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Theory and Design in Counseling and Psychotherapy
Susan X Day , Iowa State University and University of Houston
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CHAPTER 9: Cognitive-Behavioral Therapies
Chapter Review
Cognitive therapies describe the inner speech that takes place inside each person's mind. As events occur, our thoughts mediate between the external input and our outward responses. This mediation process subjectively interprets outside events according to an individual's experience. Personal constructs form the lens through which we view the world and create our own phenomenological reality. From this perspective, emotions can be changed by changing thought patterns. Rather than emotional processing as other therapies describe, cognitive counselors search for patterns of thinking that underlie mental health difficulties. Chronic and severe disorders reveal common thought patterns. However, the thinking behind more neurotic and less severe emotional distress may not be as obvious given the automatic, spontaneous nature of habitual thoughts a client may have.
Cognitive therapists share common practices with behavioral therapists; hence the title, Cognitive-Behavioral therapy. Both behaviorists and cognitive counselors know emotional factors influence client cooperation, and both use behavioral methods to establish and reinforce learning patterns. The therapy process for the cognitive approach creates a problem solving tone, collaborating with clients to develop coping skills for dealing with stressful situations. Some client crises are so stressful that automatic thinking patterns are unable to meet the demands of the circumstances. Other clients struggle to meet daily responsibilities, feeling life has become unmanageable. They process experience through a negative cognitive screen that induces ineffective responses. Therapists infer the negative schema that has led clients to emotional distress. Identifying ineffective beliefs, the counselor serves as a persuasive teacher, a trusted guide, who can help the client change thoughts that are no longer working to generate a satisfying life. The therapist creates a warm, understanding atmosphere for the cognitive work, providing a model of effective coping, but also as an example of another flawed human being who has to meet similar life demands. The goal of counseling is to change client thought patterns, to assist the client in determining realistic considerations, and to help the client learn how to establish effective responses.
In the early stages of counseling, therapist and client engage in a dialogue designed to determine the client's thinking patterns, encouraging specific descriptions, not only general descriptions of experiences. The therapist teaches the client the mechanics of completing a thought record as homework between sessions. Often the counselor and client will make a prioritized list of problems, and the counselor will offer suggestions for one of the simplest concerns to create an early success for the client. Over time, in the middle working stage of counseling, the client's belief system and how it works is thoroughly examined. Clients consider the evidence for a belief,
brainstorm alternative interpretations, and examine the implications. For homework, clients try out new cognitions or participate in experiences designed to expose thoughts to reality testing. Counselors may use Socratic questioning to lead clients into rational examination, or therapists may create experiences constructed so the client will discover new ways of looking at issues. In the final counseling sessions, clients' new schemas are reinforced, and relapse prevention interventions prepare clients to meet the demands of future difficult situations.
Ellis provides one cognitive approach called Rational Emotive Behavior Therapy (REBT). This method teaches clients a mnemonic of A, B, C, D, E, F. A stands for the activating event, B represents the client's beliefs, and C is consequential reaction. According to Ellis, people assume A, the event, happens and C, the reaction, results automatically, not realizing that the reaction has been influenced by B, the associated beliefs. Ellis presents eleven common irrational thoughts that create many negative reactions. Incorrect beliefs include assumptions that one has to be loved or perfectly competent; that experiences must conform to the person's expectations; that others are bad and should be punished. If events vary from such prescriptions, people say in their minds, "Life is awful!" and they feel burdened. To overcome faulty assumptions, REBT counselors go to D which is disputing the irrationality. The therapist, and eventually the client, refute the negative assumptions and come to more reasonable conclusions. When the disputing takes hold, E occurs and the client is effecting a new philosophy so that F, new feelings will also occur. According to Ellis the eleven irrational thoughts underlie most emotional difficulties.
Beck provides a number of errors in informational processing that lead to negative emotions and faulty responses to life events. His work with depression suggests a cognitive triad in which afflicted clients report self-concepts of being ineffectual and worthless, interpret experiences as overwhelming, and see the future as without hope. For diagnosis, the Beck Depression Inventory assembles the triad's descriptors to measure the severity of the problem. Beck's therapeutic approach is collaborative, and his interventions engage the client in an empirical search to find evidence for negative thoughts or for more balanced, rational conclusions.
Meichenbaum devised a cognitive treatment called stress inoculation (SIT), a sequence of self-talk strategies designed to help clients cope with very difficult situations such as intense memories of trauma. Psychologically damaging memories trigger a sequence of emotions, and treatments require extensive cognitive restructuring. Other clients can be prepared for intermittent stressful experiences or for chronic, continual stress. Automatic thought responses may not be adequate for dealing with unusual stress, so Michenbaum's methods prepare clients before they face the difficult circumstances. The therapy sequence begins with the conceptual phase, where clients report in detail what distressing signals can be expected and what their typical responses have been. The next phase of treatment entails the clients' gaining the appropriate skills needed, and the final phase involves applying skills in real situations. Necessary follow-up sessions help maintain new learning. Michenbaum's SIT methods have been used for a wide variety of people from surgical and cancer patients to psychiatric patients adjusting to post hospitalization to PTSD patients and their families.
Glasser designed an approach called reality therapy. His major clientele, juvenile delinquents, are described as denying realistic constraints, making excuses, and ignoring the natural consequences of their behavior. Glasser encourages empathy for client emotions, but his counseling does not emphasize affect. Instead, he teaches self-regulation using the metaphor of cybernetics, the study of how mechanical systems are designed to automatically adjust to changing conditions. Clients learn to identify what they want and how their behavior can either lead to gaining their goals or to negative consequences. The approach popularized by Glasser's colleague Wubbolding uses the letters WDEP to indicate: Wants, Direction and Doing, (self) Evaluation, and Planning. The theory also considers universal needs: survival, belonging, power or achievement, independence, and fun. Finally, much time in counseling is spent recognizing the effects of behavior on other people and emphasizing responsibility for oneself.
Lazarus created a counseling approach called multimodal therapy. As the name suggests, Lazarus describes client difficulties as affecting multiple dimensions of human personality. He devised the acronym BASIC ID, or basic identity, to indicate the different modalities requiring assessment and appropriate treatment interventions. B stands for behavior, A for affect, S for sensation, I for imagery, C for cognition, I for interpersonal relationships, and D for drugs or biological components. The client describes her personality, rating the strength of each dimension for a structural protocol. The therapist then creates a modality protocol, a plan for interventions. Treatment starts with interventions affecting the strongest personality factors and utilizing gains made in the strength modality to influence changes in other dimensions. Thus, the therapist is able to determine the sequence of interventions and to track client change across modalities. The approach utilizes techniques from many different therapy approaches and is known for its technical eclecticism.
Linehan developed another many faceted treatment approach for borderline personality disorders called dialectical behavior therapy (DBT). Linehan recognized that clients face conflicting pressures such as the need to both accept the self and to change, to let go of negative behavior but not to lose the behaviors that have worked, to validate personal experience and yet to redefine what has happened. In treating chronically distressed personalities, considerable effort is needed to help clients acquire skills in emotional self-regulation. DBT methodically educates clients in approaching many different situations with new perspectives and problem-solving methods. Linehan also has designed interventions based on Zen mindfulness methods that encourage the acceptance of life events just as they are, without demanding that reality be any different than it is.
EMDR or Eye Movement Desensitization and Reprocessing is a technique that is said to change the neurological storage of traumatic memories. The desensitization treatment essentially has the client remember difficult scenes from the past while the therapist passes two fingers back and forth to guide the client's eye movements. Before the eye movement intervention, the counselor listens to the client's history, targets the memory scenes, and prepares the client for the procedures. During each set of eye movement treatments, the client views the scene as in a movie, at a distance, and utilizes relaxation methods. Between eye movement sets, the therapist assists the client in developing positive cognitions to counter negative ones. Once the client's distress ratings have lessened, the client holds both the memory and positive cognitions together at the same time to install the new reaction. As a check for stress level, a body scan is done before final closure of the session. Between sessions the client records flashbacks, and in the next session, a reevaluation is done to determine if the memory has been reprocessed. If the ratings for stress and cognitions have not shown progress, the therapist does what is called a cognitive interweave where the positive cognitions are discussed. A controversy among practitioners exists, with some skeptical reactions conflicting with some research showing the treatment as effective as other exposure methods.
Critiques for the cognitive-behavioral approach say that it is too prescriptive, that it overemphasizes rationality and de-emphasizes dependency needs, that it can leave the client with unfinished business, and that the methods are similar to brainwashing procedures. However, cognitive therapists value empirical validation for their methods and pay attention to what works according to the research. The field will continually evolve as scientific investigations offer new results. The methods also have the advantage of working within a short term model that is becoming both acceptable and necessary for counseling practice.
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