Download Techniques of Cognitive therapy

Therapy Notes
Therapies
Insight-oriented Therapies
Definition: a type of therapy in which the therapist tries to lead the client to understanding the
psychological cause of his or her symptoms through deeply felt personal insights. There are several
types of insight-oriented therapies:
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Psychoanalysis
Psychodynamic therapy
Humanistic therapy (aka “client-centered therapy”)
Psychoanalysis/psychodynamic therapy
Psychoanalysis: an intense form of therapy started by Freud based on the idea that psychological
problems are caused by unconscious conflicts between the id, ego, and superego. Patient has sessions
(not covered by insurance) for 4-5 times a week, 50 minutes at a time, for an average of 4 years. Goal is
to bring unconscious psychological conflicts to light and come to terms with them. Past relationships
(especially with parents) are emphasized. Freud introduced the idea of the “talking cure,” which was
revolutionary in the treatment of psychological disorders.
Psychodynamic theory: a less intense form of psychoanalysis in which the patient goes to therapy for a
shorter amount of time (once or twice a week for as little as 12 sessions). It tends to focus on current,
rather than past, relationships.
Techniques used in both psychoanalysis and psychodynamic therapy:
1. Free association: Patient says whatever comes to mind. May reveal unconscious issues.
2. Dream analysis: Remember that Freud believed that dreams represented a hidden meaning
(latent content). He called dreams the “royal road to the unconscious.”
3. Interpretation: The therapist’s attempts to decipher the patients’ words and behaviors and
assign unconscious motivations to them. Through interpretation, patients are made aware of
defense mechanisms (unconscious processes that prevent unacceptable thoughts or urges from
reaching consciousness) and may experience Freudian slips—something the patient says
indicates some unconscious process.
4. Resistance: occurs when the patient resists the therapist’s interpretations; patient may refuse to
cooperate with the therapist, either consciously or subconsciously through forgetting
appointments,e tc.
5. Transference: Patient transfers some of his/her feelings for someone in the past to the therapist
(e.g., Patient may fall in love with the therapist or view him as a father figure).
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Therapy Notes
Humanistic therapy
Started by Carl Rogers. Emphasis was on free will, personal growth, self-esteem, and mastery. Rogers
called his patients clients and referred to his therapy as “client-centered therapy.” He thought that
person’s distressing symptoms arose from personal growth being blocked; goal of therapy was to
remove the block so client can reach full potential.
One reason for the lack of a coherent, unified sense of self is a mismatch, or incongruence, between the
real self and ideal self.
Two trademark techniques:
1. Empathy: Therapist shows empathy for what client says in a technique called “reflective
listening.” Therapist “reflects back” the content and emotion of what the client has said to let
the client know he’s been understood.
2. Unconditional positive regard: Therapist conveys positive feelings for the client no matter what
client has said or done.
**Bottom line about all insight-oriented therapies: These appeal to many people (especially humanistic
therapy) because they appear to provide self-knowledge. Research on psychodynamic therapies is
limited, but some studies have shown that short-term psychodynamic therapy is as effective as (but not
superior to) other short-term therapies. Best used with patients who are good at articulating feelings
and want to understand their own unconscious mental processes. (And people who have lots of time
and money.)
Humanistic therapy: Research hasn’t shown that it’s better than other forms of therapy. Almost all
therapists today employ Rogers’ view that the therapist needs to have empathy and unconditional
positive regard for the client. His therapy is hard to study scientifically.
Cognitive-Behavioral Therapies
Behavior Therapy:uses techniques based on classical and operant conditioning.
ABC’s of maladaptive behavior:
1) A: antecedents—what stimuli triggers the problematic behavior?
2) B: the problematic behavior itself
3) C: the consequences (what is reinforcing the behavior?)
Techniques based on classical conditioning are the following:
a. Exposure: based on the principle of habituation, or slowly getting used to something through
repeated encounters with the stimulus. This technique is used in the treatment of anxiety
disorders. Clients are asked to expose themselves to the feared stimulus in order to reduce the
fear it provokes. This is done gradually and can be accomplished in one of three ways: 1)
imagined exposure; 2) real (in vivo) exposure; or 3) virtual reality exposure.
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b. Exposure with response prevention: a planned, programmatic procedure that requires the client
to encounter the anxiety-provoking object or situation but prevents (or has the client abstain
from making) his usual maladaptive response. Used in the treatment of OCD. Example: Client
has to get hands dirty but is prevented from washing them. This treatment is as effective as
medication for OCD, but some clients aren’t motivated to try it because it produces extreme
anxiety. Also used in treatment of bulimia. Clients must east but aren’t allowed to throw up.
c. Stimulus control: the client controls how often he encounters a stimulus that elicits a
conditioned response, with the goal of increasing or decreasing the response. Example: A binge
eater or bulimic would buy only one doughnut, not one dozen.
d. Systematic desensitization: used in treatment of phobias; replacing the fear response with a
relaxation response because fear and relaxation are incompatible.
Techniques based on operant conditioning:
Reinforcement and punishment: Therapist and client set “response contingencies” in which certain
consequences will be given if the desirable or undesirable behavior is engaged in. E.g., Positive
reinforcement will be given to a child who is afraid to talk to anyone at school if she talks to
someone.
Extinction: a process that eliminates a behavior by not reinforcing it. Example: A depressed
woman’s husband is forbidden to respond to her self-deprecating comments.
Self-monitoring: The client is made aware of his behavior through written logs or records of the
behavior.
Behavior modification programs may rely on secondary reinforcers, such as tokens, which add up to
produce a more desirable reinforcer.
When you did your self-change project, you used self-monitoiring to record instances of your
behavior and what triggered it (classical conditioning) and then used check marks (token economy)
as reinforcers—if you got X check marks, you got a reward. Some of you used punishments in
addition to the reinforcements. The self-change project was classic behavioral therapy.
Cognitive Therapy
Instead of focusing on behaviors, cognitive therapy focuses on thoughts, which (when changed) will
result in behavioral change. Cognitive therapy is designed to help clients think rationally.
Two types:
1. Rational-emotive behavior therapy (REBT) from Albert Ellis
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Therapy Notes
2. Cognitive therapy from Aaron Beck.
REBT: (Ellis) encourages clients to engage in rational, logical thinking and assumes that distressing
feelings or symptoms are the result of illogical thinking. People may develop illogical thoughts as a result
of their experiences, and they might elevate irrational thoughts to the level to “godlike absolutist musts,
should, demands, and commands.”
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Three processes that interfere with healthy functioning, according to Ellis:
Self-downing (being critical of oneself for performing poorly or being rejected)
Hostility and rage (being unkind to or critical of others for performing poorly)
Low frustration tolerance (blaming everyone and everything for “poor dislikable conditions”)
REBT is geared toward solving problems directly (as opposed to insight-oriented therapies, which solve
problems indirectly by helping clients achieve insight). REBT therapists encourage self-acceptance and a
new way of thinking, replacing irrational beliefs with more realistic ones.
Cognitive therapy (Beck)
Like REBT, Beck’s therapy rests on the idea that automatic, irrational thoughts are the basis of
psychological problems, and recognizing this irrationality and adopting more realistic ways of thinking is
the key to reducing problems.
Beck thinks that persistent irrational beliefs arise from cognitive distortions, which are systematic biases
in the way a person thinks about events and people, including oneself.
**Unlike REBT, in which therapists try to persuade clients that their beliefs are irrational, cognitive
therapy encourages clients to view beliefs as hypotheses to be tested. In other words, the client needs to
convince himself through scientific testing that his beliefs are irrational.
Therapy relies on cognitive restructuring, the process of helping clients view their situations in a new
light, which allows them to adopt more realistic thoughts. They may be asked to keep a diary of
dysfunctional thoughts (see below), identify the situation in which the thought occurred, rate their
emotional state, write down the cognitive distortions involved, develop rational responses to these
thoughts, and rate their emotional state afterward. Can be difficult because the client has believed the
“truth” of the dysfunctional thought for so long that it no longer seems distorted or irrational.
Cognitive therapy also uses psychoeducation, in which clients are taught about therapy and their
particular disorder. This helps them understand that their thoughts are dysfunctional.
Techniques of Cognitive therapy:
1. Dichotomous thinking: black & white, all-or-none thinking; there’s no middle ground; you’re
either perfect or worthless (If I don’t get an A on this essay, I’m a failure in life.)
2. Mental filter: magnifying the negative aspects of something while filtering out the positive
(thinking of only the bad things; remembering all the times you’ve failed instead of succeeded)
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Therapy Notes
3. Mind reading: believing that you know exactly what others are thinking, particularly as it relates
to you (I know they’re looking at me and thinking I look awful)
4. Catastrophic exaggeration: thinking that your worst nightmare will come true, and it will be
awful (If I fail this test, I’ll be kicked out of college and will be working as a garbage collector all
my life.)
5. Control beliefs: believing either you’re helpless and totally subject to forces beyond your control
or that you must tightly control your life for fear that, if you don’t, you’ll never be able to regain
control. (If I eat this piece of cake, I’ll gain 10 pounds and will be a fat hog forever.)
Techniques of REBT: ABCDEF
Distressing feelings exist because of an activating event (A), which, along with the beliefs (B), lead to a
highly charged emotional consequence (C). It is not the event itself that created the problem, but rather
the beliefs attached to the event that led to a different consequence. Thus, changing the beliefs will lead
to a different consequence. This is done by helping the client dispute (D) the irrational beliefs and
perceive their illogical and self-defeating nature. Such disputes lead to an effect (E-also called effective
new philosophy), a new way of feeling and acting. Finally, clients may need to take further action (F) to
solidify the change in beliefs.
The REBT sometimes argues with the client to help him confront and dispute the faulty cognitions that
contribute to his distress. Therapist will use role-playing to help the client practice new ways of thinking
and behaving.
REBT is helpful with anxiety, unassertiveness, and unrealistic expectations. It is NOT effective with
psychotic disorders.
Cognitive therapy (and REBT) are compatible with behavioral therapy. Behavioral therapy starts with
attacking bad behaviors and allowing new cognitions to follow once the behaviors are changed.
Cognitive therapy is the opposite: start with the thoughts, and the bad behaviors will change as a result
of the change in cognition.
Biologically-based treatments
Psychopharmacology: treating disorders with medications.
Psychotic disorders
Schizophrenia and other psychotic disorders: treated with antipsychotic medications, which generally
alleviate the positive (abnormal) symptoms such as hallucinations but don’t work as well for negative
symptoms, such as avolition and alogia. Clients have better outcomes if they start taking antipsychotics
after the FIRST psychotic episode, rather than waiting for future episodes.
Two groups of antipsychotics:
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Therapy Notes
1. First-generation antipsychotics (aka traditional antipsychotics): first wave of medications used to
treat schizophrenia and other psychotic disorders; they include meds such as Thorazine and
Haldol. They can cause tardive dyskinesia, though (irreversible movement disorder in which
patient smacks his lips, displays facial grimaces, etc.)
2. Second-generation antipsychotics (atypical antipsychotics): new wave of treatment that reduces
the amount of dopamine in the brain (first-generations do this, too) without the tardive
dyskinesia side effects. Second-generations also affect other neurotransmitters. Risperdal cuts
down both dopamine and serotonin. These newer meds can cause hyperglycemia (high blood
sugar) and diabetes.
Mood Disorders
Depression has been treated with medications since the 1950s. The first class was the tricyclic
antidepressants (Elavil, Pamelor, etc.) that affect serotonin but have some side effects (constipation, dry
mouth, low blood pressure, blurry vision) and take weeks to work. Another class of antidepressants is
the MAOIs (monoamine oxidase inhibitors), which have never been as commonly prescribed because
they require users not to eat or drink anything containing the substance tyramine (present in foods such
as cheese and wine), and they’re less effective with typical symptoms of depression. They’re better with
atypical symptoms, such as increased need for sleep and increased appetite.
Third class, developed in the 1980s, are the SSRIs (selective serotonin reuptake inhibitors).Prozac was
the first. They have fewer side effects and are as effective as the earlier classes of antidepressants, so
people are more likely to keep taking them. Some side effects are decreased sexual interest and
difficulty achieving orgasm. There’s also the risk of becoming tolerant to the medication and needing
another pill or an increased dose (called “Prozac poopout.”) Finally, SSRIs have an increased risk of
suicide in children and adolescents (but not adults).
The newest class is the serotonin/norepinepherine reuptake inhibitors, or SNRIs. Serzone, Wellbutrin,
Effexor, Pristiq, Cymbalta, and Remeron are in this category.
Finally, if you want to avoid prescription drugs, you could try St. John’s wort, which seems to have the
same success rate for mild to moderate depression. (BUT…it makes birth control pills ineffective!)
Placebo effects? Studies have shown that only 25% of the benefit of antidepressants comes from the
drug itself; 75-80% of the benefits can be achieved through a placebo. Neuroimaging studies confirm
that placebos can actually change brain functioning, especially if that placebo has side effects that are
similar to the actual pill. People can often cure themselves if they truly believe they’re taking something
that’s supposed to help them. This doesn’t mean that people who are taking antidepressants should
stop taking them, though, because they would also lose the placebo effect along with the therapeutic
effects of the drug.
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Therapy Notes
Bipolar Disorder medications: There are two types: 1) mood stabilizers (Lithium) and anticonvulant
medications (Depakote, Tegretol, and Lamictal). Up to half of bipolar patients can’t tolerate Lithium’s
side effects (gastrointestinal problems, increased thirst, trembling) or are not helped substantially by the
drug. The anticonvulsants also stabilize mood and minimize manic episodes. Sometimes people with
bipolar are given antidepressants during depressive episodes, but they can trigger mania.
Anxiety Disorders
Best treatment is benzodiazepines—reduce symptoms of panic from an hour up to 36 hours (quickacting). Drawback is that they’re addictive and people build up tolerance quickly to them. They’re also
potentially lethal when taken with alcohol. These drugs should only be prescribed and used for short
periods of time. Antidepressants (tricyclics, SSRIs, or SNRIs) are prescribed for long-term management,
although the dosage may be either lower or higher (depending on the specific disorder) than it would be
to treat depression. They take several weeks to significantly lower anxiety.
Electroconvulsive therapy (ECT)
ECT is a technique used in which an electric current is passed through a patient’s brain to induce a
controlled seizure. The patient is given a muscle relaxer and anesthesia during the procedure, but a
hospital stay is usually required. Treatment requires 6-12 sessions occurring 2-3 times a week over
several weeks. Main side effect is memory loss for events right before, during, and after each treatment.
In the last 50 years, we’ve gotten better at reducing the memory loss from ECT. ECT is given to people
with disabling psychological disorders, particularly psychotic depression, manic episodes, or, less
commonly, schizophrenia) in which other treatment doesn’t work. Over 80% of the time, people who
receive ECT suffer from depression. The use of ECT has increased since the 1980s, but we still don’t
know why it’s effective.
Transcranial Magnetic Stimulation (TMS)
A newer biologically-based technique in which an electromagnetic coil is placed on the scalp,
transmitting pulses of high-intensity magnetism to the brain in short bursts lasting 100-200
microseconds. It’s given to people who haven’t improved with medication, and it works especially well
with depression, but no one knows why or how it works. TMS has been shown to be more effective
than a placebo. Two advantages over ECT: 1) easier to administer (doesn’t require anesthesia or
hospitalization), and 2) has minimal side effects. Most common side effect is a slight headache. Seems
to work as well as ECT for depression.
Different treatment modalities (forms)
Individual therapy: one client is treated by one therapist
Group therapy: groups of clients are treated by a therapist; the clients are all suffering from a similar
problems, such as PTSD. Group therapy offers information, support, and interaction with other people.
It can decrease clients’ sense of isolation and shame.
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Therapy Notes
Family therapy: the therapist treats the family as a whole or some of its members (such as a couple).
Most family therapists use systems therapy, in which a client’s symptoms are viewed in the context of
the family. The family is considered the “system,” and the client is the “identified patient.”
Self-help groups: First one was AA; these groups are sometimes referred to as support groups. There’s
usually no clinically trained leader…just a group of people with the same problem talking things over
with each other.
Therapists today are usually eclectic therapists—taking bits and pieces of several treatment approaches
to help their clients. They sometimes use therapy protocols, which are standardized manuals containing
specific techniques to help clients. One manual-based approach is called interpersonal therapy (IPT),
which seeks to help clients understand how aspects of current relationships can affect their mood and
behavior. Many manual-based treatments are short-term (12-20 sessions) and work best with people
who have specific, focused problems (rather than more global problems in multiple areas).
Therapy, medication, or both? In general, people with psychological problems improve more after they
have received therapy than if they haven’t received any treatment. No one type of treatment is better
across all disorders; instead, different treatments and techniques are better suited for different
disorders.
Depression: both therapy and medication works, but medication has side effects. The best types of
therapy are CBT (cognitive-behavioral) and IPT (interpersonal therapy).
Anxiety: Behavioral techniques of exposure and exposure with response prevention are especially
helpful with anxiety disorders that involve fear or avoidance of specific stimuli (phobias). CBT provides
as much, if not more, long-term relief of anxiety symptoms than medications do. For panic disorder,
medication and CBT work equally well, but CBT is better at preventing relapse because of the skills that
the sufferers learn.
Eating disorders: For the treatment of bulimia, CBT and IPT are effective (CBT is superior to medication
for bulimia). For adolescents with anorexia, family-based therapy is most effective. Prozac is helpful at
preventing relapses.
Schizophrenia and bipolar disorder: Medication is superior for both disorders in reducing psychotic and
manic symptoms and for lowering the chances of relapse. CBT can reduce positive symptoms of
schizophrenia and also decrease the likelihood of relapse.
How to pick a therapist
1. If you have a clearly identified problem, such as ADHD, depression, or anxiety, then search for
someone with experience in that particular area.
2. If you like a certain type of therapy, pick someone who specializes in that type.
3. Try to get the names of several therapists to pick the best one for you. Check to see what
insurance they cover. **Most importantly, pick someone you like and feel comfortable with!
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