Ch5: Cognitive Approaches to psychotherapy

● No one “father” of cog behavioral school

● At least 20 diff therapies under this approach
● current cognitive approaches to psychotherapy have in common three basic propositions
○ Mediational role of cognition
■ there’s almost always a cognitive processing and appraisal of internal and
external events that can influence a person’s life events
○ Cognitive activity may be monitored, assessed, and measured
○ Behavior change may be an indirect sign of cognitive change
● A defining characteristic of cognitive therapy is the principle that symptoms and
dysfunctional behaviors are cognitively mediated, and therefore, a therapist helps a client
improve by assisting him or her to modify dysfunctional thinking and beliefs
● most cognitive therapies are time limited
○ 12 to 16 sessions for depression and anxiety
○ much longer time—1 to 2 years—for personality disorders and other chronic
disorders
● all cognitive therapies focus on specific problems or disorders, a defining feature that
reflects their behavior therapy heritage
● The problem-focused nature of cognitive therapy helps researchers and clinicians to
document therapeutic effects and to identify the most efficacious therapy for a specific
problem
● Client is active agent during treatment
● Explicitly or implicitly educative with therapeutic models
○ This allows client to apply set of skills to diff problems in their lives
● Albert ellis
○ developed the first intentionally therapeutic approach to cognitive behavioral
psychotherapy
■ Rational emotive therapy (RET)
○ believed that all extreme, disturbing, or neurotic emotions are a result of a
person’s view of the situation, not the situation itself
○ primary goal was to modify client’s self talk
● Theoretical Influences of REBT
○ Greek Stoics, who stressed the importance of our thoughts on our behavior
■ Greek influence led Ellis to conclude that his clients’ unhappiness and
dysfunctional behavior often stemmed from irrational thoughts
○ Ellis combined the Greek influence on the power of our thoughts with learning
theory, which was a dominant theoretical perspective during the 1950s. He
asserted that people learned maladaptive behavior, and hence, they could unlearn
such behavior by changing their thoughts
 ○ Horney’s concept of the tyranny of the “shoulds” and made it a focal part of his
11 irrational beliefs. Horney had said that people suffer psychologically because
of “should pressures”: I should be loved; I should be this or that
○ According to Adler (1926/1964), our behavior often comes from our mistaken
ideals. The individual relates himself or herself to the rest of the world based on
that person’s interpretation of himself or herself and on his or her presenting
problem
○ Adler (1931) proposed that people have fictional premises and goals, and they
operate their lives on the basis of such false hypotheses. REBT maintains that
people are disturbed because they hold irrational beliefs, and they make illogical
deductions or conclusions based on their faulty beliefs.
○ Although REBT has adopted some premises of Adlerian theory, it has declined to
stress the Adlerian emphasis on the importance of early childhood memories and
social interest. Ellis does contend that we are happiest when we help others.
● View of human nature
○ REBT is based on the belief that people are born with a potential for irrational or
rational thinking
○ Ellis maintained that human beings have predispositions for self-preservation,
happiness, and growth actualization.
○ We also have leanings toward self-destruction, repetition of past mistakes, self
blame, and avoidance of self-actualization.
○ We contaminate our positive growth potential when we use negative self talk and
when we make unrealistic demands on ourselves for perfection
● Theory of Personality: Rational Emotive ABC
○ REBT emphasizes the ABC model of personality
■ Activating event or experiences
■ Belief system
■ Consequences
■ Ellis added D and E to the ABC formula. The therapist helps the client
dispute (D) the irrational beliefs for the client to enjoy the positive
psychological effects (E) of ridding himself or herself of irrational beliefs
○ There are three elements of the disputing process: detecting, debating, and
discriminating
■ Detecting irrational beliefs like “should” or “must”
■ Debate their dysfunctional beliefs by learning how to challenge irrational
beliefs
■ Discriminate irrational beliefs from rational ones
○ REBT seeks to replace irrational self talk with adaptive self talk
○ After clients are taught to distinguish their irrational beliefs from their rational
ones, they are helped to develop E, an effective philosophy
 ○ Ellis maintained that passive, nondirective therapeutic methods, such as reflection
of feeling and free association, do not work in therapy
● Healthy psychological development
○ Ellis has maintained that most people are happiest when engaged in some activity
that draws them outside of themselves.
○ The three major forms of healthy absorption include
■ (1) loving or feeling absorbed in other people
■ (2) creating or getting absorbed in things
■ (3) philosophizing or being involved in ideas. Living healthy means doing,
acting, loving, creating, and thinking.
● Theory of maladaptive behavior
○ Ellis and Harper listed 11 irrational ideas that cause people to develop
maladaptive behavior
■ These ideas constitute major causes of emotional probs and maladaptive
behavior; carry a sense of self-blame and blame of others
■ Irrational Belief 1: idea that you must have love or approval from all the
people you find significant.
■ Irrational Belief 2: “I must not fail” ; idea that you must be thoroughly
competent, adequate, and achieving
■ Irrational Belief 3: concept of damning; when people act obnoxiously and
unfairly, you should blame and damn them and see them as bad, wicked,
or horrible people
■ Irrational Belief 4: awfulizing; you have to see things as awful, terrible,
and horrible when things go wrong.
■ Irrational Belief 5: emotional unhappiness stems from external pressures
and that you have little capacity to control or to change your feelings
■ Irrational Belief 6: catastrophizing belief; It is awful and catastrophic
when your life’s conditions are not the way you would like them to be
■ Irrational Belief 7: avoiding life’s challenges is more rewarding than
seeking challenges.
■ Irrational Belief 8: you need to be dependent on someone stronger than
yourself
■ Irrational Belief 9: past events in our lives determine our destinies and that
because an event once had a strong influence on our lives, it will continue
to do so
■ Irrational Belief 10: it is irrational for us to become unduly upset about
other people’s problem
■ Irrational Belief 11: it is irrational for you to believe that there is always a
right, precise, and perfect solution to human problems
● REBT is intended to be brief therapy
● Therapeutic relationship in REBT
 ○ Therapist is collaborator and teacher
○ A warm client–therapist relationship is desirable but not necessarily sufficient in
the therapeutic process.
○ Although REBT therapists do emphasize unconditional acceptance and close
collaboration with clients, they encourage clients to accept themselves
unconditionally
● REBT provides clients with three powerful insights
○ Insight Number 1 : a person’s self-defeating behavior usually stems from the
interaction of A (adversity) and B (belief about the adversity). Disturbed
consequences (C) follow the interaction of A and B, such that A + B = C.
○ Insight Number 2: understanding that people have made themselves emotionally
disturbed because they keep indoctrinating themselves with similar irrational
beliefs
○ Insight Number 3: clients recognize that only hard work and practice will correct
irrational beliefs.
● Role of the REBT Therapist
○ The therapist’s primary role is to focus on the main irrational ideas that lie behind
the feelings clients have expressed in therapy, especially their ideas that it is awful
the way in which people have treated them
○ REBT consists of 3 phases
■ Cognitive phase: “What problems have you been bothering yourself
about?”
■ Emotive phase: clients are instructed that they can learn to control their
emotions by becoming aware of the thoughts that support such emotions
and by learning to substitute alternative thoughts
■ behavioristic phase: clients are taught to change their behavior.
● REBT Counseling Techniques
○ didactic discussion, bibliotherapy, role-playing, assertion training, operant
conditioning, and activity-oriented homework assignments
○ One technique used is called changing one’s language
■ REBT maintains that imprecise language contributes to distorted thinking
■ Clients learn how to change their “musts” to “preferences.” Instead of
saying, “It is horrible that she treats me this way,” clients learn to say, “It
would be preferable if she did not treat me this way.”
○ Disputing
■ The first part entails a detailed examination sentence by sentence of any
irrational belief that the client states during therapy.
■ The second stage consists of using three forms of disputation: cognitive,
imaginal, and behavioral.
■ Cognitive disputation attempts to persuade the client by asking direct
questions. For instance, the therapist might ask, “Can you prove it? How
 do you know? If what you say is true, what’s the worst thing that can
happen to you? As long as you believe that, how will you feel?”
○ Imaginal disputation
■ Imagining a situation in which u feel uncomfortable
● Research and Outlook for REBT
○ Currently few therapists list themselves as REBT therapists
● Albert Bandura
○ Bridged gap between behaviorism and CBT
○ Bobo doll experiment
○ Bandura and his associates drew the conclusion that children could learn new
patterns of behavior vicariously without actually performing them or receiving
rewards.
○ Bandura’s experimental study was significant because it challenged the dominant
behaviorist position that said all behavior is influenced by conditioning,
reinforcement, or rewards.
○ Although most psychology textbooks categorize Bandura’s social learning theory
with those of the behaviorists, Bandura himself noted that he never really fit well
as a behaviorist. In fact, Bandura argued that reducing behavior to a stimulus–
response cycle was far too simplistic. Even though he used behavioral
terminology, such as conditioning and reinforcement, he conceptualized these
phenomena as operating through cognitive processes. From his perspective,
psychology textbooks mischaracterized his approach as behavioristic rather than
as cognitive.
○ Concept of self-efficacy: how well people perceive that they can deal w life
tasks/challenges
● Aaron beck
○ became famous because he developed a cognitive therapy approach to depression
○ Beck’s theory of depression postulated that depressed people adopt a negative
schema of the world in childhood and adolescence. They construct such schemas
because of a loss of a parent, rejection by peers, or criticism from teachers or
parents
○ When people with a depressed schema encounter a situation that resembles the
original negative schema, depression ensues.
○ He found that suicidal risk was increased by a sense of hopelessness.
○ Beck Depression Inventory
● Beck’s cognitive therapy
○ Automatic thought
■ Automatic thoughts can bring to the surface core negative thoughts he has
about himself
○ Cognitive schemas
 ■ Schema is a cognitive framework or concept that helps us organize and
interpret info
○ Cognitive distortions
■ When our information processing is inaccurate
■ 9 cognitive distortions
● All-or-nothing thinking: When we believe that things have to be
exactly as we want them to be, we are participating in all-or-
nothing thinking.
● Selective abstraction: It exists when we form conclusions based on
an isolated detail of a situation.
● Overgeneralization: It takes place when we make a rule based on a
few occurrences of a situation.
● Mind reading: It refers to the notion that we know what another
person is thinking about.
● Magnification and minimization: They involve seeing something
as far more important or far less significant than it actually is.
● Personalization: It means that a person takes an unrelated event
and makes it related or causal to him or her
● Negative prediction: It occurs when an individual believes that
something bad is going to happen, but there is no hard evidence to
support such a conclusion
● Labeling and mislabeling: These are said to occur when a person
describes his or her identity on the basis of imperfections and
mistakes made in the past and permits such imperfections to
continue to define his or her identity
● Catastrophizing: It is a type of cognitive distortion that takes place
when we take one event and exaggerate it so that it becomes
fearful in our live
● Cognitive therapy views personality as being shaped by the interaction between people’s
innate disposition and their environment
● Theory of Maladaptive Behavior
○ psychological distress as being caused by a number of factors, including
predispositions to illness
○ most psychological disorders are caused by a bias in the way we engage in
information processing
● Cognitive Model of Depression
○ Cognitive triad model
○ Depressed people have a negative view of themselves, the world, and their future
● Cognitive model of anxiety disorders
○ Beck conceptualized anxiety disorders as excessive functioning or malfunctioning
of normal survival mechanisms
 ○ What differs between normal and anxious people is that the latter’s perception of
danger is based on false assumptions or exaggerated signs of danger
● Cognitive Model for Obsessions and Compulsions
○ Beck, Freeman, and Associates (1990) have listed a number of automatic thoughts
caused by obsessions and compulsions:
■ “What if I forget to pack something?”
■ “I better do this again to be sure I got it right.”
■ “I have to do this myself or it won’t be done correctly.”
○ People suffering from obsessions experience guilt when they do not do what they
think they should do. They experience anxiety even when they are reassured that
everything is okay
○ Habituation training is one specific technique used to treat obsessions.
Habituation training elicits clients’ obsessional thoughts on a repeated basis. Then
he or she develops ways to get the client used to obsessional thoughts without
feeling that anything needs to be done about them. Finally, the therapist asks the
client (a) to deliberately evoke the thoughts, (b) to write these thoughts down
repeatedly, and (c) to listen to a tape of the thoughts with the client’s voice
● Underlying Assumptions of Cognitive Therapy
○ People’s internal communication is available for introspection
○ clients’ beliefs contain highly personal meanings
○ clients can discover the meaning of their internal communications
○ Cognitive therapy emphasizes the present, and it usually lasts for 10 to 16
sessions. Treatment is focused on clients’ current issues rather than on their past
● Therapeutic relationship
○ In contrast to REBT, Beck’s cognitive therapy emphasizes the importance of the
therapeutic relationship
○ Beck (2005) asserted that therapists must practice empathy and positive regard for
clients
○ therapists must also have a cognitive conceptualization of a case, be active and
creative in designing therapeutic homework assignments, be able to engage
clients through a process of Socratic questioning, and be skilled in guiding clients
in order to produce important self-discovery that leads to desired changes in a
client’s thinking or behavior
○ In Beck’s cognitive therapy, the therapeutic process is governed by three
principles
■ collaborative empiricism: t both the therapist and the client jointly
determine the goals for treatment and decide how feedback will take place
■ Socratic dialogue
● What is the evidence for the belief?
● How else might you interpret the situation?
● If it is true, what are the implications?
 ■ guided discovery
● The fundamental goal of cognitive therapy is to remove or to eliminate biases in clients’
thinking that prevent them from functioning optimally
● Cognitive therapists frequently administer brief symptom checklists, including the Beck
Depression Inventory and the Beck Anxiety Inventory prior to counseling sessions to
both identify clients’ faulty thoughts and to provide a means to evaluate clients’ progress
at the end of therapy
● Therapy techniques
○ decatastrophizing, reattribution, redefining, decentering, and doing homework
○ Reattribution techniques test clients’ automatic thoughts by introducing
alternative causes of events
○ Decentering is a technique used in treating anxious clients who mistakenly
believe that they are the focus of everyone’s attention
● Cognitive neuroscience
○ One of the fastest growing fields in the CBT school
○ Cognitive neuroscience addresses how the brain creates the mind and how a
certain area of the brain is connected to feelings or thoughts. It is an
interdisciplinary approach for understanding the nature of thought.
○ Cognitive neuroscience changed this lackadaisical approach to understanding the
neural bases of mental processes. This field of study has now brought new
understanding about the brain and the mind.
○ examines areas such as attention and brain function, emotional learning and
memory, and the impact of a therapist and the therapeutic relationship on clients
○ Two types of information processing are related to a person’s cognitive thoughts
and his or her emotional state: (1) bottom-up processing and (2) topdown
processing
■ Bottom-up processing is dominated by situational cues
■ top-down information processing is deliberate and explicit. It is a strategic
form of rational processing that uses rule-based knowledge to guide the
information processing system.
○ discovery of a neural mirroring system in the premotor cortex and other areas of
the brain
○ Mirror imaging may be conceptualized as the neurobiological correlate of action
understanding, nonverbal communication, and empathy
● The Third Wave in Behavior Therapy: Mindfulness Integrated Into Cognitive Behavioral
Therapies (DBT, ACT, and MBCT)
○ Prominent in the third wave of CBT is the incorporation of the Chinese cultural
practice of mindfulness into various cognitive therapy approaches
● Dialectical Behavior Therapy: Marsha Linehan
○ Part of 3rd wave of behavior therapy
 ○ developed specifically as a treatment approach for chronically suicidal individuals
who met the criteria for borderline personality disorder
○ People diagnosed with a borderline personality disorder commit suicide more
frequently than do individuals within the average population, and they also
practice nonsuicidal self-injurious behaviors
○ DBT can be described as an integration of three theoretical positions: (1)
behavioral science, (2) dialectical philosophy, and (3) Zen practice, specifically
mindfulness.
○ Goal of DBT
■ to help clients create and maintain consistent, stable environments, in
which they are comfortable with change
■ to bring out the opposites in the therapeutic situation and in the client’s
life and to provide him or her with the conditions for synthesis.
■ Dialectical reasoning
■ . The therapy must (1) enhance and maintain the client’s motivation to
change, (2) improve the client’s capabilities, (3) ensure that the client is
assisted in generalizing his or her new capabilities to all relevant
environments, (4) enhance the therapist’s motivation and capabilities to
treat clients, and (5) structure the clinical environment for therapy
■ DBT also organizes clinical treatment into stages and targets; it also
adheres strictly to the order in which problems are addressed. The
organizational format of DBT prevents therapy from just focusing on the
crisis of the moment. Each stage of DBT has its own hierarchy for
treatment targets
■ 4 staged and goals of DBT
● Mindfulness
● Distress tolerance
● Interpersonal effectiveness
● Emotion regulation
■ Standard DBT consists of three formats or models of treatment: (1)
individual therapy, (2) skills-teaching group, and (3) coaching
○ Clients who received DBT in comparison to the treatment-as-usual group were
significantly less likely to drop out of therapy, were significantly less likely to
engage in parasuicide, reported significantly fewer parasuicidal behaviors, and,
when engaging in parasuicidal behaviors, had less medically severe behaviors.
○ clients who received DBT were less likely to be hospitalized, had spent fewer
days in the hospital, and had higher scores on global and social adjustment.
● Acceptance and Commitment Therapy: Steven C. Hayes
○ ACT adopts the perspective that suffering is an inevitable part of human life
○ ACT is based partly on relational frame theory (RFT). RFT deals with the power
of language and verbal behavior. The theory posits that psychopathology is the
 result of the human tendency to avoid negatively evaluated private events (what
we think and feel)
○ challenges the ground rules of many Western psychotherapy approaches
○ Most Western therapy models are geared to repair, change, or fix problems. ACT
does not have as its therapeutic goal symptom reduction. On the contrary, it
maintains that therapy’s attempt to get rid of symptoms actually creates a clinical
disorder.
○ the aim is to transform our relationship with our difficult thoughts and feelings so
that we no longer perceive them as “symptoms.”
○ “patients are taught
■ (a) to identify andabandon internally oriented control strategies,
■ (b) to accept the presence of difficult thoughts or feelings
■ (c) to learn to ‘just notice’ the occurrences of these private experiences,
without struggling with them, arguing with them, or taking them to be
literally true
■ (d) to focus on overt behaviors that produce valued outcomes
○ “I’m having a difficult time with this issue, and that’s all right. I’m not going to
struggle with it to make it right. I accept it as a problem, and I notice what the
problem feels like in my body.”
○ ACT considers that the core of many human problems may be attributed to the
concepts contained in the acronym, FEAR:
■ Fusion with one’s thoughts
■ Evaluation of one’s experience
■ Avoidance of one’s experiences and emotions
■ Reason-giving for one’s behavior
○ ACT interventions emphasize two primary processes:
■ (1) developing an acceptance of undesirable private experiences, which
are out of one’s personal control
■ 2) making a commitment and taking action toward living a valued life
● There are six core processes involved in ACT, and these are as follows
○ Acceptance
■ entails making room for painful feelings, urges, and sensations and
allowing them to come and go without a struggle
○ Cognitive defusion
■ involves distancing oneself from, letting go of, unhelpful thoughts, beliefs,
and memories
○ Contact with the present moment
■ Engaging fully with the here and now with an attitude of openness and
curiosity.
○ The observing self
■ Being engaged in observing one’s response to situations
 ○ Values
○ Committed action
■ set goals that are guided by his or her values and taking effective action to
accomplish those goals
● The training of ACT therapists focuses on helping therapists develop the qualities of
compassion, acceptance, and empathy, while being able to withstand a client’s strong
emotions
● Research evidence indicates that ACT reduces the negative behavioral impact of
undesirable thoughts and feelings. When ACT is applied to work site anxiety and stress,
subjects experienced an increase in the acceptance of these emotions and the positive
work behaviors suppressed by them
● Moreover, ACT appears to reduce the believability of negative private events more
rapidly than direct cognitive disputation in some clinical populations
● research has found that ACT is efficacious for sexual abuse survivors, at-risk adolescents,
and those with substance abuse or mood disorders
● ACT has been used for trauma work as well as for those with phobias and obsessive
behavior
● Mindfulness Based Cognitive Therapy
○ developed to help prevent the relapse of depression in individuals with major
depressive disorder
○ metacognitive awareness, or the ability to experience negative thoughts and
feelings as mental events that pass through the mind, instead of becoming part of
the self
○ promote “decentered” views, such as “Thoughts are not facts” and “I am not my
thoughts”
○ goal of MBCT is to prevent a relapse in depression for individuals diagnosed
with a major depressive disorder
○ In contrast to CBT, there is little emphasis in MBCT on changing the content or
specific meanings of negative automatic thoughts. The primary goal is to change
clients’ awareness of their automatic negative thoughts and their relationship to
such thoughts.
○ MBCT is an 8-week group treatment program based on Kabat-Zinn’s (1994)
MBSR
■ Teaches art of meditation
○ MBCT uses a manual, and it is delivered by trained instructors through the
following sessions
■ A one-on-one orientation session
■ Eight 2-hour core sessions delivered weekly in a group format with 9 to 15
participants who are either in full remission (meaning experiencing a
clinically normal mood) and using no medication or in partial remission
(having residual depression symptoms) and continuing use of medication
 ■ One to four 2-hour follow-up reinforcement sessions delivered in a group
format 4 to 12 months after the eight core sessions
○ Previous research has shown that MBCT is an effective treatment for mood and
anxiety disorders
○ The success of MBCT with treatment of relapse in depression has led to its use
with several other conditions including the following:
■ Chronic fatigue syndrome
■ Generalized anxiety disorder
■ Panic disorder
■ Bipolar mood disorder
● Differences Between ACT, CBT, DBT, and MBCT
○ ACT differs from CBT because instead of challenging distressing thoughts by
looking for evidence and arriving at a more rational response (CBT), ACT accepts
a thought as a thought and nothing more.
○ ACT differs from DBT and MBCT in that both DBT and MBCT are manualized
treatment protocols for specific disorders. Moreover, MBCT is designed for use
with groups for treatment of stress and depression. DBT uses a combination of
group skills training and individual therapy, and it is designed primarily for
treatment of borderline personality disorder
○ in contrast to the other theoretical approaches, ACT can be used with individuals,
couples, and groups for a wide range of clinical populations in either brief therapy
or long-term therapy. Instead of following a manualized protocol, ACT permits
the therapists to create their own approach to mindfulness
○ ACT does not just use meditation as a way for clients to practice mindfulness
● Hayes (1995) has identified four strengths of CBT in working with clients from ethnic
minority background
○ Emphasis on uniqueness of an individual
○ Client empowerment
○ Emphasizes conscious processes and specific behaviors instead of unconscious
○ Integration of assessment throughout course of therapy
● Asian American multiculturalists have pointed out the benefits of using CBT with Asian
clients
○ It has been observed that Chinese people prefer treatment that is directive,
structured, and short term
○ CBT is effective for Chinese people because there is a good cognitive match
between elements of Chinese culture (regarding authority figures as
knowledgeable, preferring an instructive and didactic style early in the therapeutic
relationship) and cognitive therapy’s educative style in teaching the elements of
that theoretical approach
● Multicultural blindspots of CBT
 ○ criticized because of their negative view of dependency and because of their
emphasis on rationality—values associated with Western cultures.
○ it may be counterproductive for a cognitive therapist to engage in confrontation (a
core part of REBT) and that it might be beneficial to emphasize collaboration
with a client whose cultural values are harmony
○ therapists should not use disrespectful terms such as irrational, maladaptive, or
dysfunctional when discussing a client’s core beliefs
○ There has also been some concern that cognitive therapies place too much
emphasis on counseling techniques rather than the importance of therapist
attitudes, values, and beliefs
● Contributions and Criticisms of the Cognitive Behavioral Approach
○ Contributions
■ mounting empirical evidence that CBT is effective for the treatment for a
variety of other problems, including anxiety, depression, and eating
disorders
■ strong commitment to empirical evaluation, revision, and openness to
integrating other points of view, especially concepts in the area of the
therapeutic alliance and conditions for therapy
■ recognizes that one treatment may not be appropriate for all types of
psychological disorders
● For instance, in psychoanalysis, the same treatment approach is
used for a broad range of psychological disorders. In contrast,
cognitive behavioral therapists assert that different cognitive
schemas exist for different disorders.
○ Criticism
■ Too structured and manualized
■ insufficient attention is paid to early experiences and unfinished business
from the past
■ Some label it as being too simplistic