Transcript Cognitive-Behavioral Therapy - Homestead

Cognitive-Behavioral Therapy
Introduction to CBT
Cognition
Emotion
Behavior
Cognitive Behavioral Therapy is based on
the observation that cognition, emotion,
and behavior are reciprocally related.
Emotion
 James-Lange Theory of Emotion
 Action or response precedes emotion
 I run, therefore I must be afraid.
 Canon-Bard Theory of Emotion
 Emotion precedes action.
 I am afraid, therefore I run.
Singer-Schacter Theory of Emotion
Emotion #3
 Emotion cannot be accessed directly, but it can
be elicited in therapy.
 Experiences that are accompanied by the arousal
of strong emotion have more powerful effects on
cognitive and behavioral patterns.
 Memory (learning) is mood congruent. A
recurrence of mood triggers recall of learning. A
reminder of learning situation triggers the original
mood.
Emotional Symptoms
 Emotional excess
 Overreactions or unpredictable emotions
 Excessive or overly extravagant expression of
emotion
 Emotionally labile
 Emotional insufficiency
 Difficulty in displaying emotion
 Difficulty in “reading” emotion in others
 Difficulty in verbal expression of emotion
 Lack of self-control, poor frustration tolerance
 Judgment is the emotionally
(socially) relevant use of
knowledge.
 Judgment takes place in the
frontal cortex.
Behavior
 Classical Conditioning
 The repeated pairing of a stimulus with a
(formerly) neutral response, resulting in
the stimulus coming to trigger the neutral
response. (Pavlovian)
 Aversion therapy
 Desensitization
 Flooding
 Stimulus control
 Alters antecedent conditions to affect
behavior
Behavior #2
 Operant Conditioning
 Modifies “voluntary behavior”
 Positive Reinforcement: a behavior is followed by
a reward. Increases behavioral frequency.
 Negative Reinforcement: a behavior is followed
by the removal of an aversive stimulus. Increases
behavioral frequency.
 Positive Punishment: a behavior is followed by an
aversive stimulus. Decreases behavioral
frequency.
 Negative Punishment: a behavior is followed by
the removal of a favorable stimulus.
Behavior #3
 Operant conditioning = instrumental learning
(Skinnerian)
 Extinction
 Differential Reinforcement of Other Behavior (DRO)
 Avoidance learning (E.g., electric shock to reduce
arousal in presence of child pornography)
Behavior #4
 A behavior that is rewarded every time is acquired
or learned quickly.
 Fading the reward schedule to intermittent makes
the behavior less vulnerable to instances of nonreward. The behavior persists for a relatively long
period of time, even if not rewarded.
Effectiveness of consequences
depends on:
 Immediacy
 Consistency (reinforcement schedule)
 Potency (cost-benefit ratio)
 Satiation (felt need for the stimulus or response)
The Premack Principle
 A desirable or often-engaged in behavior or
situation can serve as a reinforcer for another
(new) behavior.
 Example: If you always brush your teeth and
need to develop a habit of taking medicine, pair
the medicine routine with the teeth-brushing
routine.
Social Conditioning
 Complex social behavior increases
and decreases in frequency in
response to social reinforcement and
social “response cost” or punishment.
 Example: A pat on the back or a thank
you from the boss reinforces excellent
work habits better than an increase in
salary.
Behavioral Difficulties
 Behavioral excess
 Behavioral insufficiency
 Lack of skill (lack of “know-how”)
 Restricted range of coping strategies (“know-
what”)
 Behavioral inconsistency (“know-when”)
 Insufficient stimulus control (difficulty with
initiating or maintaining behavior)
 Insufficient contingency control (failure to reward
self)
Behavioral Difficulties #2
 Disorders of Executive Control
 Planning
 Organization
 Time Management
 Task Management
 Delay of Gratification / Poor Impulse Control
(inhibition of behavior)
 Goal Directedness (initiation of behavior)
Cognition
 Human cognition tends to be categorical and
hierarchical. (We sort and categorize.) This
is biologically determined – it’s how the brain
works.
 Sorting and categorizing makes learning
possible, through a process of assimilation
and accommodation.
 Categorizing and comparing allows us to
arrive at efficient rules for sorting the vast
amount of information that confronts us every
waking moment.
Cognition #2
 Early-acquired cognitive rules form basic
schema that tell us what information is
important for survival:
 what data to actively seek,
 what data is relevant and noteworthy, and
 what can be safely ignored
Cognitive Schema
Early acquired schema (probably prior to age 8
or so) form our basic assumptions about
ourselves and the world and the relationship
between those two. They form our Core
Beliefs or Basic Beliefs.
Schema tend to be partial constructs, usually
operating outside our awareness. They tend
to be fragmentary, visceral, iconic vs. verbal.
They are presumed true, unquestioned.
Characteristics of Basic Schema
 They are absolutes.
 They are unquestioningly taken as Truths.
 They are consistent across time and situation.
 They function below the level of awareness.
 They tend to be non-verbal, visceral & iconic.
 They tend to be partial constructs.
 They are highly resistant to change.
 They are evident only indirectly in patterns of
cognition, emotion, & behavior.
Cognitive Schema may be…
Compelling
Active
Latent
Non-Compelling
Self-Schema
 Beliefs about Self are acquired from:
 Stories told about the child within his/her hearing
 Stories told directly to the child about themselves
 Reflections of and reactions to the child’s behavior
by significant others
 Stories erroneously adopted (false memories)
 Events that happened to others
 Events in books or on television
 Personal experience
 Interpretations of early life events
 Experiences of success and failure
Self-Schema Examples
The Self may be experienced as…
Known
Unknown
Powerful
Powerless
Victim
Hero
Self-determining
Other-controlled
Skilled
Unskilled
Strong
Weak
Big
Small
Schema about the World - general
 The nature of God
 God is/isn’t;
 Is vengeful, just, merciful;
 Is personal/impersonal;
 Is relevant/irrelevant;
 Takes an active part/observes but does not
interfere;
 Has a personal relationship with us/is
available only through the mediation of a
shaman or intermediary
Schema about the World – general - 2
 The nature of Man
 Man is savage, noble, erring, divine;
 Is trustworthy/untrustworthy;
 Is innocent/sinful; villainous/heroic;
 Is powerful/powerless;
 Has agency and free will/has a
predestined fate.
Schema about the World – general - 3
 The nature of the World
 The world is mysterious/knowable;
 Is fair/unfair/impartial;
 Is dangerous/benign;
 Is meaningful/meaningless;
Schema about the World – 4
 Gender roles
 Men should/are/will…
 Women should/are/will…
 Power
 Family roles
 Birth order & role within the family
 Relative value of boys and girls
 Generational relationships
 Power dynamics
 Role of father, mother, children, boundary diffusion
 Matriarchal/Patriarchal
 Rules about family membership, diffuseness of
boundary around the family
 Nature of success
Schema about the World – 5
 Ethnicity/Culture/Subculture
 Foods, clothing;
 Definition of family;
 Parent/child relationship;
 Nature of respect;
 Individual-family-group balance
 Achievement & striving
 Goal of development
 Relationship with dominant culture
 Relationship with authority
Schema about the World – 6
 Country/Region - examples
 What’s edible?
 The South shall rise again.
 Texas-sized
 Revolutionists, freedom-fighters
 The “show me” state
 Northeastern taciturnity
 The Second City, a city of farmers
 More nuts per square inch…
 Sophisticated; Big Apple
Schema about the Future
 The future is…
 Controllable/uncontrollable
 Bright/dim
 Changeable/unchangeable
 Likely to be worse, better, the
same
 Frightening/unfrightening
Schema result in behavioral
imperatives:
I am…
The world is…
Therefore I must…
Schema provide us with a cognitive
map that
 Explains the past (where we’ve been)
 Makes sense of the present (where we are)
 Predicts the future (where we are likely to go next)
They tell us what signposts to look out for and what to
do along the way.
They form a basis for our personalities, making our
cognition, emotion, and behavior consistent across
time and situation.
Schema contribute to cognitive error.
 Schema are generalizations. They do not reflect
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differences between first learning experiences and the
present situation. They resist influence by new data.
Schema filter out some information, while overvaluing other information.
Schema are highly resistant to change. They are
over-valued ideas that operate outside of awareness
and are unquestioned under normal circumstances.
We resist, ignore, fail to notice, or disbelieve data that
runs counter to our basic beliefs.
We differentially note data that confirms basic beliefs.
Cognitive Errors
 Fundamental attribution error:
 The tendency to overemphasize dispositional or
personality-based explanations for others’ behavior
while dismissing situational explanations.
 The opposite typically occurs when explaining one’s
own (negative) behaviors.
 Availability heuristic – the most salient
(aggravating, desired) examples are most easily
brought to mind, and are then taken as typical or
representative.
Cognitive Error is inevitable. It occurs
simply because of the way the brain works.
It is desirable – if we did not sort and
categorize, we could not learn.
It is beatable under certain circumstances –
we can learn to notice, catch, interrupt, and
do something else with our tendency toward
error.
Types of Cognitive Error
 Minimization/Maximization
 Over-generalization
 Mind-reading
 Dichotomization
 Catastrophizing
 Selective Abstraction
 Disqualifying the Positive
 Fortune Telling
 Emotional Reasoning
 “Shoulds” and “Musts”
 Labeling
 Personalization
Underlying Assumptions
 Basic or Conditional (if-then) Beliefs
 Usually operate outside of awareness, but can be
brought to awareness with much more ease than
basic schema.
Automatic Thoughts
 Immediate, unpremeditated, “knee jerk” cognitive
interpretations of events.
 Directly shape emotion and strongly influence
behavior.
 Exaggerated, distorted, mistaken, or unrealistic
ATs play a role in psychological distress.
Other Contributors
 Vaihinger – “as if”
 Phenomenology – Immanual Kant & Husserl –
the construction of knowledge as a rule-bound,
creative act
 Karen Horney – Tyranny of the Shoulds
 Kelly – the Psychology of Personal Constructs &
fixed role therapy
 Social Learning Theory – observation of models
Assumptions of CBT
Albert Ellis
 CT highlights the role of philosophy
Most

All

Beck, then
most

Arnold
Lazarus

and self-persuasion in personal
change.
Supposes that we have a choice how
to think and feel about things, as well
as how we act.
Cognition, Emotion, and Behavior
mutually influence each other
Disorders are characterized by (not
caused by) dysfunctional thinking.
Disorders are characterized by
insufficient range of coping responses.
So CBT assesses and seeks to
intervene in three areas:
Cognition
Behavior
Emotion
 Cognitive, emotional and behavioral patterns may
cause, contribute to, maintain, contribute to
resistance in changing, or cause relapses in
symptoms.
 SITUATIONAL VARIABLES can also cause,
contribute to, maintain, resist changes in, or
cause relapses in symptoms.
 It is always important to understand the physical,
biological, developmental, and social-emotional
context in which the problem occurs.
Goals of CBT/CT
 Interrupt self-perpetuating cycles of cognitive error,
disturbed mood, and ineffective behavior.
 The client becomes less disturbed. Symptoms recede. First-
order change.
 Modify beliefs and assumptions that predispose the client
to the problems.
 The client becomes less disturbable. Ellis’s “elegant solution”
or “second-order change”.
 Provide the client with more effective ways to manage the
situations that provoke their distress or difficulties.
 The client is able to manage similar and dissimilar stressors
more effectively; the client is more skilled.
Assessment ala CBT
 Nature of the problem
 Onset (learning history, but later), duration, course
 Context:
 Stimulus variables
 Consequences (reinforcers and costs)
 The client’s explanation & understanding of the
problem
 Previous attempts to solve the problem and
relative success of these
 Client’s goals
Assessment ala CBT/CT
 Baseline data
 Current incidents
 Daily Thought Record
 Journaling
 Counting instances
 Collateral data
 Critical Incidents - history
 Cognition, emotion, behavior
 Situational variables – who, what, when, where
Thought Record – part 1
Situation
Emotions
Briefly describe the
situation
Rate strength of
emotion from
0 to 100%
Who, what, when,
where?
Behaviorally
anchor the ends of
the continuum.
Automatic
Thoughts
Try to capture your
exact thought. Then
rate your belief in each
thought 0 to 100%
Assessment ala CBT/CT cont’d.
 Formal Assessment Tools
 Beck Depression Inventory
 Beck Anxiety Scale
 Beck Hopelessness Scale
 Burns Anxiety Inventory
 Dysfunctional Attitudes Scale
 Fear Survey Schedule
 And MANY more…
 Use appropriately; use sparingly; use repeatedly.
Assessment ala DSM-IV-TR
10
9
8
7
Severity
6
5
4
3
2
1
0
Symptoms from DSM
Collaborative Empiricism
 Collaborative Goal Setting:
 Client’s goals – realistically and objectively defined
 Therapist’s goals based on practicality, theory,
conceptualization
 Mutually agreed upon
 Goals should be empirical:
 Objective – verifiable by other than subjective methods
 Observable – outside of “the black box”
 Measurable – able to be counted, recorded, scored, scaled,
 Guided Discovery
 Socratic questioning
 Stochastic questioning
 Jointly identified inter-session tasks (“homework”)