Cognitive Therapy

1. Cognitive Therapy By Barbara LoFrisco Cognitive Behavioral Seminar University of South Florida

2. Cognitive Therapy – The Theory • In order to understand an emotional disturbance, one must understand the mental processes or cognitions • These mental events are readily accessible • Patient’s beliefs are examined: him/herself, future and world • Any concern will be in one of these domains • This is the “cognitive triad” (Beck, Rush, Shaw & Emery, 1979) • Common themes are found with both anxious and depressed patients

3. Cognitive Therapy- The Process • Patient becomes aware of cognition • Patient frames cognition as a hypothesis • Patient scrutinizes belief • Patient gradually arrives at a different view • Changes in the emotional reaction should follow • Eventually, concern over recent events will diminish • Thus, negative affect is removed from ruminations about said events • Result: Less negative mood

4. Cognitive Therapy- The Process • Patient will start to apply these techniques to new events • Many of the skills learned in Cognitive Therapy are used by people who have never had depression • If the patient does not use these skills, the risk for relapse is high

5. Cognitive Therapy- Schema Work • Cognitive errors (or “automatic thoughts”) are based on schema, or “patterns of thinking” • These are the “themes” of dysfunctional thinking • All patients have them • They can be uncovered by examining cognitive errors • Can be uncovered using Downward Arrow technique • Or using “If then” logic. For example, “If I fail this exam, then I am a failure as a person”. • Old schema can be replaced with new

6. Cognitive Therapy- Cognitive Errors • We are all subject to cognitive errors • They occur more often in affective episodes • There is a list of common errors that patients can compare their own thoughts to: • All or nothing thinking • Over generalizing • Discounting the Positives • Jumping to conclusions

7. Cognitive Therapy- Cognitive Errors • Mind Reading • Fortunetelling • Magnifying/Minimizing • Emotional Reasoning • Making “should” statements • Labeling • Inappropriate Blaming

8. Cognitive Therapy- Cognitive Errors How many cognitive errors can you spot in this story? Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. “I should have done it much sooner”, she reported. Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive. “What is wrong with me? I’m never going to meet anyone!”

9. Cognitive Therapy- Cognitive Errors Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. “I should have done it much sooner”, she reported (#7 Minimizing, #9 should statements, #11 Inappropriate Blaming). Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive (#2 Overgeneralization). “What is wrong with me? I’m never going to meet anyone!” (#1 All or nothing thinking, #6 Fortune Telling).

10. Cognitive Therapy- Therapeutic Interaction • Relationship is one of collaboration • Patient is expert on his or her own experience, and the meaning he or she attaches to events • Therapist is expert on the model • Therapist does not make interpretations, rather solicits this information from clients • More of a state of “not knowing” • Thoughts are not replaced until patient understands the meaning of the thoughts and has decided they are not true

11. Cognitive Therapy- Therapeutic Interaction • Meaning system of each patient is idiosyncratic • Patients must take an active role in therapy • Differs from Michenbaum’s Cognitive Behavioral Modification: thoughts are behaviors that can simply be modified without understanding underlying meaning • Different from Michenbaum’s SIT (Self Instructional Training): client is taught to repeat specific self-coping statements rather than question their inferences • Differs from Ellis’ REBT: therapist infers clients’ thinking errors

12. Cognitive Therapy – Behavioral Methods • Behavioral methods sometimes used to increase behaviors or provide experiences in pleasure • Focus is always on changes in beliefs resulting from change in actions • Behavioral changes serve as “experiments” to check out a “hypothesis” that the patient and therapist have developed; or formulate a new one • But….Jacobson et al. (1996) found that 12 weeks of behavioral methods had outcomes comparable to 12 weeks of cognitive therapy.

13. Behavioral Methods- Applications: Self-Monitoring • Hour-by-hour record of activities and associated moods is kept • Patients record mood on a 0-100 scale, where 0 is the worst they have ever felt and 100 is the best • Beck et al. (1979) suggests the patient also record the degree of mastery or pleasure associated with the activity • Patients are sometimes surprised at how they are spending their time • Can also serve as a baseline

14. Behavioral Methods- Applications: Self-Monitoring • Detailed examination of this record is much better than patient’s memory for testing hypothesis • Patient’s memory is often selective • Therapist can ask patient to recall thoughts that occurred during both good and bad events • Therapist can look for consistencies in the record: which events are associated with good or bad moods, or with mastery or pleasure

15. Behavioral Methods: Applications: Scheduling Activities • Purpose is to get patient to engage in activities he or she is (unwisely) unwilling to do • Remove decision making as an obstacle in initiation of activity • Has decision making ever been an obstacle for you in initiating an activity? (Share with the class if you feel comfortable) • Non-adherence can be addressed therapeutically • Usually “failures” are similar to what has been troubling the patient.

16. Behavioral Methods: Applications: Scheduling Activities • A thorough analysis of cognitive obstacle can be performed • 3 Types of Activities to schedule: • Those associated with mastery, pleasure or good mood • Those that had been rewarding in the past but that the patient has been avoiding • New activities that might be rewarding or informative

17. Behavioral Methods: Applications: Scheduling Activities • Patient can use self-monitoring to monitor mood after activities • Activities can be “experiments” • Patients are more likely to do activities if they are framed as “experiments”

18. Behavioral Methods: Applications: Other Behavioral Activities • Breaking down larger tasks into smaller units • Makes task more concrete and less overwhelming • This is called “chunking” • Easier tasks can be accomplished first • This is called “Graded tasks” • Although simplistic, these methods can be effective because they change how patient views the (formerly) difficult task

19. Cognitive Methods: Daily Record of Dysfunctional Thoughts • Find DRDT in Dobson’s book. In mine it’s p. 359. • Most of the work in Cognitive Therapy centers around Daily Record of Dysfunctional Thoughts (DRDT) Beck et al. (1979) • Four most important columns correspond to the three points in the cognitive model (situation, belief, emotional consequence). • Patients first use DRDT to record unpleasant or puzzling emotions • Patient must first understand what emotions are (see handouts)

20. Cognitive Methods: Daily Record of Dysfunctional Thoughts • Some patients don’t know the difference between thoughts and feelings • Therapist may have to educate patient • Can give feeling chart to patients so that they can understand what different feelings are • In addition to situation and emotions, patient must also record thoughts in DRDT • This may be more difficult because patients often think situations “cause” emotions

21. Cognitive Methods: Daily Record of Dysfunctional Thoughts • Teach patients that it is the thoughts about the situation, not the situation that produces the emotion • Teach patient to examine his or her own inferences • It is these inferences that are the cause of distress • Automatic thoughts can be re-rated for strength of belief after alternative thought has been formulated • If ratings are similar, then the initial concern is not resolved • Affective response can also be re-rated in a similar way. • Again, lack of change means something is missing

22. Cognitive Methods: Three Questions • What is evidence for and against this belief? • What are the alternative interpretations? • What are the real implications, if the belief is correct?

23. Cognitive Methods: Downward Arrow Technique • Patient’s first thoughts are usually not therapeutically useful in that they do not describe the implications to the patient • Use Downward Arrow Technique to uncover the implications of thought • Ask “What would it mean if….?” • Or “What if it is true that….?” • Or “What about that bothers you?” • Repeat until thought is produced that will benefit from cognitive therapy

24. Cognitive Methods: Cognitive Errors • Teach patient to recognize when one of his or her thoughts falls into one of the categories of cognitive errors (p. 353 of Dobson, or slide #6) • Teaches patients that these are common cognitive errors: normalization

25. Cognitive Methods: Identifying Schemata • After a while in therapy, a certain consistency emerges in patient’s cognitive errors • These consistencies, or “themes” are the schema • They are found at the level of personal meaning • Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978) to assess schemata and track changes during treatment

26. Cognitive Methods: Indentifying Schemata with DAS • The DAS has 9 interpretable factors: • Vulnerability • Approval • Perfectionism • Need to please others • Imperatives • Need to impress others • Avoidance of weakness • Control over emotions • Disapproval Class give examples of 3 of them

27. Cognitive Methods: Socratic Questioning and Guided Discovery • Probably the most distinctive stylistic feature • Most difficult for therapists to master • Guided discovery: through use of leading questions, helping patients arrive at new perspectives • Therapists must walk a line between guiding patient and allowing patient to free-associate • Common errors of inexperienced therapists is to be in a hurry and lecture the patient or ask overly leading questions. • Even facial expression can be a factor (LoFrisco)

28. Cognitive Methods: Socratic Questioning and Guided Discovery • Therapist should avoid closed questions and declarative statements • This maximally engages client to think about problem and come up with solution • Helps foster independence and prevent relapse (LoFrisco) • Will have a greater chance of addressing any idiosyncratic issues; more client centered

29. Treatment Procedures- Beginning of Treatment • Goals: • Assessment • Beck Depression Inventory (BDI); also can be used as a session-to-session measure • Socializing patient into cognitive model • Have patient read the booklet Coping With Depression (Beck & Greenberg, 1974) • Helps to instill hope • Dealing with patient’s pessimism

30. Treatment Procedures- Middle Phase of Therapy • Solidify work on cognitive coping skills • Patient uses DRDT to track thoughts that produce negative affect • Therapist uses Downward Arrow Technique to help patient fine-tune their responses • Therapist reviews DRDT with patient • Patterns associated with schemata are identified • Developmental history of schemata is discussed. Why?

31. Treatment Procedures- Middle Phase of Therapy • Answer: to help client make sense of his or her schemata

32. Treatment Procedures- Final Phase • Gains are reviewed • Relapse prevention: • Anticipate situations that would tax patient and review the skills they have learned • Because…patients usually attribute their improvement to changes in their environment, not changes in themselves

33. Treatment Procedures- Final Phase • Patients feelings or beliefs about terminating therapy are addressed • Patient may feel like they “can’t do it on their own” • Schedule “booster” or “check-up” sessions • Jarrett et al. (1998) found that monthly check-up sessions helped to prevent relapse • Even less frequent boosters can be beneficial

34. Empirical Status- Depression • Rush et al. (1977) found that patients treated with cognitive therapy experienced greater symptom remission at the end of 12 weeks compared with those taking a tricyclic antidepressant (randomized trial) • Blackburn et al. (1981) and Murphy et al. (1984) did a similar study and found cognitive therapy equally effective • Dobson (1989) meta-analysis: a greater degree of change than wait-list, pharmacotherapy, behavior therapy and other psychotherapies

35. Empirical Status- Depression • Then…Elkin et al. (1989) discovered that cognitive therapy did not perform as well as medication in severely depressed patients • A later report (Elkin et al., 1995) showed even more dismal results • The saga continues…Hollon et al. (1992) found that cognitive therapy performed at least as well as medication, even among the severely depressed • OK, let’s get serious. DeRubeis et al. (1999) performed a mega-analysis from these studies and found cognitive therapy just as effective as medication.

36. Empirical Status- Depression • Finally, in another placebo-controlled randomized study, Jarrett et al. (1999) found that the two treatments performed equally well. Conclusion? Even in the short run, cognitive therapy is a potent alternative to medication. But does it last?

37. Empirical Status- Depression • Rush et al. (1977) found that at 12-month follow-up (but not at 6) that CT patients scored lower on depression severity measures than the antidepressant group • Murphy et al. (1984) found patients that received CT during the acute treatment phase were less likely to relapse than those treated with drugs • Hollon et al. (1992) had similar results • Several studies have found that a relatively short course of CT following a successful course of antidepressants is as effective in preventing relapse as is continuing the meds.

38. Depression- Therapist Behavior • Collaborative Study Psychotherapy Rating Scale (CSPRS) measures therapists’ adherence to CBT model. • CT- Concrete: measures active methods • CT- Abstract measures discussions about CT rationale • DeRubeis & Feeley (1990); Feeley et al. (1999) discovered that CT-Concrete was associated with greater changes in BDI; and CT-Abstract was not • Therefore, it is critical for therapists to focus on problem-solving aspects of CT, at least early on

39. Depression-Patient Cognitions • Hollon et al. (1988) proposed 3 kinds of changes that occur: • Deactivation – suppress old schema • Accommodation – modify/create new schema • Development of compensatory skills – applying CT skills to future situations

40. Depression- Patient Cognitions • DeRubeis (1990) studied patients from the Holland et al. (1992) study, found that improvement on the: • Beck Hopelessness Scale • DAS • Attributional Style Questionnaire Play a meditational role. (patients who improved on these measures also had subsequent change in depressive symptoms) Therefore, attributional style and dysfunctional attitudes mediate the reduction of risk of CT

41. Depression- Patient Cognitions • But….Miranda and Persons (1988) disagreed, stating that the depressive schemata may simply be latent. • So….they developed a negative mood induction procedure prior to administering the DAS. • Segal et al. (1996) found that scores on mood induced DAS predicted relapse, just like Hollon had found. • Measures of changes in compensory skills are less plentiful • Most measures of coping skills came from interests other than CT

42. Depression- Patient Cognitions • A method is needed to require a patient to PRODUCE rather than RECOGNIZE coping skills. Most patients can recognize them. • Barber and DeRubeis (1992) developed the Ways of Responding (WOR) to address this need. • To measure changes in beliefs as they occur in session (rather than a static measurement) Tang and DeRubeis (1999) developed Patient Cognitive Change Scale.

43. CT Course of Change • Ilardi and Craighead (1994) observed that 60% - 70% of symptom improvement occurs in the first 4 weeks. But this was inferred from group mean. • Actually….Tang and DeRubeis (1999) report 40% - 60% of change occurs in the first 4 weeks. • Why would this be clinically relevant? • Tang and DeRubeis (1999): In addition to a shorter course, individual therapy gains can be much more sudden than group therapy gains; called “sudden gains” • Occurs among more than 50% of patients • Accounts for more than 50% of total relief

44. Therapist Patient Alliance • Recent research continues to show a positive relationship between alliance and outcome • Good therapeutic alliance tends to be the RESULT of symptom improvement, rather than a PREDICTOR • So….therapists should adhere to concrete CT, and they will build alliance • This differs from past findings…. • Studies that took the average over time of the alliance, and then correlated it to the outcome

45. Therapist Patient Alliance • As opposed to measuring it at various points during the therapy process • Beckham (1989), DeRubeis and Feeley (1990), Feeley et al. (1999) found that therapeutic alliance measured early in therapy process did not predict good outcome • Furthermore, DeRubeis and Feeley (1990), Feeley et al. (1999) found that later in therapy, alliance was actually predicted by outcome • Lastly, Tang and DeRubeis (1999) found that alliance in the session prior to the sudden gain was significantly lower as compared to the session after the gain.

46. Panic Disorder and Agoraphobia • There is also cognitive therapy for OCD, anxiety and hypochondriasis, which follows a similar form to what was just described (for depression).

47. Panic Disorder and Agoraphobia • The phenomenology and treatment of panic disorder have been well developed: • Patient feels a particular symptom • Attributes it to the start of a panic attack (from experience) • Because he/she thinks it’s pathological, the progression of the panic attack continues • I.e.. chest pain= heart attack • But there are other explanations for these symptoms • I.e.. You will be lightheaded if you get up too fast

48. Panic Disorder and Agoraphobia • Patient focuses on catastrophic consequences of symptom • ** Patient loses ability to view symptoms objectively*** • This is what turns anxiety into a panic attack • Vicious cycle: fear makes symptoms worse, which makes fear worse, etc. • At this point symptoms seem uncontrollable • This spontaneous attack is a “phobia” of internal conditions

49. Panic Disorder and Agoraphobia • Recent development in treatment: beware of dependence on safety behaviors • In the mid-eighties, using relaxation or distraction procedures was the norm • This has been recently found to prevent full recovery in certain cases • Because patients think they MUST do them to stop panic attack • Harmless?

50. Panic Disorder and Agoraphobia Cognitive Therapy Treatment: • Therapist and patient map out vicious cycle • Patient beliefs are identified (i.e.. “If I hyperventilate I will die.”) • Beliefs are challenged using safety behaviors (i.e.. controlled breathing) • Safety behaviors used only to disprove belief • More realistic beliefs are identified • Images experienced by patient are altered