COGNITIVE BEHAVIORAL THERAPY

                               COGNITIVE BEHAVIORAL THERAPY  

CBT is used to help clients reframe the way they think about themselves and their impairments and to change related behaviors

1.      THEORY:  

·         Cognitive behavioral therapy is guided by the cognitive model, which proposes that dysfunctional thinking and unrealistic cognitive appraisals of life events can negatively influence feelings and behavior 

·         The cognitive model identifies three levels of cognition:

Ø  Core beliefs, which are the deepest level of beliefs; they organize how people interpret and deal with incoming information

Ø  Intermediate beliefs, which are unarticulated attitudes, rules, expectations, or assumptions reflected in a person’s thinking

Ø  Automatic thoughts and images are the ideas or images that go through one’s mind concerning immediate circumstances

Ø  Hot thoughts are recurring automatic thoughts characterized by intense emotional experience and are considered the most important automatic thoughts to work with in psychotherapy

Ø  Automatic thoughts typically occur in association with situational triggers, which are events or circumstances that evoke certain thoughts or emotions in a given client 

·         Maladaptive cognitions can be realistic or unrealistic 

·         What determines their adaptive status is how the cognitions affect a person’s emotion and behavior 

·         Cognitive Behavioral Approaches Some of the main cognitive behavioral group approaches include: behavior therapy, cognitive therapy, rational emotive behavior therapy, and reality therapy.

·         The cognitive behavioral approaches are quite diverse, they do share these attributes:

Ø  A collaborative relationship between the group member and the therapist

Ø  The premise that psychological distress is largely a function of disturbances in cognitive processes

Ø  A focus on changing cognitions to produce desired changes in affect and behavior

Ø  A present-focused model

Ø  A generally time-limited and educational treatment focusing on specific and structured target problems

Ø  A model that relies on empirical validation of its concepts and techniques

·         There are two types of maladaptive cognitions:

Ø  Errors in thinking, which are cognitive distortions that reflect incorrect logic and/or that do not reflect reality

Ø  Preoccupations, which are usually accompanied by difficult emotions, problematic behaviors, or aversive physiological reactions

2.      ASSUMTION:

·          A basic assumption underlying the cognitive behavioral approaches is that most problematic behaviors, cognitions, and emotions have been learned and can be modified by new learning.

·         Members of a group are involved in a teaching and learning process and are taught how to develop a new perspective on ways of learning.

·         They are encouraged to try out more effective behaviors, cognitions, and emotions.

·         Problems may arise due to a skills deficit—adaptive behaviors or cognitive strategies that have not been learned—and group members can acquire coping skills by participating in this educational experience.

·         Strength of the cognitive behavioral approaches is the wide range of techniques that participants can use to specify their goals and to develop the skills needed to achieve these goals.

·         The specificity of the cognitive behavioral approaches helps group members translate fuzzy goals into concrete plans of action, which enable the members to keep these plans clearly in focus.

3.      RATIONALE FOR INTERVENTION: 

·         CBT intervention generally includes three assumptions:

Ø  Cognition affects behavior

Ø  Cognition can be monitored and altered

Ø  Behavior change is mediated by cognitive change 

·         CBT teaches clients to replace distorted thinking with more realistic and adaptive cognitions 

·         During therapy, these distortions are typically identified by listening to the client’s automatic thoughts and attempting to identify the specific type of error that that client seems to be making

4.      PRACTICE RESOURCES:

4.1 ASSESSMENT:

·         Cognitive distortions and preoccupations are typically identified by interviewing clients and listening to them during therapy sessions 

·         Careful attention to what clients say can help to identify the clients’automatic thoughts 

·         Through interviewing the client and using objective knowledge about the client’s condition and situation, cognitive distortions can be differentiated from preoccupations 

·         It is important in assessment to distinguish between distorted thinking (inaccurate thoughts) and accurate thoughts that constitute preoccupations 

·         Distorted thinking is best addressed through cognitive techniques that seek to correct the thinking pattern, whereas realistic preoccupations are often best addressed through coping skills, symptom and impairment management training, and problem-solving 

·         It is also important to identify whether a client tends to have predominantly one or both thinking patterns (i.e., distortion and/or preoccupation)

      4.2 INTERVENTION: 

·         Cognitive restructuring techniques that correct distorted thinking require a comprehensive and multi-level approach to cognitive change 

·         Maladaptive automatic thoughts are addressed by identifying them and teaching the client how to respond to them (typically through the use of thought records) 

·         Intermediate and core beliefs are addressed by identifying them and teaching the client to modify them 

·         A thought record is a form that allows the client to identify and respond to automatic thoughts  The thought record includes multiple targeted questions that allow clients to reflect upon and develop alternatives to their maladaptive thoughts 

·         The process of changing intermediate thoughts and core beliefs is complex and requires thorough knowledge of the theory and methods of CBT 

·         Intermediate and core beliefs can be brought to consciousness through a very specific sequence of questioning that allows the client to probe progressively deeper levels of consciousness 

·         In addition to the cognitively oriented approaches to addressing maladaptive cognitions, there are some techniques that are more behavioral in nature 

·         Behavioral techniques include systematic desensitization, meditation and relaxation techniques, approaches that focus on activity modification, and behavioral experiments 

·         Behavioral experiments are activities that allow clients to test the validity of their beliefs 

·         CBT typically follows a very specific sequence

Ø  First, clients are taught the relationships between situational triggers, automatic thoughts, and emotional, behavioral, and physiological reactions to their cognitions

Ø  The next stages of therapy involve creating homework assignments, behavioral experiments, and learning experiences according to the client’s needs and abilities to participate in these activities

Ø  The later stages of therapy generally involve identifying and modifying the intermediate and core beliefs that underlie the automatic thoughts and predispose clients to engage in dysfunctional thinking across a variety of situations

Ø  The final stages of therapy generally focus on relapse prevention and on empowering clients to monitor and manage their own cognitive and behavior

Ø  A number of cognitive behavioral techniques can be useful for maladaptive cognitions that do not involve cognitive distortion (i.e., preoccupations)

5.      COGNITIVE BEHAVIORAL APPROACHES:      

    

5.1  BEHAVIOR THERAPY

·         Behavior Therapy The cornerstone of behavior therapy is the identification of specific goals at the outset of the therapeutic process, which serves as a way to monitor and measure the progress of group members.

·         Therapy begins with an assessment of baseline data, the degree of progress can be evaluated by comparing group members’ behavior on a given dimension at any point in a group with the baseline data

                            5.1.1 Key Concepts of Behavior Therapy:

·         Behavior therapy as applied to group work is a systematic approach that begins with a comprehensive assessment of the individual to determine the present level of functioning as a prelude to setting therapeutic goals.

·         Evaluation is used to determine how well the procedures and techniques are working. Empirically supported techniques are selected to deal with specific problems because this approach is grounded in evidence-based practice.

                           5.1.2 Therapeutic Goals of Behavior Therapy:

·         The general goals of behavior therapy are to increase personal choice and to create new conditions for learning.

·         Goals must be clear, concrete, understood, and agreed on by the members and the group leader. Behavior therapists and group members alter goals throughout the therapeutic process as needed.

·         An aim is to eliminate maladaptive behaviors and to replace them with more constructive patterns. The client and therapist collaboratively specify treatment goals in concrete, measurable, and objective terms.

                          5.1.3 Therapeutic Relationship:

·         The group counselor’s role is to teach concrete skills through the provision of instructions, modeling, and performance feedback.

·         Leaders tend to be active and directive and to function as consultants and problem solvers.

·         Group members must be actively involved in the therapeutic process from beginning to end, and they are expected to cooperate in carrying out therapeutic activities, both in the sessions and outside of therapy.

                         5.1.4 Techniques:

                               Techniques such as:

ü  Relaxation methods

ü  Role playing

ü  Behavioral rehearsal,

ü  Coaching,

ü   Guided practice,

ü   Modeling,

ü  Giving feedback,

ü   Mindfulness skills,

ü  Cognitive restructuring,

ü  Systematic desensitization,

ü  In vivo desensitization,

ü  Flooding,

ü  Problem solving,

ü  Homework assignments

5.2  COGNITIVE THERAPY

                            5.2.1 Key Concepts of Cognitive Therapy:

·         According to cognitive therapy, psychological problems stem from commonplace processes such as faulty thinking, making incorrect inferences on the basis of inadequate or incorrect information, and failing to distinguish between fantasy and reality.

·         Cognitive therapy (CT) assumes that people are prone to learning erroneous, self-defeating thoughts but that they are capable of unlearning them. People perpetuate their difficulties through the beliefs they hold and their self-talk. By pinpointing these cognitive errors and correcting them, individuals can create a more fulfilling life.

·         Automatic thoughts are personalized notions that are triggered by particular stimuli that lead to emotional responses

·          A cognitive behavioral orientation places emphasis on the group leader functioning as a teacher who encourages group members to learn skills to deal with the problems of living. The emphasis is on changing specific behaviors and developing problem-solving skills rather than expressing feelings. The cognitive therapist teaches group members how to identify inaccurate and dysfunctional cognitions through a process of evaluation. The group leader assists members in forming hypotheses and testing their assumptions, which is known as collaborative empiricism.

·         Cognitive restructuring plays a central role in the cognitive therapies. Group members sometimes engage in catastrophic thinking by dwelling on the most  extreme negative aspects of a situation.

                  5.2.2 Therapeutic Goals of Cognitive Therapy:

·         The goal of cognitive behavior therapy is to change the way clients think by identifying their automatic thoughts and begin to introduce the idea of cognitive restructuring.

·          Changes in beliefs and thought processes tend to result in changes in the way people feel and how they behave.

·          Members learn practical ways to identify their underlying faulty beliefs, to critically evaluate these beliefs, and to replace them with constructive beliefs.

                 5.2.3 Therapeutic Relationship:

·         Group leaders combine empathy and sensitivity with technical competence in establishing their relationship with members.

                 5.2.4 Techniques:

                                Cognitive therapy is present-centered, psychoeducational, and timelimited.

ü  Socratic dialogue

ü  Guided discovery

ü  Home work

ü  Relapse prevention

5.3  RATIONAL EMOTIVE BEHAVIOR THERAPY

                   5.3.1  Key Concepts of Rational Emotive Behavior Therapy:

·         Rational emotive behavior therapy (REBT), our problems are caused by our perceptions of life situations and our thoughts, not by the situations themselves, not by others, and not by past events. It is our responsibility to recognize and change self-defeating thinking that leads to emotional and behavioral disorders.

·         REBT also holds that people tend to incorporate these dysfunctional beliefs from external sources and then continue to indoctrinate themselves with this faulty thinking.

·         To overcome irrational thinking, therapists use active and directive therapy procedures, including teaching, suggestion, and giving homework.

·         REBT in groups emphasizes education, with the group leader functioning as a teacher and the group members as earners.

·         REBT group practitioners employ a directive role in encouraging members to commit themselves to practicing in everyday situations what they are learning in the group sessions.

                   5.3.2 Therapeutic Goals of Rational Emotive Behavior Therapy:

·         The goals of REBT are to eliminate a self-defeating outlook on life, to reduce unhealthy emotional responses, and to acquire a more rational and tolerant philosophy.

·         REBT offers group members practical ways to identify their underlying faulty beliefs, to critically evaluate these beliefs, and to replace them with constructive beliefs.

                  5.3.3 Therapeutic Relationship:

·         REBT practitioners strive to unconditionally accept the members of their groups and to teach them to unconditionally accept others and themselves.

·         Group leaders do not blame or condemn members; rather, they teach members how to avoid rating and condemning themselves.

·          REBT practitioners accept their clients as imperfect beings who can be helped through a variety of cognitive, emotive, and behavioral techniques.

                5.3.4 Techniques:

·         REBT utilizes a wide range of cognitive, emotive, and behavioral methods with most group members.

·         This approach blends techniques to change members’ patterns of thinking, feeling, and acting.

·         Techniques are designed to induce clients to critically examine their present beliefs and behavior. REBT focuses on specific techniques for changing a group member’s self-defeating thoughts in concrete situations.

ü  Coping self-statements.

             5.4 REALITY THERAPY

                          5.4.1 Key Concepts of Reality Therapy:

·         The assumption that humans are internally motivated and behave to control the world around them according to some purpose within them.

·          Reality therapy is based on the assumption that human beings are motivated to change

1.      when they determine that their current behavior is not getting them what they want

2.       when they believe they can choose other behaviors that will get them closer to what they want.

·         Reality therapy group leaders expect group members to make an assessment of their current behavior to determine if what they are doing and thinking is getting them what they want from life.

·         Group members are encouraged to explore their perceptions, share their wants, and make a commitment to counseling. Because clients can directly control their acting and thinking functions more than they can control what they are feeling, their actions become the focus of work in the group.

·         A key concept of reality therapy and choice theory is that no matter how dire our circumstances may be, we always have a choice. An emphasis of reality therapy is on assuming personal responsibility and on dealing with the present.

                        5.4.2 Therapeutic Goals of Reality Therapy:

·         This approach is to help people find better ways to meet their needs for survival, love and belonging, power, freedom, and fun.

·         Changes in behavior tend to result in the satisfaction of basic needs.

                        5.4.3 Therapeutic Relationship:

·         Group leaders combine empathy and sensitivity with technical competence in establishing their relationship with members

                        5.4.5 Techniques:

·         Two major components:

1.       The counseling environment and

2.      Specific procedures that lead to change in behavior. Reality therapy is active, directive, and didactic.

·         The group leader assists members in making plans to change those behaviors that they determine are not working for them. Skillful questioning and various techniques are employed to help members make this self-evaluation. Some of the specific procedures in the practice of reality therapy have been developed by Robert Wubbolding (2011).

These procedures are summarized in the WDEP model, which refers to the following clusters of strategies:

                             W = Wants: exploring wants, needs, and perceptions.

                             D = Direction and doing: focusing on what clients are doing and the direction this is taking them.

                             E = Evaluation: challenging clients to make an evaluation of their total behavior.

                             P = Planning and commitment: assisting clients in formulating realistic plans and making a commitment to carry them out.

·         A reality therapy group is assisting members in making a self-evaluation of their current behavior. This self-assessment provides a basis for making specific changes that will enable the members to reduce their frustrations.