Cognitive-Behavioral Therapy
Donald Meichenbaum
Goals
"Enabling people to recognize, assess, and modify their dysfunctional cognitions; changing persistent underlying cognitions such as 'I must be perfect' and 'I am unlovable'; and helping people make positive changes in their self-talk and sense of empowerment"
(Seligman & Reichenberg, 2014, p. 356)
"Enabling people to recognize, assess, and modify their dysfunctional cognitions; changing persistent underlying cognitions such as 'I must be perfect' and 'I am unlovable'; and helping people make positive changes in their self-talk and sense of empowerment"
(Seligman & Reichenberg, 2014, p. 356)
The Development of Cognitive-Behavioral Therapy
In CBT, the emphasis is placed on thoughts rather than behaviors; however, behaviors are still important. The therapeutic alliance is important and this type of therapy is brief. The strategies used in this therapy do not dictate how people should act but rather how to test their hypotheses.
Cognitive-Behavior Modification
This approach was created by Meichenbaum "in an effort to integrate psychodynamic and cognitive treatment systems with the 'technology of behavior therapists'" (Meichenbaum, 1993, p. 202). In order to achieve success, one must combine different treatment systems because one alone will not work.
Constructive narrative : People actively construct their own reality; "reality is a product of person meanings"
Information processing : An activating event taps into a person's core cognitions, leading to an unhelpful, inaccurate, and distorted thought.
People experience negative emotions and engage in unwise and harmful behaviors because they distort reality as
a result of cognitive errors and misperceptions.
Conditioning : Cognitions are viewed as covert behaviors hat have been conditioned. Correspondingly, they can be deconditioned and
modified through both external and internal contingencies (rewards or negative consequences), thereby strengthening new
and healthier cognitions. Modeling, mental rehearsal, and other strategies are important in effective cognitive change.
(Meichenbaum, 1993)
"The role of the therapist is that of co-constructivist: helping people alter their stories and cognitions so they can build' new assumptive worlds.' To accomplish this, treatment via CBM entails the use of cognitive interventions, such as Socratic dialogue (questions designed to promote clearer perceptions and thoughts) and reframing (changing terminology in an effort to change perceptions)."
(Meichenbaum, 1993)
Cognitive-Behavioral Strategies and Interventions
Stress /inoculation Training
The goal is to reduce life's stressors in order to reduce stress. It's believed that if people can cope with minor stressful things than they will be able to cope with more intense ones. "Treatment usually consists of 12 to 15 weekly sessions plus additional follow-up sessions over 6 to 12 months" (Seligman & Reichenberg, 2014, p. 346).
Three phases of stress inoculation training
1. Conceptualization : The client and counselor form a collaborative relationship where the counselor educates the client on stress. In
addition, the link between stress and coping is explored as well as how our behaviors can trigger stress. Self-talk and
statements are used to identify things that induce stress and those that reduce stress.
2. Skills acquisition and rehearsal phase : In this phase, clients are taught how to cope and how to use problem solving to get over their
fears using these five steps:
- Problem identification
- Goal selection, focusing on small manageable units of stress
- Development of alternatives
- Evaluation of each possible solution and its probably consequences
- Decision making and rehearsal of coping strategies
(Meichenbaum, 1985)
3. Application and follow-through : At this point clients are initiating the plan they created to reduce stress. As people get better at
reducing their stress, they attempt to cope with even bigger stressors.
Throughout treatment, the counselor gives reinforcement as well as evaluating the successes of the client. "Strategies such as coping imagery and cognitive rehearsal are used to solidify gains, generalize learning to more significant fears, and help people to prevent or cope with relapses. Learning ways to reduce their fears, along with increased confidence from initial successes in managing stress, facilitates people's efforts to address others fears and problems successfully" (Seligman & Reichenberg, 2014, p. 347).
Behavioral Activation Therapy
This type of therapy is used with depressed clients. In entails increasing daily activity so that people who suffer with depression can be more motivated. As well as increasing their level of motivation, it also helps to improve their mood . They create a schedule where they participate in activities pleasing to them and they can monitor their progress.
Habit Reversal Training
"HRT uses reinforcement and other behavior techniques to help people recognize tics before they happen, monitor their own behavior during stressful situations, use relaxation techniques, and perform alternative behaviors that are incompatible with the behavior they are trying to extinguish, such as tics, trichotillomania, skin scratching, and skin picking" (Adams, Adams, & Miltenberger, 2008; Veale & Neziroglu, 2010).
Exposure
"Through the use of exposure, the person learns to identify fear responses; recognize maladaptive cognitions; confront or 'sit with' the uncomfortable feelings without avoiding, running away, or otherwise modifying the experience; and achieve a certain method of self-efficacy or control over the feelings of distress" (Bandura, 1977).
Elements of exposure-based therapies
Flooding- exposing someone to something he greatly fears; also known as implosion.
Pacing - provides intense exposure over 30 minutes to 8 hours.
Graduated exposure - having the person confront the fear for a short period of time, and then gradually increasing the length of exposure
with each session.
Systematic desensitization - reduces fears, phobias, obsessions, compulsions, and anxiety.
(Seligman & Reichenberg, 2014, p. 348)
Virtual reality therapy - "by creating a human/computer interaction that imitate in vivo exposure, virtual reality can be particularly helpful
for anxiety disorders including social anxiety, phobias, OCD, PTSD, and the fear of public speaking"
(Powers & Emmelkamp, 2008; Wallach, Safir, & Bar-Zvi, 2009).
Eye Movement Desensitization and Reprocessing
"Eye movement desensitization and reprocessing (EMDR) is a form of exposure that combines bilateral Stimulation (eye movements, alternating sounds, and tapping), behavioral desensitization, and cognitive restructuring in a structure eight-phase process" and was discovered by Francine Shapiro (Seligman & Reichenberg, 2014, p. 349).
Problem-Solving Therapy
"Provides a positive intervention that focuses on the acquisition of constructive problem-solving skills to address increased stress, relationship conflict, anxiety, mood disorders, and a variety of other issues that arise in daily life" (Nezu, Nezu, & D'Zurilla, 2010).
Four-step process
1. Identify the problem
2. Brainstorm alternatives
3. Conduct a cost/benefit analysis of possible solutions
4. Monitor and evaluate outcomes
Seligman & Reichenberg, 2014, p. 350)
For this therapy, it's recommended that there is role-play where the counselor acts out the problem and the client gives possible solutions. This helps the client to not only come up with different solutions but also to envision success.
The Third Generation of Behavior Therapy
Dialectical Behavior Therapy
DBT is used to treat people that are suffering from personality disorder who often considered suicide. This type of therapy is also used to treat substance abuse disorders, impulse control disorders, anxiety and mood disorders, and other personality disorders (Marra, 2005). DBT is perfect for people who deal with a lot of emotions and who try to escape from reality.
Dialectics : This is a way of looking at reality. Dialectics is used to help clients:
- Develop a broader perspective on their problem
- Learn to look for dialectic pole (alternative story)
- Consider more options as a result
- Get unstuck and develop competence
(Almagor, 2011)
Example : Married couple and the use of free time. One person is satisfied with the way things are while the other wants to spend more
time with their partner.
(Seligman & Reichenberg, 2014, p. 351)
Worldview
The counselors try to understand the reality of their clients. "An underlying assumption of DBT is that clients are experiencing a dialectical conflict between themselves and their environment.
(Seligman & Reichenberg, 2014, p. 351)
Biopsychosocial View
People who are vulnerable emotionally and have an invalidating environment could result in borderline personality disorder. By using DBT, it helps the client to see the choices and possible solutions to his/her problem and to achieve his/her goals. In addition, it helps the client to realize that by trying to evade their feelings and emotions, he/she is actually making it worse. Clients feel empowered to use their coping skills to help keep their emotions stable.
(Seligman & Reichenberg, 2014, p 352)
7 assumptions that guide DBT
- Clients are doing the best they can
- Clients want to improve
- Clients must learn their new behaviors in all relevant contexts
- Clients cannot fail in DBT; any effort is progress
- Clients may not have caused all of their problems, but they have to solve them anyway
- Clients need to do better, try harder, or be more motivated to change
(Smith & Peck, 2004, pp. 30-31 )
DBT Treatment
Four stages
1. Clinicians helps people make a commitment to treatment and facilitate their attainment of basic competencies such as keeping
themselves safe, reducing self-destructive behaviors (e.g. drug and alcohol use, unwise sexual activity, self-injury), and teaching
relevant skills such as interpersonal effectiveness, self-care, and emotion regulation.
2. Desensitization and other strategies help people deal with traumatic experiences and the impact of past message and events.
3. Self-respect, problems of living, and individual goals are the focus of this stage, as clients begin to look to the future and apply what
they are learning.
4. The final stage promotes synthesis and generalization of gains; integration of past, present, and future; development of spirituality;
acceptance of self and reality; increase self-respect; achievement of individual goals; better coping skills; and a greater capacity
for happiness.
(Seligman & Reichenberg, 2014, p. 353)
Client and counselor are both active participants in the counseling sessions; furthermore both parties are changed as a result of counseling.
Acceptance and Commitment Therapy
Development
Stephen Hayes is the theorist associated with ACT. ACT is based off research and is used to treat anxiety, depression, and chronic pain.
(Hayes, Strosahl, & Wilson, 2012; Morris & Oliver, 2012)
Theories and Strategies
ACT is based on relational frame theory, a behavioral theory of human language and cognition that helps people recognize how they become entangled in thoughts and words and how those entanglements result in internal struggles against themselves. Instead of trying to change thoughts, people learn how to accept them for what they are and gain skills and clarity about behavioral change. The main goal is for clients to accept thoughts and emotions outside of their control to make a promise to build a life in which they value.
A = Accept and embrace thoughts and feelings, especially difficult feelings such as anxiety or pain.
C = Choose a direction in life that reflects who the client truly is.
T = Take steps toward action.
The alliance between counselor and client where the impact is mutual and the relationship is strong where differences are appreciated.
Mindfulness-Based Cognitive Therapy
The development of MBCT
MBCT is an experimental therapy that was initially created for dealing with relapse prevention and to reduce stress.
MCBT Theories and Strategies
Research shows that this type of therapy is more effective than medication because "the mechanism by which mindfulness and acceptance strategies are effective is that of exposure and response by prevention" (Holzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2011). By helping the client achieve acceptance, this will help the client to change and minimizes his/her need to escape reality. MCBT helps to reduce the mechanism of depression by helping to reduce the threat by breaking the cycle in which ruminative thoughts erupt in an effort to problem solve a given situation to be deemed unacceptable by the person. Because of this cycle, clients try to be active in solving the problem which in turn triggers that cycle. Instead of "doing," the client should be "being." By "being," this helps the client to have an openness to new experiences rather than trying to problem solve.
(Seligman & Reichenberg, 2014, p. 355; Crane, 2012)
Components of mindfulness meditation that create a process of self-regulation
- Attention regulation
- Body awareness
- Emotion regulation
- Change in perspective of self
(Holzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2011)
MCBT Treatment
MCBT is conducted in eight group sessions that last from 2 to 2.5 hours in length, including one all-day session. Follow-up sessions may be scheduled randomly in the following year to reinforce practice. If it's a group session, groups are usually not more than 10 to 12 participants and each person is interviewed in advance to ensure that they are ready for treatment.
Treatment protocol
Weeks 1-4
Developing skills, mindfulness meditation training, present-moment awareness, recognition of thoughts, emotions, bodily sensations, and behaviors
Weeks 5-8
Shift toward recognition of more challenging thoughts and feelings, working on acceptance
(Crane, 2012)
Mediation practices are taught and clients need to make time in their daily life to practice. In addition, meditation teaches them how to redirect their mind when thoughts start to wander. This helps the client to stay in the here and now as well as reducing such extremes as black and white.
Treatment Using Cognitive-Behavioral Therapies
Goals
"Enabling people to recognize, assess, and modify their dysfunctional cognitions; changing persistent underlying cognitions such as 'I must be perfect' and 'I am unlovable'; and helping people make positive changes in their self-talk and sense of empowerment"
(Seligman & Reichenberg, 2014, p. 356).
Therapeutic Alliance
As with other theories, CBT is collaborative with the clinicians fulfilling many different duties and roles. It's important for the counselor to always employ active listening and help the clients change. Even though change is the ultimate goal, counselors also want their clients to be genuine. Rather than giving praise, counselors want clients to acknowledge and take credit for their success.