Introduction to CBT

Cognitive-Behavioral Therapy

Cognitive Behavioral Therapy is based on the observation that cognition, emotion,

and behavior are reciprocally related.

EmotionJames-Lange Theory of Emotion

Action or response precedes emotionI run, therefore I must be afraid.

Canon-Bard Theory of EmotionEmotion precedes action.I am afraid, therefore I run.

Singer-Schacter Theory of Emotion

Emotion #3Emotion cannot be accessed directly, but it can

be elicited in therapy.

Experiences that are accompanied by the arousal of strong emotion have more powerful effects on cognitive and behavioral patterns.

Memory (learning) is mood congruent. A recurrence of mood triggers recall of learning. A reminder of learning situation triggers the original mood.

Emotional SymptomsEmotional excess

Overreactions or unpredictable emotionsExcessive or overly extravagant expression of

emotionEmotionally labile

Emotional insufficiencyDifficulty in displaying emotionDifficulty in “reading” emotion in othersDifficulty in verbal expression of emotionLack of self-control, poor frustration tolerance

Judgment is the emotionally (socially) relevant use of knowledge.

Judgment takes place in the frontal cortex.

BehaviorClassical Conditioning

The repeated pairing of a stimulus with a (formerly) neutral response, resulting in the stimulus coming to trigger the neutral response. (Pavlovian)Aversion therapyDesensitizationFloodingStimulus control

Alters antecedent conditions to affect behavior

Behavior #2Operant Conditioning

Modifies “voluntary behavior”Positive Reinforcement: a behavior is followed by a

reward. Increases behavioral frequency.Negative Reinforcement: a behavior is followed by

the removal of an aversive stimulus. Increases behavioral frequency.

Positive Punishment: a behavior is followed by an aversive stimulus. Decreases behavioral frequency.

Negative Punishment: a behavior is followed by the removal of a favorable stimulus.

Behavior #3Operant conditioning = instrumental learning

(Skinnerian)ExtinctionDifferential Reinforcement of Other Behavior (DRO)Avoidance learning (E.g., electric shock to reduce

arousal in presence of child pornography)

Behavior #4A behavior that is rewarded every time is

acquired or learned quickly.

Fading the reward schedule to intermittent makes the behavior less vulnerable to instances of non-reward. The behavior persists for a relatively long period of time, even if not rewarded.

Effectiveness of consequences depends on:Immediacy

Consistency (reinforcement schedule)

Potency (cost-benefit ratio)

Satiation (felt need for the stimulus or response)

The Premack Principle

A desirable or often-engaged in behavior or situation can serve as a reinforcer for another (new) behavior.

Example: If you always brush your teeth and need to develop a habit of taking medicine, pair the medicine routine with the teeth-brushing routine.

Social Conditioning

Complex social behavior increases and decreases in frequency in response to social reinforcement and social “response cost” or punishment.

Example: A pat on the back or a thank you from the boss reinforces excellent work habits better than an increase in salary.

Behavioral DifficultiesBehavioral excessBehavioral insufficiencyLack of skill (lack of “know-how”)Restricted range of coping strategies (“know-

what”)Behavioral inconsistency (“know-when”)Insufficient stimulus control (difficulty with

initiating or maintaining behavior)Insufficient contingency control (failure to reward

self)

Behavioral Difficulties #2Disorders of Executive Control

PlanningOrganizationTime ManagementTask ManagementDelay of Gratification / Poor Impulse Control

(inhibition of behavior)Goal Directedness (initiation of behavior)

CognitionHuman cognition tends to be categorical and

hierarchical. (We sort and categorize.) This is biologically determined – it’s how the brain works.

Sorting and categorizing makes learning possible, through a process of assimilation and accommodation.

Categorizing and comparing allows us to arrive at efficient rules for sorting the vast amount of information that confronts us every waking moment.

Cognition #2Early-acquired cognitive rules form basic

schema that tell us what information is important for survival:

what data to actively seek,

what data is relevant and noteworthy, and

what can be safely ignored

Cognitive SchemaEarly acquired schema (probably prior to age 8

or so) form our basic assumptions about ourselves and the world and the relationship between those two. They form our Core Beliefs or Basic Beliefs.

Schema tend to be partial constructs, usually operating outside our awareness. They tend to be fragmentary, visceral, iconic vs. verbal. They are presumed true, unquestioned.

Characteristics of Basic SchemaThey are absolutes.They are unquestioningly taken as Truths.They are consistent across time and situation.They function below the level of awareness.They tend to be non-verbal, visceral & iconic.They tend to be partial constructs.They are highly resistant to change.They are evident only indirectly in patterns of

cognition, emotion, & behavior.

Cognitive Schema may be…

Compelling

Non-Compelling

Active Latent

Self-SchemaBeliefs about Self are acquired from:

Stories told about the child within his/her hearingStories told directly to the child about themselvesReflections of and reactions to the child’s behavior

by significant othersStories erroneously adopted (false memories)

Events that happened to othersEvents in books or on television

Personal experienceInterpretations of early life events Experiences of success and failure

Self-Schema ExamplesThe Self may be experienced as…

Known Unknown

Powerful Powerless

Victim Hero

Self-determining Other-controlled

Skilled Unskilled

Strong Weak

Big Small

Schema about the World - generalThe nature of God

God is/isn’t; Is vengeful, just, merciful; Is personal/impersonal; Is relevant/irrelevant; Takes an active part/observes but does not

interfere; Has a personal relationship with us/is

available only through the mediation of a shaman or intermediary

Schema about the World – general - 2The nature of Man

Man is savage, noble, erring, divine; Is trustworthy/untrustworthy; Is innocent/sinful; villainous/heroic;Is powerful/powerless; Has agency and free will/has a

predestined fate.

Schema about the World – general - 3The nature of the World

The world is mysterious/knowable;

Is fair/unfair/impartial; Is dangerous/benign; Is meaningful/meaningless;

Schema about the World – 4

Gender rolesMen should/are/will…Women should/are/will…Power

Family rolesBirth order & role within the familyRelative value of boys and girlsGenerational relationshipsPower dynamicsRole of father, mother, children, boundary diffusionMatriarchal/PatriarchalRules about family membership, diffuseness of

boundary around the familyNature of success

Schema about the World – 5Ethnicity/Culture/Subculture

Foods, clothing; Definition of family; Parent/child relationship; Nature of respect; Individual-family-group balanceAchievement & strivingGoal of developmentRelationship with dominant cultureRelationship with authority

Schema about the World – 6Country/Region - examples

What’s edible? The South shall rise again.Texas-sized Revolutionists, freedom-fightersThe “show me” stateNortheastern taciturnityThe Second City, a city of farmersMore nuts per square inch…Sophisticated; Big Apple

Schema about the FutureThe future is…

Controllable/uncontrollableBright/dimChangeable/unchangeableLikely to be worse, better, the same

Frightening/unfrightening

Schema result in behavioral imperatives: I am…

The world is…

Therefore I must…

Schema provide us with a cognitive map thatExplains the past (where we’ve been)

Makes sense of the present (where we are)

Predicts the future (where we are likely to go next)

They tell us what signposts to look out for and what to do along the way.

They form a basis for our personalities, making our cognition, emotion, and behavior consistent across time and situation.

Schema contribute to cognitive error.Schema are generalizations. They do not reflect

differences between first learning experiences and the present situation. They resist influence by new data.

Schema filter out some information, while over-valuing other information.

Schema are highly resistant to change. They are over-valued ideas that operate outside of awareness and are unquestioned under normal circumstances.

We resist, ignore, fail to notice, or disbelieve data that runs counter to our basic beliefs.

We differentially note data that confirms basic beliefs.

Cognitive ErrorsFundamental attribution error:

The tendency to overemphasize dispositional or personality-based explanations for others’ behavior while dismissing situational explanations.

The opposite typically occurs when explaining one’s own (negative) behaviors.

Availability heuristic – the most salient (aggravating, desired) examples are most easily brought to mind, and are then taken as typical or representative.

Cognitive Error is inevitable. It occurs simply because of the way the brain works.

It is desirable – if we did not sort and categorize, we could not learn.

It is beatable under certain circumstances – we can learn to notice, catch, interrupt, and do something else with our tendency toward error.

Types of Cognitive ErrorMinimization/MaximizationOver-generalizationMind-readingDichotomizationCatastrophizingSelective AbstractionDisqualifying the PositiveFortune TellingEmotional Reasoning“Shoulds” and “Musts”LabelingPersonalization

Underlying AssumptionsBasic or Conditional (if-then) BeliefsUsually operate outside of awareness, but can be

brought to awareness with much more ease than basic schema.

Automatic ThoughtsImmediate, unpremeditated, “knee jerk” cognitive

interpretations of events.Directly shape emotion and strongly influence

behavior.Exaggerated, distorted, mistaken, or unrealistic

ATs play a role in psychological distress.

Other ContributorsVaihinger – “as if”Phenomenology – Immanual Kant & Husserl –

the construction of knowledge as a rule-bound, creative act

Karen Horney – Tyranny of the ShouldsKelly – the Psychology of Personal Constructs &

fixed role therapySocial Learning Theory – observation of models

Assumptions of CBTAlbert Ellis

Most

All

Beck, then most

Arnold Lazarus

CT highlights the role of philosophy and self-persuasion in personal change.

Supposes that we have a choice how to think and feel about things, as well as how we act.

Cognition, Emotion, and Behavior mutually influence each other

Disorders are characterized by (not caused by) dysfunctional thinking.

Disorders are characterized by insufficient range of coping responses.

So CBT assesses and seeks to intervene in three areas:

Cognitive, emotional and behavioral patterns may cause, contribute to, maintain, contribute to resistance in changing, or cause relapses in symptoms.

SITUATIONAL VARIABLES can also cause, contribute to, maintain, resist changes in, or cause relapses in symptoms.

It is always important to understand the physical, biological, developmental, and social-emotional context in which the problem occurs.

Goals of CBT/CT Interrupt self-perpetuating cycles of cognitive error,

disturbed mood, and ineffective behavior.The client becomes less disturbed. Symptoms recede. First-

order change.

Modify beliefs and assumptions that predispose the client to the problems.The client becomes less disturbable. Ellis’s “elegant solution”

or “second-order change”.

Provide the client with more effective ways to manage the situations that provoke their distress or difficulties.The client is able to manage similar and dissimilar stressors

more effectively; the client is more skilled.

Assessment ala CBTNature of the problem

Onset (learning history, but later), duration, courseContext:

Stimulus variablesConsequences (reinforcers and costs)

The client’s explanation & understanding of the problem

Previous attempts to solve the problem and relative success of these

Client’s goals

Assessment ala CBT/CTBaseline data

Current incidentsDaily Thought RecordJournalingCounting instancesCollateral data

Critical Incidents - historyCognition, emotion, behaviorSituational variables – who, what, when, where

Thought Record – part 1

Situation

Briefly describe the situation

Emotions

Rate strength of emotion from 0 to 100%

Automatic Thoughts

Try to capture your exact thought. Then rate your belief in each thought 0 to 100%

Who, what, when, where?

Behaviorally anchor the ends of the continuum.

Assessment ala CBT/CT cont’d.Formal Assessment Tools

Beck Depression InventoryBeck Anxiety ScaleBeck Hopelessness ScaleBurns Anxiety InventoryDysfunctional Attitudes ScaleFear Survey ScheduleAnd MANY more…

Use appropriately; use sparingly; use repeatedly.

Assessment ala DSM-IV-TR10

9

8

7

6

5

4

3

2

1

0

Severity

Symptoms from DSM

Collaborative EmpiricismCollaborative Goal Setting:

Client’s goals – realistically and objectively definedTherapist’s goals based on practicality, theory,

conceptualizationMutually agreed upon

Goals should be empirical:Objective – verifiable by other than subjective methodsObservable – outside of “the black box”Measurable – able to be counted, recorded, scored, scaled,

Guided DiscoverySocratic questioningStochastic questioningJointly identified inter-session tasks (“homework”)