths-Based CBT

(Three applications)

1. An add-on for classic CBT

2. A four-step model to build resilience and other positive qualities

3. The NEW paradigm for chronic difficulties and personality disorders

Strengths-Based CBT

(Four Steps)

• Search

• Construct

• Apply

• Practice

Donald Meichenbaum

Cognitive Behavior Modification

Donald Meichenbaum’s Cognitive Behavior Modification

• Focus

Client’s self-statements or self-talk

Donald Meichenbaum’s Cognitive Behavior Modification

• Premise

As a prerequisite to behavior change, clients must notice how they think, feel, and behave, and what impact they have on others.

Donald Meichenbaum’s Cognitive Behavior Modification

• Basic assumption

Distressing emotions are typically the result of maladaptive thoughts.

Donald Meichenbaum’s Cognitive Behavior Modification

• Self-instructional therapy focus

• Trains clients to modify the instructions they give to themselves so that they can cope more effectively.

• Emphasis is on acquiring practical coping skills.

Donald Meichenbaum’s Cognitive Behavior Modification

• Cognitive structure

• The organizing aspect of thinking, which seems to monitor and direct the choice of thoughts

• The “executive processor”

The three phases of behavior change:

1. Self-observation

2. Starting a new internal dialogue

3. Learning new skills

The Phases of Stress Inoculation Training (SIT)

1. The conceptual-educational phase

2. Skills acquisition and skills consolidation phase

3. Application and follow-through phase

The Phases of Stress Inoculation Training (SIT)

• The conceptual-educational phase

The Phases of Stress Inoculation Training (SIT)

• Skills acquisition and skills consolidation phase

The Phases of Stress Inoculation Training (SIT)

• Application and follow-through phase

The Phases of Stress Inoculation Training (SIT)

• The conceptual-educational phase

1

The Phases of Stress Inoculation Training (SIT)

• Skills acquisition and skills consolidation phase

2

The Phases of Stress Inoculation Training (SIT)

• Application and follow-through phase

3

A Cognitive Narrative Approach to CBT

• It focuses on the plots, characters, and themes in the stories people tell about themselves and others.

  • We reconstruct that storyline for clients to identify their strengths and what they can do differently

• Meichenbaum claims that we are all “storytellers.”

• In therapy, clients learn how they construct reality, examine the implications and conclusions they draw from their stories, and develop resilient-engendering behaviors.

Strengths From a Diversity Perspective

• CBT uses the individual’s belief system, or worldview, as part of the method of self-exploration.

  • Quite applicable to different cultures

• Emphasis on cognition, action, and relationship issues appeals to clients from diverse backgrounds.

• CBT and multicultural therapy share common assumptions that make integration possible.

Emotional disturbances according to Ellis

Concepts and applications of Beck’s cognitive therapy

Strengths-Based CBT Four Steps

• Search

1

Strengths-Based CBT Four Steps

• Construct

2

Strengths-Based CBT Four Steps

• Apply

3

Strengths-Based CBT Four Steps

• Practice

4

Strengths-Based CBT Four Steps

• Construct

Strengths-Based CBT Four Steps

• Apply

Strengths-Based CBT Four Steps

• Practice

Cognitive distortions