Thursday, October 11, 2007

Chapter 8 - Cognitive Therapy

My Lecture Notes
Current Psychotherapies
Chapter 8
Cognitive Therapy
Aaron T. Beck and Marjorie E. Weishaar

Instructor: Jeff Garrett Ph.D.

Research on depression in the 1960s, which served as the foundation of cognitive therapy, was conducted by Aaron Beck.

Beck Depression Inventory - 2. (In class).

Seven Basic Assumptions
Beck et al (1979) provided a list of general assumptions that underlie the theory.

1. Perception and experiencing in general are active processes which involve both inspective and introspective data.

2. The patient's cognitions represent a synthesis of internal and external stimuli.

3. How a person appraises a situation is generally evident in his cognitions (thoughts and visual images).

4. These cognitions constitute the person's “stream of consciousness” or phenomenal field, which reflects the person's configuration of himself, his world, his past and future.

5. Alterations in the content of the person's underlying cognitive structures affect his or her affective state and behavioural pattern.

6. Through psychological therapy a patient can become aware of his cognitive distortions.

7. Correction of these faulty dysfunctional constructs can lead to clinical improvement. [p. 8 Beck, A. T., Rush, J. A., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.]

Basic Concepts.
CT is based on the role information processing plays in survival.
The theory behind cognitive therapy asserts that altering thoughts influences feelings, motivations and behaviors.
The theory states cognition, behavior, affect, and motivation are intertwined and co-occurring.
Therapeutic intervention focuses on the primacy of cognition.
Cognitive Schema – a structure containing self-perceptions; thoughts about others and the world; our memories, goals, fantasies; and everything we’ve learned. (Structures that contain an individual's core beliefs and assumptions are labeled Cognitive Schemas) Cognitive Theory states that an individual's fundamental beliefs and assumptions are contained in structures termed cognitive schemas.)

Cognitive Shift – a systematic bias in information processing.
Cognitive Vulnerabilities – specific attitudes predisposing the interpretation of experiences.
Cognitive Distortion - refers to a systematic error in reasoning.
A cognitive therapist relies on collaborative empiricism and guided discovery. Focus is on patients testing beliefs and behaviors. Cognitive and behavioral techniques are both employed. The preferred method of dialoguing with a patient in cognitive therapy is through the use of Socratic questions.

Networks of cognitive, affective, motivational, and behavioral schemas.
Primal modes are universal and related to survival.
They include primal thinking which is rigid, absolute, automatic and bias.
Dysfunctional modes are treated by deactivating them, altering their structure and content and developing more adaptive modes.

CT’s Cognitive Triad.
Pattern that triggers depression:
1. Client holds negative view of themselves and blames themselves.
2. Selective abstraction: Client has tendency to interpret experiences in a negative manner.
3. Client has a gloomy vision and projections about the future.

Basic Characteristics of CT.
Symptom focused.
Empirically derived techniques.
Acknowledges underlying precursors of symptoms while remaining in present.
Case conceptualization drives treatment.
Primary Roles of the CBT Therapist.
Conceptualizing the patient in cognitive terms.
Structuring the sessions.
Using collaborative empiricism and guided discovery to specify problems and set goals.

The Cognitive Model - see diagram from class notes.

The Cognitive Model.
Automatic thoughts influence not only one’s emotional response, but also one’s behavioral, motivational, and physiological responses.
The relationship is bi-directional (all systems act together as a mode) therefore simultaneously biology, emotions, behavior (and motivation) influence thoughts.
Subsequently, biological treatments can change thoughts and CBT can change biological processes.
We all have cognitive vulnerabilities (i.e., core beliefs) which predispose us to interpret information a certain way.
These vulnerabilities are developed early.
When these beliefs are rigid, negative, and ingrained we are predisposed to pathology.
These core beliefs give rise to conditional assumptions, i.e., rules for living, as we mature.
In psychopathology there are systematic biases toward selectively interpreting information in a certain manner which are disorder specific.

Strategies of Cognitive Therapy.
Collaborative Empiricism.
Guided Discovery (Guided discovery refers to the process by which a therapist serves as a guide to clarify problem behaviors and thoughts).
Deactivation of Dysfunctional Modes.
Techniques which directly deactivate them.
Modifying their content and structure.
Constructing more adaptive modes to neutralize them.

Comparing CT to other Therapies.
CT Compared to Psychoanalysis.
Both assume behavior is influenced by beliefs of which we may be unaware.
CT focuses on linkages among symptoms, conscious beliefs and current experiences; little concern with unconscious feelings or repressed emotions as in psychoanalysis.
CT has minimal focus on childhood or developmental issues except in terms of assessment or when addressing core beliefs.
CT is highly structured and generally short term (12-16 weeks) whereas psychoanalysis is unstructured and long-term.
In CT the therapist actively collaborates with the patient.

CT Compared to REBT.
CT labels thoughts as dysfunctional while REBT labels thoughts as irrational.
CT uses inductive reasoning while REBT uses deductive reasoning.
CT proposes cognitive specificity for each disorder while REBT proposes a core set of irrational beliefs (In contrast to REBT cognitive therapists hypothesize that each mental disorder has its specific cognitive content).
CT’s view of the problem is functional; pathology arises from multiple cognitive distortions while REBT’s view of the problem is philosophical; pathology arises from shoulds, musts, and oughts.
CT therapists are more collaborative while REBT therapists are more confrontive.
CT therapists emphasize psychoeducation as an early critical component of treatment while REBT therapists have a higher reliance on psychoeducation throughout.
CT focuses on "hot cognitions" as critical, but obtain them in a less aggressive manner while REBT is more aggressive.
CT therapists encourage clients to use inductive reasoning whereas REBT therapists rely on deductive reasoning.

CT Compared to BT.
CT is very different from Applied Behavioral Analysis.
CT is the most commonly practice form of CBT, an overarching term to represent therapies. which integrate cognitive and behavioral theories and techniques.
CT sees the individual as more active rather than passive in the change process.
CT stresses expectations, interpretations, and reactions.

CT Compared to MMT.
Cognitive therapy, in contrast to multimodal therapy (MMT) stresses the primacy of cognition.

CT Compared to Medication
Studies generally show CT to be equivalent to psychotropic medications for depression, bulimia, and some anxiety disorders.
General research suggests the combination of the two approaches is superior to either used in isolation.
CT shows longer efficacy (less relapse) and increased likelihood of continuing gains when treatment is discontinued.
CT and antidepressants (TCAs/1st Generation SSRIs) show equal efficacy rates.

Developed by Aaron T. Beck M.D.
He was investigating the "anger turned inward" psychoanalytic concept regarding depression in the 1960s and found evidence of negative cognitions.
Bandura, Ellis, Mahoney, and Mechenbaum ideas were all influential in the development of CT as they were developing their approaches simultaneously.

Other major influences were…
Phenomenological approaches.
Structural theory and Depth Psychology.
Cognitive Psychology.

Current Status of CT.
Controlled Studies have shown the efficacy of CT with:
Panic Disorder.
Social Phobias.
Generalized Anxiety Disorders.
Substance Abuse.
Eating Disorders.
Marital Problems.
Post-traumatic Stress Disorder.

Resources in CT.
Center for CT (U/Penn) and Beck Institute are the Major Training Sites (Both in Philadelphia).
Multiple other training sites in the US and internationally.
Cognitive Therapy and Research and Journal of Cognitive Psychotherapy.
Academy of Cognitive Therapy (for more information go to

CT’s View of Personality.
Thinking is Problematic or Distorted when it is very ...
Comfort Seeking.

Belief Hierarchy.
The belief hierarchy proposed in cognitive theory goes from core beliefs or assumptions which are the most stable, least accessible cognitions to voluntary thoughts which are the least stable but most accessible cognitions.

Cognitive Distortions
1. Arbitrary Inference: Drawing a conclusion without evidence or in the face of contradictory evidence. Example - a young woman with anorexia nervosa believes that she is fat although she is dying of starvation.
2. Selective Abstraction: Dwelling on a single negative detail taken out of context. Example – While on a date you say one thing you wish you could have said differently and now see the entire evening as a disaster.
3. Overgeneralization: A single negative event is viewed as a never-ending pattern of defeat. Example - Following a job interview an accountant does not receive the job. She/he begins thinking that they will never find a job despite their qualifications.
4. Magnification and/or Minimization: The binocular trick. Things seem bigger or smaller than they truly are (depending on which lens you are looking through). Example: An employee believes that a minor mistake will lead to being fire vs. an alcoholic who believes he/she doesn’t have a problem.
5. Personalization: Assuming personal responsibility for something for which you are not responsible. (Attributing external events to oneself without evidence supporting a causal connection is termed Personalization.). Example – sometimes seen in patients who have been sexually or physically abused.
6. Dichotomous Thinking: Is All or Nothing Thinking. Things are seen as black or white, there is no gray (middle ground). Example 1. – Things are wonderful or awful, good or bad, perfect or a failure. Example 2. - Kate has anorexia nervosa and when she gains one pound she believes she is fat. If she loses one pound she can perceive herself as thin. Kate's thought process reflects Dichotomous Thinking. Example 3. - A patient with anorexia nervosa believes that she is thin when she exercises, but fat if she eats. This would be an example of the all or nothing thinking cognitive distortion
7. Mind Reading: Assuming you know the motives, thoughts, intentions of others. Example – If your friend is in a bad mood you assume it’s your fault and don’t asked what is wrong.
8. Fortune Teller Error: Creating a negative self fulfilling prophesy. Example: You believe you will fail an important exam so you do not study and fail.
9. Emotional Reasoning: You assume your negative feelings result from the fact that things are negative. Example – If you feel bad, then that means that the world or situation is bad. You don’t consider that your feelings are a misrepresentation of the facts.
10. Should Statements: The use of words like should, ought, must rather than "it would be preferred" to guilt self. Example: "I should be perfect".
11. Labeling and Mislabeling: Labeling yourself or others in a demeaning way. Example: Name calling "I am worthless" or "He’s a total failure".

Process of Psychotherapy in CT.
Early in treatment a cognitive therapist may rely more on behavioral techniques whereas later in treatment the focus shifts towards cognitive techniques.
Through the process of guided discovery cognitive therapy patients create homework. assignments for themselves called "behavioral experiments" with input from their therapist.

Structure of a CBT Session.
Mood check.
Setting the Agenda.
Bridging from last session.
Today’s agenda items.
Homework assignment.
Summarizing throughout and at the end.
Feedback from patient.

General Principles of CT.
Goal Is to correct dysfunctional thinking and help patients modify erroneous assumptions.
Patient is taught to be a scientist who generate and tests hypotheses.
Relationship between patient and therapist is collaborative.

Fundamental Concepts.
Collaborative Empiricism – goal is to demystify therapy by helping the client search for empirical evidence that supports beliefs.
Socratic Dialogue – form of questioning used to help patients come to their own conclusions about their thoughts and behaviors.
Guided Discovery – therapist collaborates with patient to develop behavioral experiments to test hypothesis.

Process of Therapy.
Initial Sessions – essential to build rapport, focus on problem definition, goal setting, and symptom relief, psychoeducation, behavior interventions. (Symptom relief is a primary goal in the initial cognitive therapy interview).
Middle Sessions – emphasis shifts from symptom/behaviors to patterns of thinking.
Termination – Expectation that therapy is time-limited.

Examples of Behavioral Interventions in CT.
Weekly Activity Monitoring.
Activity Schedule.
Graded Tasked Assignments. (Assisting a patient in initiating a task at a nonthreatening level and then gradually increasing the task difficulty).
Behavioral Experiments.
Exposure Techniques.
Role Plays.

More Details about a Specific Behavior Technique: Weekly Activity Monitoring.
Patient records activities and rates them for pleasure and Mastery.
Can be used in several different ways, the activity monitoring form allows the therapist and patient to:
Assess how pt is spending time.
Measure a sense of accomplishment and/or pleasure received by certain activities.
Evaluate automatic thoughts or emotional shifts.
Fill in specific times with planned activities such as pleasant activities for depressed pts or activities that must be accomplished for procrastinating pts.
Compare predicted ratings of accomplishment and pleasure with actual ratings.

Examples of Cognitive Interventions in CT.
Eliciting automatic thoughts through Dysfunctional Thought Records.
Identifying whether thoughts represent distortions in information processing.
Using Socratic questions to evaluate thought process.
Generating alternatives in terms of how to think or how to behave differently.
More Details about a Specific Cognitive Technique.
Basic Question: What just went through your mind?
Ask when an emotional shift is noted in session.
Create an emotional shift by having the pt describe or visualize a recent situation when they felt intense emotions and then answer the question.
If pt still cannot answer the question try asking.
Do you think you were thinking of _____________?
If someone else was in the situation what do you think they might have been thinking?
Where you thinking _____________? (insert something paradoxical).

More Details about a Specific Cognitive Technique.
Using Socratic Questioning to have pt examine and refute their dysfunctional thoughts.
What evidence do you have to support the belief?
What evidence do you have to refute it?
What would your spouse, best friend sibling (or anyone whom you admire greatly) say in this situation?
What would you say to your spouse, friend, or sibling if they were thinking the same thing you are thinking.
How could you look at this situation so you would feel less depressed? Is this view as reasonable as your first choice?

Downward Arrow Technique.
Use the downward arrow technique to obtain less accessible beliefs.
If that were true what would it mean to you (about you)?
And, then what?
What then?

Principles for Setting Effective Homework.
Make sure rationale is clear.
When feasible, have client choose task.
Personalize task to therapy goals.
Begin where client is, not where client thinks he/she should be.
Be specific and concrete: where, when, with whom, etc.
Formalize the task e.g., write on paper.
Plan ahead for potential obstacles and "trouble shoot".
Practice the task in session.
Review homework at the beginning of each session.

Other CT Techniques
De-catastrophizing – Asking a patient to ponder "what if" scenarios about feared consequences is known as De-catastrophizing.
Reattribution – Alternative explanations systematically explained.
Redefining – Help client define the problem differently e.g., "Nobody ever talks to me" becomes "I need to try to initiate conversations so other people become interested in me."
Decentering – Used with social anxiety to shift focus: Client is taught to see that thoughts are just thoughts and not "them" or "reality".
Modifying Core Beliefs creates the most significant change in a dysfunctional mode for a client.


Eva said...

I was looking for the definition of de-catrosphicizing, I could not find it in my text book or anywhere else but here in your blog. Thank you for the valuable information.

logancsmama said...

We are all cramming for an exam in our graduate Theories class. This post is very nicely done and I'm sure took a lot of work.Thank you for the post Jeff.