Cognitive Theory and Therapy

SOW6425 Assessment and Planning

Professor Nan Van Den Bergh

Cognitive Theory: Overview

• Cognitive mediation: influence of one’s thinking between the occurrence of a stimulus and response– This was an evolution from behavioral theory

• Cognitions: beliefs, assumptions, expectations and ideas about the causes of events, attitudes and perceptions– Processed in the cerebral cortex

Cognitive Theory: Overview (cont.)

• Emotions: physiological responses that follow our cognitive evaluation of input– Thoughts precede emotions and produce them– Limbic system processes emotions, engenders a

neurochemical response that then creates a physiological response

• Cognitive interventions’ focus:– rationality of thinking– conclusions about self and world based on evidence– connections between thoughts, feelings and

behaviors

Influences on Development of Cognitive Theory

• Logical positivism: – To be considered true, something must be empirically verifiable

• Information processing theory: – Information is received from environment – Information coded through sensory receptors and stored for

present or future adaptation to environment– Stored cognitions used for problem solving

• Personal construct theory (social constructivism):– Constructs are interpretations of events – “truth” exists when one’s perceptions are consistent with one’s

constructs

Originators of Cognitive Therapy

• Alfred Adler began in 1911 to disagree with Freud’s structural theory (id, ego, superego and conflict between internal and external drives)– Saw personality as a unified whole, known as holistic approach– Adler believed it was in accurate perceptions and not underlying

unconscious processes that resulted in a persons’ inappropriate behavior

Originators of Cognitive therapy (cont.)

• Albert Ellis: founded rational emotive therapy in 1955. – Rational thoughts help people to achieve their goals – Irrational thoughts do not help people achieve their goals– Client’s assumptions about SELF are focus of intervention

• Created ABC model:– A= activating event or perception of the event– B= way that the perceived event is evaluated– C=emotional and behavioral consequences that stem from B

• “Musturbation”: Behind distressing emotions are irrational beliefs about dogmatic and absolutist evaluations about events such as:

• “musts, shoulds, have to’s, ought's” • Adhering to these creates psychological disturbances

Originators of Cognitve therapy(Ellis con.t)

• Cognitive distortions:– All or nothing thinking

– Jumping to conclusions

– Fortune telling

– Focusing on the negative

– Disqualifying the positive

– Allness or Neverness

– Minimization

– Emotional Reasoning

– Labeling and generalization

– Personalizing

– Phonyism

– Perfectionism

Originators of Cognitive Therapy (cont.)

• Aaron Beck, Cognitive Therapy and the Emotional Disorders:

• Depressed people have negative schemas in their cognitive processing, manifested as: – Negative views of Self– Negative views of the world– Negative views of the future

• Beck Depression Inventory: widely used short form psychometric assessment

Major Concepts of Cognitive Theory• Schemas :

– How thought processes are organized– How information is stored– How new information is processed– Cognitive errors or distortions are derived from schemas

• Schemas develop through:– Direct learning (our experiences)– Social learning (observing and watching the experiences of

others)

• Schemas are not “correct or “incorrect:– They are “functional or nonfunctional”

• With new experience we:– Assimilate it into our existing schema– Accommodate: change schema to accept new information

Major Concepts of Cognitive Theory (cont.)

• Rational thinking:– Based on external evidence– Life preserving– Directed toward personal goals– Decreases internal conflicts

• Cognitive therapy clients must be over age 12 since they must be able to engage in abstract thought

• Not appropriate for adults with dementia, mental retardation and some psychotic disorders

Change through Cognitive Theory

• Cognitive deficits:– Remedied through education (socialization as to

common social expectations)

• Causal attributions: beliefs about what one can do or not do (locus of control)

• Cognitive distortions: thinking habits that bias interpretations of new experiences

Social Work Client Relationship

• Worker as educator:– Information on cognitive distortions and restructuring

• Worker as collaborator:– Goals, objectives and interventions with clients input

• Role model: – Demonstrating rational thinking and problem solving

• Coach: – Encouraging trying new ways of thinking

• Empathy is important as confrontation is used to point out cognitive discrepancies

COGNITIVE THEORY

A B C

Event Thought Emotion & Behavior

(Rational or

irrational)

Clients often believe that “A” causes “C”

The social worker promotes the viewpoint that “B” often causes C

BASIC ASSUMPTIONS OF COGNITIVE THEORY• Thinking is the determinant of behavior

• Thoughts and feelings are separate mental processes

• Most emotions and behaviors are the result of what we think, tell ourselves, or believe about ourselves

• The past is important only for identifying the origins of faultythinking.

– It is present thinking that motivates behavior.

• We are not controlled by unconscious forces. – Some mental activity is preconscious, meaning that it is out of

awareness, but it can be brought into consciousness.

• People are active in constructing their realities – (Perception and thinking are subjective)

BASIC ASSUMPTIONS OF COGNITIVE THEORY (cont.)

• Many problems result from people’s :– misconceptions – conclusions that are based on internalized patterns of

thought– not enough available evidence about themselves, other

people, and various life situations.

• “Rational” thinking:– Is based on external evidence– Is life-preserving– Keeps us directed toward personal goals– Decreases internal conflicts

• Not all unpleasant emotions are dysfunctional, and not all pleasant emotions are functional.

SOME DISTINGUISHING CHARACTERISTICS OFCOGNITIVE THEORY (VS. EGO PSYCHOLOGY)

• Focuses on conscious thought processes

• Assumes significance of preconscious but not unconscious

mental processes

• Thoughts are prior to most emotions

• Emphasis is primarily on present (vs. past) functioning

• Less emphasis on developmental stages

• Less attention to the intricacies of the client - worker relationship

• Intervention techniques are more concrete and specific

• Some techniques are similar to those utilized by ego psychology:– Sustainment

– Exploration, description, ventilation

– Education

– Partializing

– Person-situation reflection (cognitive distortions)

– Pattern-development reflection (search for schemas)

Review of Major Cognitive Functions

Intellect - the ability to think abstractly and logically, and to express oneself clearly

Judgment - the ability to choose behaviors that are likely to promote positive adjustments and goal attainment

Reality testing - proper orientation to time, place, and person; no evidence of psychosis or incoherent thinking

Flexibility - the ability to consider alternatives when making decisions

Questions Guiding Client Assessment in Cognitive Therapy

• What are the client’s core beliefs relative to the presenting problem

• What is the logic behind the client’s beliefs regarding the problem?

• What is the evidence to support the client’s views?• Does the client possess sufficient knowledge to

understand and address the problem issue?• Are there exceptions to the client's generalizations

about the problem? • Are there experiences from the past that could lead to

another conclusion? • What has usually happened during similar situations in

the past?

Questions Guiding Client Assessment in Cognitive Therapy (cont.)

• What other explanations exist for the client’s perceptions?

• How do client’s beliefs influence her thinking about an event’s significance and meaning?

• How strongly does the client believe that approval from others is necessary to feel good about herself?

• What reinforcers tend to be most influential in the client’s life?

• How can the client’s thoughts and behaviors be monitored over time?

• NOTE: At end of assessment workers helps client to arrive at a tentative conclusion about the rationality of her/his thought patterns

• If distortions present, workers assesses client's willingness to consider alternative perspective

THE INFLUENCE OF CORE BELIEFSRelevant Early Life Experience

For example: Negative comparison of self with siblings

Core Beliefs / SchemasFundamental assumptions regarding the self, others, the world, the

future;When problematic these involve themes of helplessness or unlovability

“I don’t have qualities that can attract other people”“I’m not capable of being successful”

Coping Assumptions

May be constructive or destructive“If I work hard, I can do well”

“If I don’t do great, then I am a failure”

Coping StrategiesFor example: High standards, hard work, correct shortcomings

(positive),Over-preparation, manipulation, avoid seeking help (negative)

Specific Situations

(For example, performance in graduate school)

Thoughts and their Meanings

(May be constructive or destructive)

“I can get through this if I go to every class and do half the reading.”

“I can’t do all this work. I don’t have the energy”

Emotions

Pride, excitement

Depression, guilt

Behaviors

Organizing a study schedule

Cheating, quitting

INFLUENCE OF CORE BELIEFS (cont.)

Overall Focus of Cognitive Therapy Assessment

• Assessment: – Observes and identifies thinking patterns with respect

to current situation• Cognitive distortions present?• Explore underling schemas at root of distortions

– Considers the evidence supporting client’s conclusions about the situation

Focus of Cognitive Therapy Interventions

• If client's conclusions are valid, provide education about presenting issue and implement:– Problem solving (six step process)– Cognitive coping mechanisms (education and skills

development)• Self-scripts• Communication skills

Focus of Cognitive Therapy Interventions

• If client’s conclusions are distorted, utilize thought modifying strategies to assist client in achieving desired goals via Cognitive Restructuring

• ABC model of Cognitive Restructuring–Identify situations that trigger misconceptions–Determine how they can be most efficiently adjusted or replaced–Implement corrective tasks

• Cognitive restructuring can:–Adjust cognitive assumptions (beliefs and expectations)–Change habits of thinking (cognitive distortions)

DECIDING ON AN INTERVENTION STRATEGY IN COGNITIVE THEORY

Assessment

Rational Thinking Cognitive Deficits Cognitive Distortions

Problem Solving Education Cognitive Restructuring

Skills Development Skills Development

TESTING A CLIENT’S COGNITIVE ASSUMPTIONS

• Identify and articulate the client’s assumptions or beliefs via:– Probing ( Socratic questioning: detailed, focused . Client arrives at

self-answers by virtue of responding to questions)– Noting shifts in the client’s mood

• Walk the client through a process of examining the evidence for and against the problem-related assumption

• Move the client toward a conclusion about the rationality of the thought pattern

• Consider alternative perspectives

• In light of the evidence, perform an analysis and critique of maintaining the assumption

SOME VERBAL BARRIERS TO COMMUNICATION WITH RELEVANCE TO COGNITIVE THEORY

• Reassuring, consoling, or excusing• Giving suggestions prematurely• Using humor inappropriately• Judging, criticizing• Lecturing, instructing, or trying too hard to

convince the client about a point• Analyzing too much• Asking leading questions (so that your client

accepts your point of view)• Interrupting excessively• Responding infrequently• Dwelling on the remote past

Types of Cognitive Interventions

• Cognitive Restructuring: Used when client’s thinking patterns are distorted and contribute to problem development and persistence– Through discussion and exercise social worker helps

client experiment with alternative ways of approaching challenges that will promote goal attainment

• Problem Solving Training

COGNITIVE RESTRUCTURING

• Eliminates the cognitive distortions that affect a client’s behavior and mood

• Replace them with more “rational” beliefs about the self, the world, and the future

• ABC model is the basis of cognitive restructuring– A=activating event– B=belief/thought– C=emotion, action

COGNITIVE RESTRUCTURING (cont.)

Cognitive restructuring (changing client’s beliefs) requires three steps:•(1)Help person identify thoughts preceding and accompanying the distressing emotions and nonproductive action:

– What was going on through your mind….?

– Imagery “See yourself in that situation…”

– Role play “Let’s pretend that you are…..”

COGNITIVE RESTRUCTURING (cont.)

• (2) Determine client’s willingness to consider alternative thoughts related to problem situation

– Cost/benefit: costs and benefits of maintaining her current beliefs pertaining to the problem

• Pen and paper: write down pros and cons of beliefs

– Point/counterpoint: Playing out opposites of emotion and thought

COGNITIVE RESTRUCTURING (cont.)

• (3) Challenge irrational beliefs by designing tasks (experiments) client can carry out in life to test validity of beliefs– Ask client to try undertaking an action which

could lead to a refutation of a core belief

THE “THOUGHT RECORD:”Cognitive Restructuring Technique

Purpose• For clients to become able to more effectively

evaluate and respond to their automatic thoughtsProcedure: Homework

• Ask the client to record, on a sheet of paper with three columns:– Column A:Situations or events that produce the stress

response (as they occur)

– Column B: The (automatic) thoughts that accompany the events

– Column C: The emotional response(s) to the automatic thought

The “Thought Record” (continued)

• This procedure should be implemented in the client’s natural environment

• By reviewing the thought record with the social worker’s help, the client is helped to:

• Consider the assumptions underlying the automatic thoughts

• Record and experiment with alternative thoughts as replacements

• Record the outcomes of those alternative thoughts and behaviors

• The above two steps require the client to add two new columns to the sheet of paper

THOUGHT STOPPING

• Process of concentrating on an unwanted thought; then interrupting the thought. – The vocal or non-vocal command “Stop!”, some other loud

noise, or a sensory “jolt” is used to interrupt the thought pattern

• The command, STOP!, serves as a “punishment,” and inhibits the “thinking” behavior

• The command serves as a distraction, and the imperative self instruction is incompatible with obsessive thinking

• Thought stopping is an assertive response and can be followed by thought substitutions or reassuring or self-accepting statements

Instructions for Thought Stopping (cont.)

• Explore and articulate the unwanted thought

• Imagine the unwanted thought

• Interrupt the thought:– Practice with an egg timer or alarm clock set at some interval

(3 minutes, 2 minutes, etc.); – When it goes off, empty your mind of the thought for 30 seconds (or

so)– Tape record yourself loudly exclaiming “stop!” at various

intervals, and proceed with the timer / clock• May also use rubber bands, pinching, pressing nails into palm of the

hand

• Practice interrupting the thought without external cues, working toward expressing the “stop” message in quieter tones

• Make a substitution for the unwanted thought:– Self-talk– “Stop and breathe”

COGNITIVE RESTRUCTURING WITH “IMAGES”

• Images are mental pictures, and represent a type of thinking. – Like thoughts, they may be “rational” or “irrational” – A client usually experiences images spontaneously – Images can also be induced as a method of intervention.

• Strategies– Encourage the client to follow a problematic image to its “natural”

completion –– This may result in a resolution of the event or in a catastrophic

conclusion.– If the client moves to the latter, move on to other strategies.

• Help the client cope more effectively with the image – Guide the client through a process of incorporating coping

mechanisms into the existing image.

• Change the image: – rearrange the sequence of events or change the ending with

realistic content.

COGNITIVE INTERVENTION WITH “IMAGES”

• Reality-test the image – Evaluate its “rationality” with Socratic questioning.

• Repeat the image – This is an “extinguishing” procedure in which the client may come to feel less distress with each repetition.

• “Stop” the image – Implemented exactly like the “thought stopping” technique

• Substitute images - Interrupt troublesome images with pleasant ones (similar to thought stopping)

• Induce new images – Rehearse coping techniques with the client, using completely new

images

• Help the client achieve distance from the worst-case scenario

• Modify the nature of the threat

POINT – COUNTERPOINT: A Cognitive Restructuring Technique

PurposeTo challenge irrational thinking that is the source of the client’s emotional responses

Steps•Articulate the (perceived) faulty assumption or belief•Assign the client to play the role of “emotion”, endorsing the (dysfunctional) feeling; the social worker plays the role of “intellect”•Both persons use “I” statements in their roles•Discuss (“argue”) a problem situation. “Emotion” expresses itself and “intellect” points out the irrationality of “emotion”•Switch roles. The client now plays “intellect” and argues against the irrational “emotion”•The worker uses the client’s own words as much as possible to help the client respond more precisely to his or her own stated concerns•Ask the client how much he or she adheres to the belief after the role play

Cognitive Coping Interventions

• Practitioner helps client learn and practice new or more effective ways of dealing with negative moods and stress

• Combining new thinking patterns with new situations that may provide reinforcement of new behaviors

• Clients can modify their cognitive distortions when they experience positive results from practicing new coping skills

Self Instruction Training: A Cognitive Coping Intervention

• Giving clients an internal cognitive framework for instructing themselves in how to cope more effectively with problem situations– Internal “pep talk:” “I can handle this….”

• Client and worker devise a “script” that can be said to oneself within a challenging situation

• Client and worker “rehearse” implementation• Client gradually moves from overt self-dialogue to covert

self-talk• Client then uses script in “natural environment”

Communication Skills Training: A Cognitive Coping Technique

• Focuses on client’s social, assertiveness and negotiation skills via communication skills’ training

• “I” messages:– “I feel ____about ______”

• Active and empathic listening– Paraphrasing back the feelings an discontent of someone’s statement– Acknowledging another’s perspectives and assumptions as understandable

given circumstances

• Making clear behavior change requests– Specific:” pick up your toys” – Measurable: “call me in one week”– stated in terms of positive behavior rather than absence of

negative behaviors: “I need to decompress for a moment before..”

• Clients can modify cognitive distortions when they experience positive results from practicing new skills

PROBLEM SOLVING • Can be used with children, adolescents, and

adults

• Goal: Help client become a better problem solver– They could produce a variety of potentially effective

responses to their problems

• Assumptions of the technique:– Inability to generate, evaluate, and implement problem

solving strategies contributes to maladaptive behavior

• Problem solving process:– Increases the number of effective alternatives for

resolving a problem– Increases the probability that the most effective

response will be selected from the pool of alternatives

5 Steps in Problem Solving Training

• Define the problem in concrete terms• Brainstorming: Compile a list of uncensored alternatives• Evaluate alternatives

– Each alternative discussed as to its advantages and disadvantages

– May require accessing additional information• Choosing and implementing an alternative

– Client praised for effort and use of good judgment regardless of outcome

• Evaluation – Success: How to generalize to other situations within client’s life– Failures:

• Look for elements that might have gone well• Potentially select another option

Role Playing Use in Cognitive therapy Interventions

• NOTE: Role playing is an effective teaching strategy that can be used in all of the cognitive therapy interventions

• Method of role playing:– Worker models the skill– Role play created wherein worker acts as client (protagonist)and

client acts as person with whom client has a concern (antagonist)

• Roleplaying provides:– Information to the worker about what other people are like with

whom clients has issue– Information to client as to what it is like to be in the role of the

“other”