PSY 245 CLINICAL PSYCHOLOGY-II

PSY 245CLINICAL PSYCHOLOGY-II

Assoc. Prof. Dr. BAHAR BAŞTUĞ Clinical Psychologist

Cognitive-Behavioral Theory and Therapy

Welcome

Back in the 1970s, most behaviorists didn’t want to think about cognition. Some behaviorists included cognitions from the beginning.

Joseph Wolpe allowed clients to use imagery in the desensitization. He accepted a form of cognition into his therapeutic work. However, Wolpe criticized Michael Mahoney’s use of a technique referred to as “mirror time” or “streaming”. Streaming involved having the client free-associate while looking at himself in a mirror.

Pressure from the behaviorists did not reduce the “cognitivists” motivation, instead, increased it.

Now, most practitioners just refer to CBT as an approach that integrates both behavioral and cognitive therapies.

Whenever you experience an unpleasant feeling or sensation, try to recall what

thoughts you had been having prior to this feeling. Aaron Beck

Historical Context and Biographical Information

Cognition as an important focus dates back to at least Socrates. Socratic questioning is to discover an individual’s method of reasoning.

Wundt used introspection as a method of studying humans in his first psychological laboratory.

Watson and Skinner rejected the introspection.

Historical Context and Biographical Information II

There are three key figures and streams of thought linked to the history of cognition in counseling and psychotherapy.

– Albert Ellis and Rational Emotive Behavior Therapy

– Aaron Beck and Cognitive Therapy– Donald Meichenbaum and Self-Instructional

Therapy

Historical Context and Biographical Information III Ellis developed REBT and focused on

irrational thinking.

Beck developed cognitive therapy and focused on maladaptive thinking.

Meichenbaum focused on inner speech and developed self-instructional training.

Albert Ellis: Rational-Emotive Behavior Therapy

Ellis was born in Pennsylvania, in 1913 into Jewish family. He had a similar childhood to Adler. He was the eldest of 3 children. His father was often away from home. His mother was egosentric and bipolar. He hospitalized 8 times between 5-7 ages due to kidney problem.

After being rejected his first 8 novels, he graduated Columbia Univ. Clinical Psy programme. K. Horney analyzed him. He formulated his approach after discovering in his psychotherapy practice that psychoanalysis was ineffective.

Albert Ellis (1913 –2007)

Ellis summarizes five basis components of his theory:

1. People have irrational ideas and personal philosophies.

2. These irrational ideas cause people great distress and sadness.

3. These ideas can be set down to a few basic categories.

4. Therapists can find these irrational categories easily in clients’ reasoning.

5. Therapists can teach clients how to give up their irrational beliefs.

Ellis credits Adler’s pioneering acceptance of cognition; he also notes that his “rational psychotherapy” is based on the philosophical writings of ancient Greek and Roman stoics, particularly Epictetus. The first CBTist in the Western world was the philosopher Epictetus (c. 50–138 ..). He was born a slave in Phrygia, in what is now central Turkey.

Albert Ellis: Rational-Emotive Behavior Therapy

Ellis initially referred to his approach as rational psychotherapy,

later changing the name to Rational-Emotive Therapy.

In 1993, he inserted the word behavior, thus creating Rational Emotive Behavior Therapy (REBT).

Aaron Beck and Cognitive Therapy

A. Beck was born in 1921 in Rhode Island. His family was Russian Jewish immigrants. Older brother and sister died of influenza, he saw himself as a replacement child. He had physical problem during childhood, similar to Adler and Ellis. Because of hospitalization, when he restarted the school, he believed he wasn’t smart. He overcame this negative thougths, obtaining a medical degree from Yale Univ.


Beck was psychoanalytically trained. Early in his career he was interested in validating Freud’s theory of depr, but he ended up rejecting Freud’s theory.

Many psychoanalists ignored Beck for questioning Freud. However, over time, Beck’s work on depr was recognized as empirically valid, and his theory of depr represents one of the best-known.


Beck’s approach has been known as cognitive therapy. He reasoned that psychological problems can be mastered by sharpening discriminations, correcting misconceptions and learning more adaptive attitudes. Introspection, insight, reality testing, and learning are basically cognitive processes.


Beck is a soft-spoken, gentle man who works with clients in a collaborative manner. Beck is not interested in convincing clients of their irrational beliefs. He uses collaborative empiricism. In collaborative empiricism, he works together with clients to help them discover the maladaptive nature of their automatic thoughts and core beliefs.

Ellis emphasizes the forceful eradication of irrational thoughts, Beck emphasizes the collaborative modification of maladaptive thoughts.

Donald Meichenbaum and Self-Instructional Strategies

Meichenbaum followed the path of behavior therapy into the field of cognitive therapy. He noticed that people on the streets in NY city would sometimes talk to themselves.

He focused on impulsive schoolchildren and hospitalized adults with SCH. He discovered that both schizophrenics and children could improve their functioning after being taught to talk to themselves or to think aloud.

Donald Meichenbaum


Meichenbaum integrated the work of Soviet psychologists Vygotsky and Luria with Bandura’s vicarious learning model and the operant conditioning principle.


Meichenbaum’s focus was on self-instructional training (SIT), which he referred to as a form of cognitive behavior modification.

He later developed stress inoculation training, a specific approach for helping clients manage difficult stressors. He is openly empathic and emotionally oriented.


More recently, Meichenbaum shifted toward an empirically constructive model. He is also redefining cognitive therapy as an integrational approach.

Meichenbaum’s progression—from behavior therapy, to cognitive behavior modification, to cognitive-behavioral therapy, to constructivist cognitive-behavioral therapy —reflects a trend toward integration.

Theoretical Principles

CBT is a critically minded, empirically based treatment approach that doesn’t advocate a specific treatment approach.

In addition to classical and operant conditioning, CBT is based on two additional learning theories:– Social Learning Theory– Cognitive Appraisal Theory

Social Learning Theory (SLT) was developed by Albert Bandura (1925 –

present).

Social Learning Theory (SLT)

SLT includes stimulus-influence components (classical conditioning) and consequence influence components (operant conditioning), but it also adds a strong cognitive mediational component.


It emphasizes two main cognitive processes:

1. A significant portion of human learning is observational. Bandura documented the power of observational or vicarious learning as a source of behavior change. This process has come to be known as modeling. It includes covert mental processes that cannot be observed by experimenters.

Social Learning Theory (SLT) 2. Reciprocal interactions occur between the individual’s behavior and the environment. Bandura postulates that individuals have thoughts about the future, behavioral consequences and goals. Because of these reciprocal interactions, individuals are capable of self-directed behavior change. In opposition to Skinner and Watson, Bandura sees free will and self-determination as possible.


One of the most important social learning theory concepts is self-efficacy.

SELF-EFFICACY is defined as an individual’s belief or expectation that he or she can adequately complete a specific situation or task.

“The conviction that one can successfully execute the behavior required to produce an outcome.” Bandura


Higher self-efficacy is associated with success.

Lower self-efficacy is associated with negative self-talk, giving up easily and reduced concentration.


A primary purpose of therapy is to help clients develop and strengthen self-efficacy. A client who comes to therapy to quit smoking may initially have little confidence in his ability to quit. If therapy is to be successful, it will be necessary to enhance the client’s smoking cessation self-efficacy. The therapist teaches the client self-monitoring procedures, PMR, and strategies for coping with uncomfortable feelings associated with nicotine withdrawal.

Cognitive Appraisal Theories

The essence of cognitive theory can be summarized in one sentence that Ellis attributes to Epictetus:

“People are disturbed, not by what happens, but by what they think of what happens.”

Skinner: Behavior is a function of its consequences.

S-R theory

Now: Behavior is a function of what organism thinks about its consequences.

S-O-R theory

Cognitive Appraisal Theories

Cognitive theory emphasizes the individual organism’s processing of environmental stimuli as the force determining his or her specific response.

Rational Emotive Behavior Therapy

REBT views humans as neither inherently good nor inherently bad. Ellis considers humans to have the potential for thinking both rationally and irrationally. Humans have a strong tendency to think in mistaken, and irrational ways and this is the primary source of human distress.

Ellis used an A-B-C model. “A” = the “activating event” that has occurred in an

individual’s life; “B” = the individual’s belief about the activating

event;“C” = the consequent emotion and behavior linked to

the belief.

Rational Emotive Behavior TherapyCem’s Activating Event: His wife is late for

dinner.

Cem’s Belief: His wife doesn’t love or respect him any more. She’s probably having an affair.

Cem’s Consequent Feelings: Anger, sadness, hurt, resentment, and jealousy;

and Behavior: yelling and accusing her of having an affair.

Rational Emotive Behavior Therapy

Ellis refers to this sort of belief as an irrational belief=iB.The purpose of REBT is to help substitute a rational

belief = rB for a current iB, which will result in more positive and more comfortable new feeling =F

Rational Emotive Behavior TherapyThe main purpose of confronting is to dispute (D)

the irrational belief. “Is it true that your wife must always be home right on time to prove her love for you?”

Ellis’s dispute of Cem’s irrational belief will have an emotional effect (E) on Cem. This effect will be the development of a set of alternative, rational more effective beliefs. If therapy is successful, Cem will experience a new feeling (F).

Rational Emotive Behavior Therapy The ABCDEF Cognitive Model (Ellis)

– A = Activating event– B = Belief about the activating event– C = Consequent emotion and behavior linked to

the belief– D = Disputation of irrational belief– E = Effect– F = Feeling

Beck’s Cognitive Theory

The theoretical principles of Beck’s cognitive therapy are similar to Ellis’s REBT.

Similarities: 1.Cognition is at the core of human suffering.

2. The therapist’s job is to help clients modify distress-producing thoughts.

Beck criticizes Ellis’s use of the term irrational.


Components of Beck’s cognitive theory: – Development of inaccurate/negative beliefs.– Self-schema– People develop systematically distorted

irrational thoughts.– This results in biased information processing

cognitive content consistent with specific mental disorders.

– Modification is possible via cognitive therapy.

Beck’s theory includes the following characteristics:1. In the process of living, individuals are exposed to

a variety of life events, some of which trigger automatic, maladaptive thoughts.

2. These maladaptive thoughts are characterized by their faultiness; they are too narrow, too broad, too extreme, or simply inaccurate.

3. An individual’s maladaptive thoughts are usually derived from deeply held maladaptive core beliefs (=schemas or dysfunctional attitudes).

4. Individuals acquire these core beliefs during childhood.

5. These automatic thoughts, core beliefs, and their associated emotional disturbances, can be modified via cognitive therapy, the procedure does not require exploration of a client’s past.

According to Beck, cognitions are based on attitudes or schemas, developed from previous experiences. If a person interprets all his experiences in terms of whether he is competent and adequate, his thinking may be dominated by the schema, “Unless I do everything perfectly, I’m a failure.” Consequently, he reacts to situations in terms of adequacy even when they are unrelated to whether or not he is personally competent.


Beck’s core beliefs = Adler’s life style

Beck’s automatic thoughts = Adler’s basic mistakes.


Beck uses a different procedure for modifying clients thoughts. Cognitive therapists use collaborative empiricism to help clients discover inaccurate or maladaptive thoughts.

Collaborative empiricism emphasizes:joint work of client and therapist,Socratic questioning and different techniques.

This approach requires the therapist to work within the client’s frame of reference, trying to see the world through the client’s eyes.

In the Socratic questioning, therapists ask questions that help clients focus on (1) awareness of automatic thoughts and core beliefs, (2) evaluation of the usefulness and accuracy of automatic thoughts and core beliefs, and (3) possible strategies for modifying automatic thoughts and core beliefs.

Meichenbaum and Self-Instructional Theory

Meichenbaum’s self-instructional model is based on internal speech or verbal mediation. His model is reciprocal: interactive relationship between the individual and the environment.

Preparation: Inner speech that occurs before the stressful event

Coping: Inner speech that occurs during the stressful event

Aftermath: Inner speech that occurs after the stressful event

Theory of Psychopathology

In REBT, psychopathology is a direct function of irrational beliefs. Ellis’s theory of psychopathology is consistent with Horney’s “tyranny of the shoulds.”

The REBT approach to psychopathology is direct, straightforward, and sometimes offensive.

Ellis had a list of 12 basic irrational beliefs that cause emotional suffering. He later added a 13th, other REBT writers have added additional irrational beliefs. Ellis decided that all irrational beliefs could be boiled down to the three very basic beliefs:

1. “I must do well and be approved by significant others, and if I don’t do as well as I should or must, there’s something really rotten about me.” That irrational belief leads to feelings of depr, anxiety, despair and self-doubting. It’s an ego must.

2.“You other humans with whom I relate, my original family, my later family, my friends, my relatives, and people with whom I work, must, ought, and should treat me considerately and even specially.” That’s anger, that’s rage, that’s homicide, that’s genocide.

3.“Conditions under which I live, my environment, social, economic or political conditions, must be arranged so that I easily and immediately have a free lunch, get what I command. Isn’t it horrible when those conditions are harsh and when they frustrate me? I can’t stand it! I can’t be happy at all under those awful conditions and I can only be miserable or kill myself!” That’s low frustration tolerance.

Theory of Psychopathology

Beck’s theory of psychopathology is similar to REBT. Ellis focused on three basic irrational beliefs, Beck emphasizes the client’s cognitive distortions or faulty assumptions and misconceptions. These distortions, triggered by external events produce automatic thoughts, which are linked to underlying core beliefs or schemas. Beck has described several different types of cognitive distortions. In his work, Beck listed seven.

Cognitive distortions:

Personalization (self-referencing),

Dichotomous or Polarized Thinking,

Labeling and Mislabeling,

Magnification and Minimization,

Overgeneralization,

Mind Reading.

Cognitive triad

Beck theorized that specific automatic thoughts and core beliefs were indicative of specific mental disorders. As a consequence of his research on depr, he concluded that a particular cognitive triad characterizes depressive conditions. Beck’s cognitive triad consists of

• Negative evaluation of self:

• Negative evaluation of the world or events:

• Negative evaluation of the future:

THE PRACTICE OF CBT

1. Access clients’ irrational or maladaptive thoughts.

2. Instruct clients in more adaptive or more rational thinking.

3. Support clients as they apply these new and developing skills in their lives.

Cognitive therapy requires extensive training and supervision to achieve competence.

CBT begins with initial contact between therapist and client. During this contact terapists focus on developing the therapeutic relationship and on educating clients about CBT.

Assessment Issues and Procedures

Primary goals:

1.Diagnosing that best describes client symptoms.

2.Developing a formulation that can be used for treatment.

Cognitive therapists use a wide variety of assessment strategies:– Collaborative Interviewing– Setting an Agenda– The problem List– Self-Rating Scales– Cognitive-Behavioral Self-Monitoring– Case Formulation

Collaborative Interviewing

In opposite to other theories, some CBtherapists consider the therapeutic relationship secondary. CBT focuses on remediation the problems and existing research on whether the alliance contributes to positive outcome is mixed.

Collaborative Interviewing

CBT emphasizes collaboration. The therapist is not the expert on whom all therapy success depends. The client and therapist join together and use collaborative empricism to guide assessment and treatment.

Setting an Agenda

CBT is agenda-driven. To set an agenda in the first few minutes of every session is crucial.

The Problem List

The major task is to set a clear and detailed problem list. Operational definition: simple, concrete and descriptive.

Benefits of generating a problem list:

1.It gives therapists a chance to show interest in client problems.

2.Antecedents and consequences are identified and initial hypothesis about client’s core beliefs can be generated.

3.As therapists use Socratic questioning, clients become oriented to CBT.

Examples of questions to explore client problems: • What was going through your mind just before you

started to feel this way?• What does this say about you?• What does this mean about you . . . your life . . .

your future?• What are you afraid might happen?• What is the worst thing that could happen if this

were true?• What does this mean about the other person(s) or

people in general?• Do you have images or memories in this situation?

If so, what are they?

Self-Rating Scales

At the beginning of therapy and throughout the therapy process, CB therapists use of self-rating scales.

Beck Depression Inventory (BDI)

Beck Anxiety Inventory

Beck Hopelessness Inventory

Penn State Worry Questionaire

Cognitive-Behavioral Self-Monitoring

It is important to teach clients to pay attention to their automatic thoughts. Cognitive self-monitoring is effective to help clients increase awareness of automatic thoughts, emotions and behaviors.

“Thought Record.” To use a Thought Record, clients are instructed to jot down the basic information immediately after experiencing a strong emotional response:

Cognitive-Behavioral Self-Monitoring

(1) date and time of the emotional response, (2) situation that elicited the emotional

response, (3) behaviors the client engaged in, (4) emotions that were elicited, (5) associated thoughts that occurred during

the situation, (6)any other related responses.

Thought Record Sample Situation Emotion Automatic

Thoughts Cognitive Distortion

Rational Response

Outcome/ New Feeling

Briefly describe the situationlinkedto the unpleasantfeelings.

Specify andrate the emotion(Sad,Anxious,Angry) on a0-100 scale.

State theautomaticthought thataccompaniedtheemotion.

Classify thecognitive distortionpresentwithinthe automaticthought.

Replace theautomaticthought witha more rational(oradaptive)response.

Rate the feelingsagainto see if therational responsemodified them.

Home aloneon Saturdaynight

Sad: 85 “I’m alwaysalone. Noone will everlove me. Noone will everwant to bewith me.”

Dichotomousthinkingand catastrophizing

Being homeon Saturdaynight is betterthan beingwithsomeone Idon’t like.Just becauseI’m not in arelationshipnow doesn’tmean I’llnever be inone.

Sad: 45

Case Formulation

Case formulation is a bridge from assessment to treatment. It helps clinicians develop a treatment plan.

Four elements:

1. Creating the problem list.

2. Identifiying mechanisms underlying the problems.

3. Identifiying precipitants activating current problems.

4. Consideration of the origins of the client’s current problems. ???

Psychoeducation

CB therapists educate clients about psychological (CBT) rationale, problems and procedures. Educating clients is not as a lecture. CB therapists prefer using stories, demonstrations and life examples.

«Bump in the night»: about how cognition influence emotion.

Methods for Exploring and Identifying Automatic Thoughts and Core Beliefs

• CBT work often focuses on helping clients develop an awareness of their automatic thoughts and core beliefs.

• Many techniques exist for helping clients become more tuned in to their cognitions.

Methods for Exploring and Identifying Automatic Thoughts and Core Beliefs

• Guessing the Thought: therapists take a guess at the underlying thought.

• the Downward Arrow• To uncover underlying core beliefs.

• Chasing cognitive distortions: Beck identified 7 cognitive distortions.

• Conducting a cost-benefit analysis (to mind reading)

• Applying the double standard technique (to dichotomous thinking)

Specific Therapy Techniques

The following techniques come from Ellis and Meichenbaum.

Vigorous and Forceful Disputing

A Favorite Technique from Albert EllisThis technique stems from Ellis’s view that an individual can

begin to lightly adopt a rational belief (e.g., “I want people to like me, but I can live happily if they don’t”) while at the same time strongly holding onto an opposing irrational belief with more intensity (e.g., “But I really absolutely need their approval and have nothing to live for if I don’t get it!”).

Ellis’s homework assignment essentially amounts to repeated practice at more and more forceful cognitive disputing procedures. If clients can build a forceful and rational counterattack against their irrational beliefs, they’ll be able to minimize and hopefully eliminate their irrational thinking.

Stress inoculation training

Meichenbaum uses it for a variety of clinical problems.

SIT includes three phases: Conceptualization: a collaborative relationship,

Socratic questioning, educate about stress. Skills acquisition and rehearsal: specific skills are

taught, practiced in office and in vivo. Application and follow-through.

Thinking in Shades of Gray

This technique is derived from Burns. It involves taking automatic thoughts, assumptions, or conclusions about a specific performance and placing them on a concrete, measurable scale.

«Black-white» rating scale: 96-100 complete success, below 95 complete failure

«Shades of gray» rating scale: 96-100 complete success, 85-95 partial success, 75-84 marginally acceptable, 0-74 complete failure

Cultural and Gender Considerations

CBT focuses on symptoms as manifest within individuals. This position is often considered culture and gender blind.

For most cognitive-behavioral therapists, culture and gender are not primary significance.

Evidence-Based Status

There are two main lists published that catagorize psychological treatments as either (a) well established, (b) probably efficacious, or (c) possibly efficacious.

One list focuses on treatments for adults, and the other list focuses on treatments for children and adolescents.

CBT approaches dominate both of these lists.

Evidence-Based Status

CBT is well-suited to the modernist research paradigm.

Some CBT practitioners emphasize that a positive therapy relationship is essential.

Concluding Comments

There’s little doubt about the efficacy of CBT.

Philosophically and empirically, it is a logical and effective form of treatment for many disorders.

It’s possible that new approaches to counseling and psychotherapy might even be more effective than CBT.

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PSY 245 CLINICAL PSYCHOLOGY-II