Cognitive-Behavioral Therapy

Up to this point in the course, we have focused on behavior. Either we were looking at ways in which we could decrease behavior excesses (too much of undesirable behaviors) or increase behavior deficits (not enough desirable behavior).

Now, we are going to look at the role of cognitions, our beliefs, assumptions, expectations, attributions, and attitudes.

A major theoretical assumption of cognitive therapy is that individuals interpret and react to events in terms of their perceived significance, i.e., that human behavior is mediated by cognition.

A second theoretical assumption is that cognitive deficiencies can cause emotional disorders.

It follows from these assumptions that the primary focus of therapy is a fundamental change in the cognitions that maintain a wide variety of psychological problems.

The nature of cognitive-behavioral therapy

The nature of cognitive behavioral therapy is revealed by its hyphenated name. Clients’ cognitions are modified in two ways: cognitively and behaviorally.

Cognitions can either be modified directly by focusing on and changing distorted our maladaptive thoughts.

Which of the following is an example of a distorted thought that might contribute to a person’s depression?
Life has downs as well as ups.
My last relationship ended unhappily.
I failed my last History exam.
I’m a failure.

Or, cognitions can be modified indirectly by changing behaviors. Behavior changes can lead to changes in thinking.

Which of the following behavioral techniques previously discussed in this course lead to changes in a person’s cognitions about some event?
a token economy
exposure therapy
avoidance training

Spiegler and Guevremont suggest that cognitive-behavioral therapies fit two basic models: cognitive restructuring therapy and cognitive-behavioral coping skills therapy.

Cognitive restructuring therapy

Cognitive restructuring therapy is used when clients’ problems are maintained by an excess of maladaptive or distorted thoughts.

Clients not only are taught to recognize and change erroneous cognitions but also are taught to substitute more adaptive cognitions for these maladaptive thoughts.

Cognitive-behavioral coping skills therapy

Cognitive-behavioral coping skills therapy is used when there is a deficit of adaptive cognitions.

This therapy teaches clients adaptive responses—both cognitive and overt behavioral—to deal effectively with difficult situations they encounter.

Which of the following would be an example of cognitive-behavioral coping skills therapy?
Teaching an immigrant Muslim student how to deal with the questions, and occasional hostility, she encounters in her new high school in America.
Teaching a girl who does not meet American standards of beauty to question her belief that she is a loser.

We will begin with cognitive restructuring therapy.

Cognitive restructuring therapy

Cognitive behavior therapy grew out of the behaviorist approach.

Assessing cognitions

If you think about it, the whole notion of a cognitive-behavioral therapy seems like a contradiction in terms.

After all, behaviorism is the approach that suggests that psychologists should only focus on observable and measurable events, i.e., stimuli, behavior, and consequences.

Cognitions are, by their nature, unobservable.

The way cognitive behaviorists handle this apparent contradiction is to treat cognitions as self-talk.

Basically, when we are thinking about some problem in our lives, we say things to ourselves. What we say can include words, sentence fragments, or complete sentences.

Thus, self-talk is treated as a behavior by cognitive behaviorists.
true
false

Therapies

Thought stopping

Thought stopping is a technique used to help clients deal with disturbing obsessive thoughts.

The first step involves teaching the client to interrupt disturbing thoughts by saying loudly “Stop!” when these thoughts are occurring.

For example, Carol was a client who suffered frequent obsessive thoughts about her former boyfriend, Fred. Carol and Fred had been engaged for 3 years when he left her for another woman.

The therapist taught her thought stopping by first having her close her eyes, think about Fred, and raise her finger when she began to feel unhappy. The therapist then yelled loudly, “Stop!” Carol was startled, opened her eyes, and thoughts about Fred temporarily ceased.

She was then asked to repeat the procedure, but say “Stop” loudly herself. She was then asked to think about Fred and then imagine saying “Stop”.

If a disturbing thought is abruptly interrupted by yelling “stop” or pinching oneself, do you think that the thought will be permanently terminated?
yes
no

Simply saying stop every time one has an obsessive thought isn’t enough. The person will simply return to the obsessive thoughts.

What else might eliminate these thoughts for good?
Treat the return of the obsessive thoughts as an example of spontaneous recovery after extinction. Continue saying “stop” and the thoughts will eventually terminate.
Add a punishment contingency to thought stopping. When obsessive thoughts occur, the client should not only say “stop”, but also should self-punish by jogging until exhausted, engaging in self-criticism, or engaging in some other unpleasant behavior.
When obsessive thoughts occur, the client should not only say “stop”, but should also think competing adaptive thoughts.

Rational emotive behavior therapy (REBT)(Albert Ellis)

This last Thanksgiving, I ate dinner at my son’s in-laws with about 27 other people. I was sitting next to the wife of a UConn professor. As I was passing her a water jug so that she could fill her glass, I let go of the jug before she had securely grasped it. The jug fell to the table, but bumped a wine glass which fell over in slow motion drenching the table and her lap.

I silently said to myself, “What a klutz. I can’t believe I was that careless. I’m always screwing things up. She must think I’m an idiot.”

Those are examples of irrational thoughts. One missed hand-off does not make me a klutz and I don’t always screw things up.

Definition

Rational emotive behavior therapy is a cognitive restructuring therapy designed by Albert Ellis to counteract such “irrational” self-statements with more positive and realistic statements.

Ellis believed that negative emotions and maladaptive behaviors are maintained by the interpretations people give to the events in their lives.

This philosophy was first stated almost 2000 years ago by the Greek Stoic philosopher Epicetus who stated that people are disturbed not by things, but by the views they take of them.

Most people, including myself at times, would disagree with this statement saying that “things” cause negative emotions.

Let’s go back to my spilled wine episode. I was embarrassed and mad at myself. Wasn’t this caused by the dropped water jug and spilled wine (things)?

Ellis would say no. As proof, he would say that I could just as easily have made rational statements about this event that would not have made me so upset.

Which of the following would not be a rational alternative to my irrational thoughts about the spilled wine?
It might be just as much her fault as mine.
This could happen to anyone.
It’s just spilt wine, something we must wipe up, but no big deal.
Maybe she thinks it was her fault. If so, she isn’t thinking I’m an idiot.
None of the above. All are rational alternatives.

Types of irrational beliefs

Absolute thinking is viewing an event in an all-or-none, black-or-white fashion.

For example, the statement “I must do well in all my courses” is an example of absolute thinking.

Overgeneralization is drawing the conclusion that all instances of a situation will turn out a particular way because one or two did.

“Because this relationship failed, I’ll never be able to keep a relationship.”

Catastrophizing involves seeing minor situations as disastrous.

For example, if a student gets a poor grade on an exam, he catastrophizes and concludes that he will get a poor grade in the course and this will ruin his chances to go to graduate school.

Try to determine which type of irrational belief is illustrated in each of the following examples.

“Since I didn’t do very well in my first day of student teaching, I should give up the idea of ever becoming a teacher.” This statement is an example of
catastrophizing.
absolute thinking.
overgeneralization

“Because I was so embarrassed the other day, I will never be able to face these people again.” This statement is an example of
overgeneralization
catastrophizing.
absolute thinking.

“I must always be positive and never complain in order to maintain my relationships.” This statement is an example of
overgeneralization
catastrophizing.
absolute thinking.

Themes found in irrational ideas

According to Ellis, 2 themes are found in the irrational ideas that lead to psychological problems:
1) a sense of personal worthlessness, and
2) a sense of duty.

Personal worthlessness results from overgeneralization when we have failed in some activity.

“I always find a way to screw things up.”

A sense of duty is expressed every time we use the expressions “have to”, “must”, “should”, or “ought to.”

Ellis referred to all these musts, oughts, shoulds, and have to’s in our lives as musterbation.

What is irrational about musterbation? One way to test whether a “must” or “have to” is irrational is to imagine what might happen if you became too sick to do your “musts”. Could you do them later? Would it be a catastrophe?

What is the rational alternative to the absolute thinking involved in “musterbation” and the catastrophe that we feel will occur when we fail to do what we “should” do?
There are things that I need to or ought to do. However, if I fail to do them, it may create difficulties or unpleasant consequences, but it won’t be a catastrophe.
There are no “shoulds” or “musts” in life, but only in our minds. Using these terms will only create unhappiness.

Steps in rational emotive behavior therapy

What are the steps in rational emotive therapy?
1) Identification of the troublesome thoughts that are based upon irrational beliefs, i.e.,

“I’m a walking disaster and always screw things up.”

2) In a very confrontational argumentative way, Ellis challenges the client’s irrational beliefs.

“What do you mean you always screw up? You told me you got a “B” on the last exam.

3) The thoughts based upon irrational beliefs are replaced with thoughts based upon rational beliefs.

What might be a more appropriate and rational thing to say to oneself if one does poorly on an exam?
Since I am disturbed by the view I take of things, not by things themselves, it is ridiculous for me to be upset over getting a “D” on the exam.
Sometimes, but not always, I do poorly on an exam. This is unpleasant, but is not a catastrophe. If I put in extra effort for the next exam, I may be able to bring up my grade. Even if I end up with a lower grade than I had hoped for, this does not make me a screw-up.

Ellis originally called his therapy rational emotive therapy. Later, he added the word “behavior” to make it rational emotive behavior therapy because he frequently uses “in vivo” homework assignments.

For example, in a real case, a person who was terrified of making a fool of himself was instructed to ride the N.Y. subway and at each stop stand up and loudly announce the name of the station that the train was entering. His previous self-statement was something to the effect of “I couldn’t stand it if I made a complete fool of myself in public. I think I would die of shame.”

The therapist should then ask the client, “Did you survive making a fool of yourself? Could you stand it.?
true
false

Cognitive therapy (Beck)

Psychiatrist Aaron Beck has developed procedures he calls cognitive therapy that are very similar to Ellis's rational emotive therapy, although the 2 apparently developed their theories and techniques independently.

Similarities and differences between REBT and cognitive therapy

Both approaches see psychological disorders as the product of distorted thinking and both approaches attempt to challenge and modify these cognitions.

However, the way that distorted cognitions are challenged by Beck and Ellis differ.

Ellis would directly dispute distorted beliefs and persuade a client of their irrationality. Thus, Ellis uses rational disputation to counteract these beliefs.

On the other hand, Beck treated these beliefs as tentative hypotheses about events. The client then tests the validity of these hypotheses by gathering evidence that either supports or refutes them. In contrast to Ellis, Beck uses empirical disputation.

Another difference is that Beck viewed the irrational cognitions as automatic thoughts. To him, this meant that the thoughts would automatically occur like reflexes in situations with prior reasoning or reflection. This automatic property makes these cognitions seem especially valid to the client.

Cognitive therapy has been used primarily to treat depression, although other target behaviors have included phobic behavior, obsessions, psychosomatic disorders, and schizophrenic behavior.

Cognitive distortions

Distorted perceptions and interpretations are the result of making logical errors, and Beck has identified 6 common logical errors that are frequently made by distressed clients.

Arbitrary inference--- Drawing conclusions without sufficient evidence, or when the evidence is actually contrary.

An example would be misinterpreting a frown on the face of a passerby to mean that the passerby disapproves of him or her.

Selective abstraction---Attending to a detail while ignoring the total context.

In Piagetian terms, you centrate on one selected element to the exclusion of all other elements in a situation.

An example would be feeling rejected if someone asks you to call back later because she is in the middle of the meal. You focus on the “call back later” rather than the larger context of the person being in the middle of a meal.

Overgeneralization---Drawing a general conclusion on the basis of too few incidences.

An example would be assuming that a single failure means that one cannot succeed at anything.

Personalization---Erroneously attributing an external event to oneself.

An example would be walking by a group of people who are laughing and assuming that they are laughing at you.

Polarized thinking---Thinking in extremes, in a black or white or all or none fashion.

An example would be thinking of oneself a failure as a student if one gets anything less than an “A”.

Magnification---Exaggerating the meaning or significance of a particular event.

An example would be to believe that it is terrible or catastrophic not to obtain something that one wants very badly.

You are hurt because you haven’t been invited to a friend’s party even though you are aware that the party is a family gathering. This is an example of
selective abstraction.
arbitrary inference.

You sit down next to some people who are speaking in hushed tones. You are certain they are talking about you. Your thinking is an example of
magnification
personalization

You are hurt and mad at a friend because she made some insensitive joke at your expense. Despite the fact that your friendship is longstanding, you can’t get past her joke because you believe a good friend would never be insensitive to your feelings. Your thinking would be an example of
polarized thinking.
arbitrary inference.

A student is the last to finish an exam. She looks around the room, thinking, “I must be stupid.” His thinking is an example of
magnification.
polarized thinking.
arbitrary inference.

A very good high school student has her heart set on going to an Ivy League college. Despite her excellent grades and recommendations, she fails to get into one of these schools. She concludes that without that Ivy League degree, her chance of success in life is over. Her thinking is an example of
magnification
personalization
selective abstraction

A college student breaks up with his long-time girlfriend. He concludes that he will never have a permanent relationship. His thinking is an example of
personalization
selective abstraction
overgeneralization

Goals of cognitive therapy

Beck’s therapy involves three general goals:
1) to help clients identify the dysfunctional thoughts and maladaptive assumptions that may be causing debilitating emotions,

2) to help clients counteract the basic premises of their illogical thoughts, and

3) to provide the client with the skills and experiences that create adaptive thinking.

Components of cognitive therapy

Homework assignments

Clients are required to actively participate in the therapy, including homework assignments

Recognition of dysfunctional beliefs through Socratic dialogue

Socratic dialogue is a question and answer technique used by a teacher (therapist) in which the student (client) gradually learns to recognize dysfunctional beliefs and automatic thoughts.

A difference between this and REBT is that in REBT the therapist directly points out irrational thoughts while in Socratic dialogue, the client comes to recognize them himself or herself.

One might consider Socratic dialogue superior to REBT because a client is more likely to accept that a belief is irrational when she comes to that conclusion herself rather than when told by a therapist that her belief is irrational.
true
false

Beliefs are viewed as hypotheses (rather than established facts) that can be empirically tested.

Homework assignments are collaboratively designed by the therapist and client to test these hypotheses. This is called collaborative empiricism.

The text example was of a woman who was attracted to a co-worker but felt that he disliked her because he did not talk with her, i.e., her hypothesis was that he disliked her because he didn’t talk with her.

In a situation such as this, which of the following hypotheses might be correct?
My co-worker does not like me very much.
My co-worker doesn’t talk with anybody very much.
Both of the above.

What would be an empirical test of the woman’s hypothesis?
Use logic to examine the rationality of her belief that her co-worker dislikes her.
Have the woman count how frequently her co-worker interacts with other women in the workplace.
Both of the above.

If the woman finds that her co-worker interacts with other women but not her, her hypothesis was probably
correct
incorrect

Specific techniques

Two categories:

Cognitive interventions

These are based upon cognitive restructuring.

Three-column technique

This involves keeping records of automatic thoughts that occur during a person’s day.
Column 1: Situations
Column 2: Automatic thoughts
Column 3: Logical errors

For example: a student finds herself among the last to finish an exam.

Automatic thoughts = I must be stupid.
Logical error = Arbitrary inference.

Generating alternative interpretations

For above example, an alternative interpretation would be “I’m giving more thought to the questions and am being more careful about what answers I give.”

Reattribution of responsibility
Counteracting the notion that one has more control over a situation than one has.

Decatastrophizing

Overt behavioral interventions

These involve behavioral techniques that are not unique to cognitive therapy.

They include:

Activity schedule making

Activities are scheduled for most hours of the day in order to elevate the mood of depressed clients.

Which of the following would explain why activity scheduling improves the mood of depressed clients?
It counteracts the disorganization found in depressed people.
It gives the client a sense of control.
It distracts the client from his depressing thoughts.
All of the above.

Graded task assignments

This is a specialized shaping technique in which the client is asked to perform a series of tasks beginning with very brief and simple behaviors, ones that the therapist is certain that the client can do, and gradually increasing in complexity and duration as the client succeeds at each task.

Such procedures are often employed with clients who are so depressed that they do not perform even the most mundane and routine behaviors.

For example, a man who did not feel capable of preparing his own meals first might be given the task of making a cup of tea. When the client successfully did this, he and the therapist would design a slightly more complex task until the client's behavior was shaped so that he was preparing an entire meal on his own.

Cognitive-behavioral coping skills therapy

As I said previously, cognitive-behavioral therapy comes in two forms. Some therapies focus on cognitive restructuring when there is an excess of maladaptive thoughts, while other therapies are used when a client has a deficit of adaptive cognitions.

The focus is not so much on what clients are thinking as on what they are not thinking.

Self-instructional training

When we are faced with a difficult situation, we tell ourselves things about the situation and our ability to handle it.

The problem is that sometimes these self-statements are maladaptive, in that they focus on the negative aspects of the external events and on our personal inadequacies for coping with them.

Self-instruction is a cognitive behavioral therapy developed by Donald Meichenbaum to teach people to make useful, positive self-statements when they encounter problems, i.e., to instruct themselves in how to effectively cope with the situation.

Meichenbaum’s self-instruction therapy has been used to treat such problems as
*deficits in problem solving among children and the elderly
* performance anxiety and lack of creative thinking of college students
* bizarre thoughts and speech of patients diagnosed as schizophrenic

Self-instruction is a treatment package in which the major components are cognitive modeling (model verbalizes adaptive thoughts or strategies), and cognitive behavior rehearsal (client mentally practices a behavior, such as thinking about what one is going to say before making a telephone call.

The emphasis is more on coping with the negative emotions than on completely eliminating them.

Cognitive therapy summary questions

A therapy which attempts to directly change maladaptive cognitions is
cognitive-behavioral coping skills therapy
cognitive restructuring therapy

Rational disputation is to Beck what empirical disputation is to Ellis.
true
false

According to Beck, what makes an individual’s distorted cognitions seem valid?
logical errors in thinking
automatic thoughts
tentative hypotheses

You have a client who experiences tremendous fear when meeting new people. The fear is so overwhelming that she avoids even making eye contact with anyone. The first homework assignment from therapy is to make eye contact with the cashier at the supermarket. Next time, she is to make eye contact and say “hello” to the cashier. The next time, she is to make eye contact, say “hello”, and wish the cashier a nice day upon leaving. This is an example of
self-instruction.
thought-stopping.
graded task assignments.

A 4.0 student is one of your clients. She has never received anything lower than an A- on an exam or paper. She lives in fear of ever getting a B when grades come out after each semester, since she thinks that her family would be so disappointed in her. They have been bragging about her grade point average since her freshman year. This senior in college is instructed by her therapist to pretend to her parents that she got a B+ for one of her grades (probably Behavior Analysis) in order to see their reaction. The therapist is using which cognitive-behavioral technique?
active disputing
self-instructing
empirical testing

In the above scenario, the therapist tells the student to rehearse what she will say to herself if she, in fact, does receive her first B. The therapist is using which cognitive-behavioral technique?
active disputing
self-instructing
empirical testing

 

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