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  1. PSY 245CLINICAL PSYCHOLOGY-II • Assoc. Prof. Dr. BAHAR BAŞTUĞ • Clinical Psychologist

  2. Cognitive-Behavioral Theory and Therapy

  3. Welcome • Back in the 1970s, most behaviorists didn’t want to think about cognition. Some behaviorists included cognitions from the beginning.

  4. Joseph Wolpe allowed clients to use imagery in the desensitization. He accepted a form of cognition into his therapeutic work. However, Wolpe criticized Michael Mahoney’s use of a technique referred to as “mirror time” or “streaming”. Streaming involved having the client free-associate while looking at himself in a mirror. Pressure from the behaviorists did not reduce the “cognitivists” motivation, instead, increased it.

  5. Now, most practitioners just refer to CBT as an approach that integrates both behavioral and cognitive therapies.

  6. Whenever you experience an unpleasant feeling or sensation, try to recall what thoughts you had been having prior to this feeling. Aaron Beck

  7. Historical Context and Biographical Information Cognition as an important focus dates back to at least Socrates.Socratic questioning is to discover an individual’s method of reasoning. Wundt used introspection as a method of studying humans in his first psychological laboratory. Watson and Skinner rejected the introspection.

  8. Historical Context and Biographical Information II There are three key figures and streams of thought linked to the history of cognition in counseling and psychotherapy. • Albert Ellis and Rational Emotive Behavior Therapy • Aaron Beck and CognitiveTherapy • Donald Meichenbaum and Self-InstructionalTherapy

  9. Historical Context and Biographical Information III • Ellis developed REBT and focused on irrational thinking. • Beck developed cognitive therapy and focused on maladaptive thinking. • Meichenbaum focused on inner speech and developed self-instructional training.

  10. Albert Ellis: Rational-Emotive Behavior Therapy Ellis was born in Pennsylvania, in 1913 into Jewish family. He had a similar childhood to Adler. He was the eldest of 3 children. His father was often away from home. His mother was egosentric and bipolar. He hospitalized 8 times between 5-7 ages due to kidney problem. After being rejected his first 8 novels, he graduated Columbia Univ. Clinical Psy programme. K. Horney analyzed him. He formulated his approach after discovering in his psychotherapy practice that psychoanalysis was ineffective.

  11. Albert Ellis (1913 –2007)

  12. Ellis summarizes five basis components of his theory: 1. People have irrational ideas and personal philosophies. 2. These irrational ideas cause people great distress and sadness. 3. These ideas can be set down to a few basic categories. 4. Therapists can find these irrational categories easily in clients’ reasoning. 5. Therapists can teach clients how to give up their irrational beliefs.

  13. Ellis credits Adler’s pioneering acceptance of cognition; he also notes that his “rational psychotherapy” is based on the philosophical writings of ancient Greek and Roman stoics, particularly Epictetus. The first CBTist in the Western world was the philosopher Epictetus (c. 50–138 ..). He was born a slave in Phrygia, in what is now central Turkey.

  14. Albert Ellis: Rational-Emotive Behavior Therapy Ellis initially referred to his approach as rational psychotherapy, later changing the name to Rational-Emotive Therapy. In 1993, he inserted the word behavior, thus creating Rational Emotive Behavior Therapy (REBT).

  15. Aaron Beck and Cognitive Therapy A. Beck was born in 1921 in Rhode Island. His family was Russian Jewish immigrants. Older brother and sister died of influenza, he saw himself as a replacement child. He had physical problem during childhood, similar to Adler and Ellis. Because of hospitalization, when he restarted the school, he believed he wasn’t smart. He overcame this negative thougths, obtaining a medical degree from Yale Univ.

  16. Aaron Beck and Cognitive Therapy Beck was psychoanalytically trained. Early in his career he was interested in validating Freud’s theory of depr, but he ended up rejecting Freud’s theory. Many psychoanalists ignored Beck for questioning Freud. However, over time, Beck’s work on depr was recognized as empirically valid, and his theory of depr represents one of the best-known.

  17. Aaron Beck and Cognitive Therapy Beck’s approach has been known as cognitive therapy. He reasoned that psychological problems can be mastered by sharpening discriminations, correcting misconceptions and learning more adaptive attitudes. Introspection, insight, reality testing, and learning are basically cognitive processes.

  18. Aaron Beck and Cognitive Therapy Beck is a soft-spoken, gentle man who works with clients in a collaborative manner. Beck is not interested in convincing clients of their irrational beliefs. He uses collaborative empiricism. In collaborative empiricism, he works together with clients to help them discover the maladaptive nature of their automatic thoughts and core beliefs. Ellis emphasizes the forceful eradication of irrational thoughts, Beck emphasizes the collaborative modification of maladaptive thoughts.

  19. Donald Meichenbaum and Self-Instructional Strategies Meichenbaum followed the path of behavior therapy into the field of cognitive therapy. He noticed that people on the streets in NY city would sometimes talk to themselves. He focused on impulsive schoolchildren and hospitalized adults with SCH. He discovered that both schizophrenics and children could improve their functioning after being taught to talk to themselves or to think aloud.

  20. Donald Meichenbaum

  21. Donald Meichenbaum and Self-Instructional Strategies • Meichenbaum integrated the work of Soviet psychologists Vygotsky and Luria with Bandura’s vicarious learning model and the operant conditioning principle.

  22. Donald Meichenbaum and Self-Instructional Strategies • Meichenbaum’s focus was on self-instructional training (SIT), which he referred to as a form of cognitive behavior modification. • He later developed stress inoculation training, a specific approach for helping clients manage difficult stressors. He is openly empathic and emotionally oriented.

  23. Donald Meichenbaum and Self-Instructional Strategies More recently, Meichenbaum shifted toward an empirically constructive model. He is also redefining cognitive therapy as an integrational approach. Meichenbaum’s progression—from behavior therapy, to cognitive behavior modification, to cognitive-behavioral therapy, to constructivist cognitive-behavioral therapy —reflects a trend toward integration.

  24. Theoretical Principles • CBT is a critically minded, empirically based treatment approach that doesn’t advocate a specific treatment approach. • In addition to classical and operant conditioning, CBT is based on two additional learning theories: • Social Learning Theory • Cognitive Appraisal Theory

  25. Social Learning Theory (SLT) was developed by Albert Bandura (1925 – present).

  26. Social Learning Theory (SLT) SLT includes stimulus-influence components (classical conditioning) and consequence influence components (operant conditioning), but it also adds a strong cognitive mediational component.

  27. Social Learning Theory (SLT) It emphasizes two main cognitive processes: 1. A significant portion of human learning is observational. Bandura documented the power of observational or vicarious learning as a source of behavior change. This process has come to be known as modeling. It includes covert mental processes that cannot be observed by experimenters.

  28. Social Learning Theory (SLT) 2. Reciprocal interactions occur between the individual’s behavior and the environment. Bandura postulates that individuals have thoughts about the future, behavioral consequences and goals. Because of these reciprocal interactions, individuals are capable of self-directed behavior change. In opposition to Skinner and Watson, Bandura sees free will and self-determination as possible.

  29. Social Learning Theory (SLT) One of the most important social learning theory concepts is self-efficacy. SELF-EFFICACY is defined as an individual’s belief or expectation that he or she can adequately complete a specific situation or task. “The conviction that one can successfully execute the behavior required to produce an outcome.” Bandura

  30. Social Learning Theory (SLT) • Higher self-efficacy is associated with success. • Lower self-efficacy is associated with negative self-talk, giving up easily and reduced concentration.

  31. Social Learning Theory (SLT) A primary purpose of therapy is to help clients develop and strengthen self-efficacy. A client who comes to therapy to quit smoking may initially have little confidence in his ability to quit. If therapy is to be successful, it will be necessary to enhance the client’s smoking cessation self-efficacy. The therapist teaches the client self-monitoring procedures, PMR, and strategies for coping with uncomfortable feelings associated with nicotine withdrawal.

  32. Cognitive Appraisal Theories The essence of cognitive theory can be summarized in one sentence that Ellis attributes to Epictetus: “People are disturbed, not by what happens, but by what they think of what happens.” Skinner: Behavior is a function of its consequences. S-R theory Now: Behavior is a function of what organism thinks about its consequences. S-O-R theory

  33. Cognitive Appraisal Theories • Cognitive theory emphasizes the individual organism’s processing of environmental stimuli as the force determining his or her specific response.

  34. Rational Emotive Behavior Therapy REBT views humans as neither inherently good nor inherently bad. Ellis considers humans to have the potential for thinking both rationally and irrationally. Humans have a strong tendency to think in mistaken, and irrational ways and this is the primary source of human distress. Ellis used an A-B-C model. “A” = the “activating event” that has occurred in an individual’s life; “B” = the individual’s belief about the activating event; “C” = the consequent emotion and behavior linked to the belief.

  35. Rational Emotive Behavior Therapy Cem’s Activating Event: His wife is late for dinner. Cem’s Belief: His wife doesn’t love or respect him any more. She’s probably having an affair. Cem’s Consequent Feelings: Anger, sadness, hurt, resentment, and jealousy; and Behavior: yelling and accusing her of having an affair.

  36. Rational Emotive Behavior Therapy Ellis refers to this sort of belief as an irrational belief=iB. The purpose of REBT is to help substitute a rational belief = rB for a current iB, which will result in more positive and more comfortable new feeling =F

  37. Rational Emotive Behavior Therapy The main purpose of confronting is to dispute (D) the irrational belief. “Is it true that your wife must always be home right on time to prove her love for you?” Ellis’s dispute of Cem’s irrational belief will have an emotional effect (E) on Cem. This effect will be the development of a set of alternative, rational more effective beliefs. If therapy is successful, Cem will experience a new feeling (F).

  38. Rational Emotive Behavior Therapy • The ABCDEF Cognitive Model (Ellis) • A = Activating event • B = Belief about the activating event • C = Consequent emotion and behavior linked to the belief • D = Disputation of irrational belief • E = Effect • F = Feeling

  39. Beck’s Cognitive Theory The theoretical principles of Beck’s cognitive therapy are similar to Ellis’s REBT. Similarities: 1.Cognition is at the core of human suffering. 2. The therapist’s job is to help clients modify distress-producing thoughts. Beck criticizes Ellis’s use of the term irrational.

  40. Beck’s Cognitive Theory • Components of Beck’s cognitive theory: • Development of inaccurate/negative beliefs. • Self-schema • People develop systematically distorted irrational thoughts. • This results in biased information processing cognitive content consistent with specific mental disorders. • Modification is possible via cognitive therapy.

  41. Beck’s theory includes the following characteristics: 1. In the process of living, individuals are exposed to a variety of life events, some of which trigger automatic, maladaptive thoughts. 2. These maladaptive thoughts are characterized by their faultiness; they are too narrow, too broad, too extreme, or simply inaccurate. 3. An individual’s maladaptive thoughts are usually derived from deeply held maladaptive core beliefs (=schemas or dysfunctional attitudes). 4. Individuals acquire these core beliefs during childhood. 5. These automatic thoughts, core beliefs, and their associated emotional disturbances, can be modified via cognitive therapy, the procedure does not require exploration of a client’s past.

  42. According to Beck, cognitions are based on attitudes or schemas, developed from previous experiences. If a person interprets all his experiences in terms of whether he is competent and adequate, his thinking may be dominated by the schema, “Unless I do everything perfectly, I’m a failure.” Consequently, he reacts to situations in terms of adequacy even when they are unrelated to whether or not he is personally competent.

  43. Beck’s Cognitive Theory • Beck’s core beliefs = Adler’s life style • Beck’s automatic thoughts = Adler’s basic mistakes.

  44. Beck’s Cognitive Theory Beck uses a different procedure for modifying clients thoughts. Cognitive therapists use collaborative empiricism to help clients discover inaccurate or maladaptive thoughts. Collaborative empiricism emphasizes: joint work of client and therapist, Socratic questioning and different techniques. This approach requires the therapist to work within the client’s frame of reference, trying to see the world through the client’s eyes.

  45. In the Socratic questioning, therapists ask questions that help clients focus on (1) awareness of automatic thoughts and core beliefs, (2) evaluation of the usefulness and accuracy of automatic thoughts and core beliefs, and (3) possible strategies for modifying automatic thoughts and core beliefs.

  46. Meichenbaum and Self-Instructional Theory Meichenbaum’s self-instructional model is based on internal speech or verbal mediation. His model is reciprocal: interactive relationship between the individual and the environment. Preparation: Inner speech that occurs before the stressful event Coping: Inner speech that occurs during the stressful event Aftermath: Inner speech that occurs after the stressful event

  47. Theory of Psychopathology In REBT, psychopathology is a direct function of irrational beliefs. Ellis’s theory of psychopathology is consistent with Horney’s “tyranny of the shoulds.” The REBT approach to psychopathology is direct, straightforward, and sometimes offensive.

  48. Ellis had a list of 12 basic irrational beliefs that cause emotional suffering. He later added a 13th, other REBT writers have added additional irrational beliefs. Ellis decided that all irrational beliefs could be boiled down to the three very basic beliefs: