Lecture 3: Cognitive therapy

Question 1

Cognitive therapy

Answer 1

Based on theory of personality which maintains that people respond to life events through cognitive, affective, motivational, behavioural responses. Deals with learning and how individuals perceive, interpret and assign meanings to events

Question 2

What are basic concepts related to cognitive therapy?

Answer 2

Cognitive schemas- people’s perceptions of themselves, others, goals and expectations, memories, fantasies and previous learning
Cognitive shift towards selectively interpreting certain themes
Core beliefs which predispose people due to certain life events to interpret experiences in biased way-> cognitive vulnerabilities
Linear relationship between activation of cognitive schemas and changes in systems
Modes- networks of cognitive, affective, motivational and behavioural schemas which can be primal

Question 3

What are the strategies used?

Answer 3

Collaborative empiricism which is interpreting stimuli but which has been mis-interpreted
Guided discovery is discovering what leads to a patient’s misperceptions and beliefs and linking to past experiences
Socratic dialogue which uncovers a patient’s views and examining maladaptive features. Involves asking questions, listening, summarizing, asking analytical questions
Reducing cognitive distortions to shift to a more neutral condition. Involves deactivation, modifying content and structure and constructing more adaptive modes

Question 4

Techniques

Answer 4

Aims to correct errors and biases in information processing and modifying core beliefs which lead to false conclusions. Also make use of behavioural techniques like skills training, role-playing, behavioural rehearsal and exposure therapy.

Question 4

Cognitive therapy compared to psychoanalysis

Answer 4

Both look at conscious common themes in reactions, narratives and imagery used which is similar to psychoanalysis as it focusses on unconscious meanings, needs, repressed childhood memories and sexuality. But CT is highly structured and short term but PT is long-term and unstructured. CT uses logic and behavioural experiments so similar to REBT as changes assumptions in an active and directive form of therapy.

Question 4

Cognitive therapy compared to REBT

Answer 4

CT argues that each disorder has cognitive specificity that each disorder has its own cognitive profile which needs a different technique to treat based on the disorder. Cognitive deficits are in psychopathology which can impact people’s ability to see later occurring negative consequences, hinder concentration, direct thinking or recalling

Question 5

CT compared to behavioural therapy

Answer 5

BT ignores internal events but focuses more on behavioural analysis but not entirely true. Similarities include:
→ both are empirical
→ both focus on the present
→ problem-oriented focus
→ explicit identification of problems and situations is required
These are complementary as expectations and negative automatic thoughts are vocalized

Question 5

Sources of CT’s background

Answer 5

1. Phenomenological psychology (individual’s self and personal world are central in determining behavior)
2. Structural theory and depth psychology (cognition structured into primary and secondary processes)
3. Cognitive psychology

Question 5

Beginnings of cognitive therapy

Answer 5

Emerged from Beck’s research on depression and found a negative bias in clients’ cognition and used observations to develop own model on emotional disorders. Ellis rejected psychoanalysis and underlying assumptions in the client most important-> directive style. There were some behaviourist influences like reinforcement, modelling and vicarious learning

Question 6

What is the current status of the cognitive model?

Answer 6

Significant support also with cognitive triad, negatively biased processing of stimuli and dysfunctional beliefs. Cognitive specificity shown in many disorders like danger-related bias in anxiety disorders. Has led to lower rates of relapse of anxiety and depression than other treatments

Question 7

What has been found to be a key factor in suicide?

Answer 7

Hopelessness leads to individuals being more likely to commit suicide, and CT reduces rates of reattempting suicide by 50%

Question 8

What has cognitive therapy been integrated in?

Answer 8

→ schema therapy (focus on identifying maladaptive core beliefs)

→ mindfulness-based cognitive therapy (uses acceptance + meditation strategies to promote resilience)

→ dialectical behavior therapy

→ acceptance and commitment therapy

→ compassion-focused therapy

Question 9

Assessment scales

Answer 9

Some examples include the Beck Depression Inventory, the Scale for Suicide Ideation, and the Beck Self-Concept Test.

Question 10

Theory of personality

Answer 10

CT sees aspects of human functioning as a made when a situation needs a response. It develops as an interaction between innate disposition and environment. Personality attributes reflect interpersonal strategies. Learning history can affect psychological distress and when vital interests of an individual are threatened.

Question 11

Cognitive vulnerability

Answer 11

Schemas can be dysfunctional and often latent but can become active due to specific stressors, circumstances or stimuli

Question 12

Dimensions of personality

Answer 12

Social dependence (sociotropy) is being depressed after relationships are disrupted and autonomy which is being depressed after a desired goal is not attained

Question 13

Theory of causality

Answer 13

Distress is caused by various innate, biological, developmental, and environmental factors which interact with each other.

Question 14

Cognitive distortions

Answer 14

Arbitrary inference: drawing a specific conclusion without supporting evidence

Selective abstraction: considering a situation based solely on a single detail taken out of context and while ignoring other information

Overgeneralization: abstracting a general rule from one or few isolated incidents

Magnification and minimization: making something seem much more important or less important than it actually is

Personalization: attributing external events to the self

Dichotomous thinking: categorizing experiences in one of 2 extremes

Question 15

Cognitive model of depression

Answer 15

Cognitive triad which is a negative view of the self, the world and the future. The self is seen as inadequate and worthless. Immense barriers are present when reaching goals and pessimistic view of the future. Involves increased dependency and seeing yourself about being incompetent

Question 16

Cognitive model of anxiety disorders

Answer 16

These disorders usually reflect an excessive functioning / malfunctioning of adaptive survival mechanisms. These physiological responses usually prepare the body for escape or self-defense.

Anxious individuals often struggle with recognizing signs of safety and correcting misperceptions with logic and evidence.

Question 17

Mania

Answer 17

Manic individuals think of each life experience as giving them significant gains and block out negative experiences or reinterpret them as positive. Overly positive thinking drives continuous goal-directed activity.

Question 18

Panic disorder

Answer 18

Individuals with panic disorder reinterpret any unexplained symptom or sensation as reflecting an impending catastrophe. They usually conclude that vital systems will collapse once experiencing a triggering symptom.
These individuals show an inability to view symptoms or sensations realistically.

Question 19

Agoraphobia

Answer 19

Being vigilant towards bodily sensations

Question 20

Phobia

Answer 20

Anticipate physical and psychological harm in specific situations and contribute to producing the feared reaction

Question 21

Paranoid states

Answer 21

Individuals with paranoia attribute abusive, interfering, and critical prejudices to others. They believe others treat them unjustly.

Question 22

Obsessions and compulsions

Answer 22

Individuals with obsessions attribute uncertainty to situations normally thought of as safe and show continual doubts about them. They feel a sense of responsibility about having done an action to counter the obsession

Question 23

Suicidality

Answer 23

Hopelessness and cognitive deficit for problem-solving

Question 24

Anorexia nervosa

Answer 24

body shape and weight determine one’s worth and social acceptability

Question 25

Schizophrenia

Answer 25

impaired integrative function and various cognitive deficits increase vulnerability to stressors, thus leading to dysfunctional beliefs.The activation of the dopaminergic system can lead to delusions and hallucinations and cognitive disorganization is due to neurocognitive deficits. Negative self-schemas contribute to auditory hallucinations and delusions rooted in cognitive biases

Question 26

Theory of psychotherapy

Answer 26

Corrects information processing and modifies assumptions which maintain maladaptive emotions and behaviours. Focusses on symptom relief to modifying core beliefs which are testable hypotheses. The usefulness and function of beliefs are examined. Cognitive changes promote new behaviours and emotions help with this

Question 27

Hierarchy of cognitive change

Answer 27

→ voluntary thoughts (most accessible, least stable)

→ automatic thoughts (clients can be taught to recognize and monitor these)

→ underlying assumptions (give rise to automatic thoughts, can often be unconscious)

→ core beliefs (vulnerability can be changed if these maladaptive core cognitive schemas can be changed)

Question 28

The therapeutic relationship

Answer 28

Should be collaborative, sometimes more directive in severe cases but the client leads in determining therapeutic goals. Functions as a guide to understand how beliefs affect emotions and behaviour and identify the experiences that can induce cognitive change. Warmth, accurate empathy and genuineness are all important

Question 29

Collaborative empiricism

Answer 29

joint determination of goals, eliciting and providing feedback, demystifying the therapeutic process, but also testing assumptions of the client as hypotheses and subjecting them to logical analysis

Question 30

Socratic dialogue

Answer 30

questioning things with the purposes of
1. clarifying problems
2. assisting in identifying thoughts, images, assumptions
3. examining the meanings of events for the client
4. assessing the consequences of maintaining maladaptive thoughts and behaviors
⇒ questions are aimed at a better understanding of the client, not at trapping them

Question 31

Guided discovery

Answer 31

therapist shows problem behaviors and logical errors by designing behavioral experiments that give new skills and perspectives to the client

Question 32

Mechanisms of psychotherapy

Answer 32

1. Comprehensible framework
2. Client’s emotional engagement in the problem situation
3. Reality testing in the problem situation
   Change can only happen if problematic situations seen as real threats and with affective arousal

Question 33

Goals of the initial sessions

Answer 33

• initiating the relationship
• getting essential information (diagnosis, past history, current life situation, psychological problems, attitudes about treatment, motivation for treatment)
• providing symptom relief
• misconceptions about therapy should be cleared
• homework with connections between thoughts, feelings, behaviour
• defining the problem in its functionality, cognitive analysis
• problem list with symptoms, behaviours, pervasive problems which are prioritized

Question 34

Middle and later sessions

Answer 34

Shift from symptoms to thinking patterns and identifying underlying assumptions of thoughts and more emphasis on cognitive techniques which can be modified through logical analysis. Then more responsibility for identifying problems and homework-> more independence

Question 35

Ending treatment

Answer 35

-length of therapy differs for each person as can be difficult to give up old ways of thinking
- becoming own therapist and monitoring progress with observations, self-reports and questionnaires. Experiences both successes and failures

Question 36

Who can we help with CT?

Answer 36

Those with cognitive distortions, used when those with depression refuse medication and best results for good reality testing, good concentration and sufficient memory functions. Not recommended stand alone for bipolar, psychotic depression, schizophrenia

Question 37

Evidence for cognitive therapy

Answer 37

Evaluated on treatment efficacy and causal relation to outcome and utility or generalizability. Large effect size for depression, GAD, PD, SAD. Moderate for anger, marital distress, somatic disorders and pain. Effective for preventing suicide. Small effect size for schizophrenia and bulimia.

Question 38

Cognitive techniques

Answer 38

Therapists do not interpret thoughts but explore their meaning together and automatic thoughts are tested. Involves:
Decatastrophizing: considering the “what-if”: if a situation occurs what kind of problem-solving strategies could be useful?
Reattribution: alternative causes of events are considered which help test automatic thoughts; particularly useful when problems are overpersonalized
Redefining:potentially making a problem more concrete and specific and stated in the terms of the client’s own behaviors so that catastrophizing can be avoided
Decentering:after examining the conviction behind being the center of attention, testing the hypothesis using behavioral experiments (primarily used in anxious clients)
Intrusive imagery can be remodified by reexamining aspects

Question 39

Benefits of behavioural techniques

Answer 39

→ expanding response repertoires (skills training)

→ relaxation (progressive muscle relaxation)

→ activation (activity scheduling)

→ prepare individuals for avoided situations, often videotape to serve as an objective source of information (behavioral rehearsal)

→ exposure to feared stimuli (exposure therapy)

Question 40

Behavioural techniques

Answer 40

Hypothesis testing involves making specific and concrete hypotheses and examining them both with cognitive and behavioral techniques.

Diversion techniques are also often used to reduce strong emotions and negative thinking and often include social contact, work, play.

Graded-task assignment involves the client initiating an activity at a nonthreatening level and the therapist gradually increasing the difficulty of the task.

Question 41

When can problems arise?

Answer 41

→ the client misunderstands what the therapist says (⇒ therapist should elicit thoughts and find alternative interpretations together with client)

→ client has unrealistic expectations about quick behavioral change (⇒ distortions in logic should be monitored and tackled)

Question 42

Guidelines to deal with difficult clients and those who were unsuccessful with therapy previously

Answer 42

1. Avoid stereotyping the client as being the problem
2. Remain optimistic
3. Identify and deal with your own dysfunctional cognitions
4. Focus on the task instead of blaming the client
5. Maintain a problem-solving attitude