Lecture 3: Cognitive therapy Flashcards
1 Identify the basic concepts of cognitive therapy. 2 Describe how cognitive therapy differs from other forms of psychotherapy. 3 Describe the causes of psychological distress according to cognitive therapy. 4 Identify the forms of cognitive distortions. 5 Explain how cognitive therapy works. 6 Explain the role of the cognitive therapist. 7 Identify the three fundamental components of cognitive therapy. 8 Explain what evidence-based practice means. 9 Assess the principles of cognitive therapy as
Cognitive therapy
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
What are basic concepts related to cognitive therapy?
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
What are the strategies used?
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
Techniques
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.
Cognitive therapy compared to psychoanalysis
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.
Cognitive therapy compared to REBT
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
CT compared to behavioural therapy
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
Sources of CT’s background
- Phenomenological psychology (individual’s self and personal world are central in determining behavior)
- Structural theory and depth psychology (cognition structured into primary and secondary processes)
- Cognitive psychology
Beginnings of cognitive therapy
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
What is the current status of the cognitive model?
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
What has been found to be a key factor in suicide?
Hopelessness leads to individuals being more likely to commit suicide, and CT reduces rates of reattempting suicide by 50%
What has cognitive therapy been integrated in?
→ 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
Assessment scales
Some examples include the Beck Depression Inventory, the Scale for Suicide Ideation, and the Beck Self-Concept Test.
Theory of personality
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.
Cognitive vulnerability
Schemas can be dysfunctional and often latent but can become active due to specific stressors, circumstances or stimuli
Dimensions of personality
Social dependence (sociotropy) is being depressed after relationships are disrupted and autonomy which is being depressed after a desired goal is not attained
Theory of causality
Distress is caused by various innate, biological, developmental, and environmental factors which interact with each other.
Cognitive distortions
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
Cognitive model of depression
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
Cognitive model of anxiety disorders
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.
Mania
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.
Panic disorder
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.
Agoraphobia
Being vigilant towards bodily sensations
Phobia
Anticipate physical and psychological harm in specific situations and contribute to producing the feared reaction
Paranoid states
Individuals with paranoia attribute abusive, interfering, and critical prejudices to others. They believe others treat them unjustly.
Obsessions and compulsions
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
Suicidality
Hopelessness and cognitive deficit for problem-solving
Anorexia nervosa
body shape and weight determine one’s worth and social acceptability
Schizophrenia
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
Theory of psychotherapy
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
Hierarchy of cognitive change
→ 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)
The therapeutic relationship
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
Collaborative empiricism
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
Socratic dialogue
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
Guided discovery
therapist shows problem behaviors and logical errors by designing behavioral experiments that give new skills and perspectives to the client
Mechanisms of psychotherapy
- Comprehensible framework
- Client’s emotional engagement in the problem situation
- Reality testing in the problem situation
Change can only happen if problematic situations seen as real threats and with affective arousal
Goals of the initial sessions
- 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
Middle and later sessions
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
Ending treatment
-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
Who can we help with CT?
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
Evidence for cognitive therapy
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.
Cognitive techniques
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
Benefits of behavioural techniques
→ 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)
Behavioural techniques
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.
When can problems arise?
→ 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)
Guidelines to deal with difficult clients and those who were unsuccessful with therapy previously
- Avoid stereotyping the client as being the problem
- Remain optimistic
- Identify and deal with your own dysfunctional cognitions
- Focus on the task instead of blaming the client
- Maintain a problem-solving attitude
