Chapter 15: Cognitive Psychotherapy & Mindfulness-Based Therapies PDF

CHAPTER 15: COGNITIVE PSYCHOTHERAPY & MINDFULNESS-BASED THERAPIES Josée L Jar r y, Ph.D., C.Psych. Introduction to clinical psychology (PSYC 3330) University of Windsor November 14 & 19, 2024  COGNI T I VE AND M I NDFU LNESS THERAPIES Brief, structured, and...

CHAPTER 15: COGNITIVE PSYCHOTHERAPY & MINDFULNESS-BASED THERAPIES Josée L Jar r y, Ph.D., C.Psych. Introduction to clinical psychology (PSYC 3330) University of Windsor November 14 & 19, 2024  COGNI T I VE AND M I NDFU LNESS THERAPIES Brief, structured, and targeted Represents a reaction to both behavioral and psychodynamic therapy More empirical/observational than psychodynamic Still values internal mental processes The way we think about or interpret events determines the way we respond emotionally Continues to evolve with third-wave therapies  COGNITIVE THERAPY Strict focus on classical and operant conditioning Does not always explain behaviour Is not always sufficient for change Consider why abused spouses stay with the abuser and even seek similar people after leaving the abuser How people think helps us understand how they behave Addresses symptoms directly Less focus on the past and more on the present  GOAL OF COGNITIVE THERAPY Premises: Psychological problems come from illogical thinking Psychological health comes from logical thinking Main goal: Increase logical thinking, or fix faulty thinking Cognition = thoughts, beliefs, or interpretations Although we often describe our feelings as stemming directly from events, cognitions actually intervene A two-step model is flawed: Events don’t make us happy or sad, the way we interpret those events does Three-step model: “Cognition Feeling Event ” Interpretatio Something Interpretatio n influences happens n of the mood event Note that the end step is not behaviour, it is feelings.  REVISING COGNITIONS & TOOLS USED TO DO SO Goal: Ensure that the thoughts a person has about particular events rationally and logically correspond to the event itself. Revise thoughts to make them less extreme and more realistic Reduces anxiety and fear Done with cognitive restructuring  REVISING COGNITIONS: COGNITIVE RESTRUCTURING Three-stage method: 1. Identifying automatic illogical cognitions These are fast and often feel implicit (not unconscious) Not a slow, deliberate process So habitual and immediate that they often go unnoticed 2. Challenging the illogical cognitions, 2 methods: a) Therapist uses verbal persuasion b) Client tests the accuracy of beliefs with homework Goal is to instill doubt about the belief & consider that changing it may lead to feeling better 3. Revising Replacing with logical cognitions, (….and then go out and do something different)  REVISING COGNITIONS: TEACHING & HOMEWORK Teaching The therapist actively teaches the client the rationale for therapy e.g. the 3-step model Train clients to identify illogical thoughts, label them, self-monitor & document The goal is for the client to become proficient at this process and no longer need the therapist Homework Therapist frequently assigns homework – strength of cognitive therapy Record of events, thoughts, feelings Behavioural experiments: test illogical thoughts, try a new skill Much of the therapy work is done between sessions Homework completion depends on: client factors, therapist factors, the therapeutic alliance (trust) REVISING COGNITIONS: COGNITIVE RESTRUCTURING But what if thoughts are negative but reasonable? Find the point at which they are irrational  B R I E F, S T R U C T U R E D , FOCUSED Therapy is relatively brief—often 15 sessions or less Structured and planned Sessions may not be as free-flowing or spontaneous as in other therapies The therapist, not the client, sets the agenda Focused on particular, present-focused goals determined by client and therapist at the outset Typical structure: 1) Check-in: mood and brief updates 2) Set agenda for the session 3) Link with previous session, often by reviewing homework 4) Proceed with agenda items 5) Develop and assign new homework 6) Summarize session and solicit client feedback  ALBERT ELLIS’ REBT Originally called his approach Rational Emotive Therapy (RET), then Rational Emotive Behaviour Therapy (REBT) Emphasizes a connection between rationality and emotion People are uniquely rational, as well as uniquely irrational Happiness comes from minimizing irrational thinking and maximizing rational thinking The ABCDE Model Activating event (A) Belief (B) Emotional Consequence (C) Dispute (D): targets B Effective new belief (E)  EXAMPLE OF ABCDE MODEL A Activating event Studying for or thinking about the GRE exam “I absolutely have to get high scores on the GRE exam on my first attempt. If I B Belief don’t, I’ll never get into graduate school and my career is doomed, and that would destroy me.” Consequence C Anxiety (emotional) “Who says you have to get extremely high scores on the GRE exam on your first attempt? I understand that’s a preference, but is it a life-or-death necessity? Realistically, don’t quite a few people retake the GRE exam to improve their scores or have to apply to graduate school more than once? And don’t many go D Dispute on to have successful careers? And even if you don’t end up with the career as a psychologist you envisioned, does that mean your life is ruined? There are plenty of ways for you to have a rewarding career that don’t involve being a psychologist at all.” “I want to do very well on the GRE exam on my first attempt, but it’s not an absolute necessity. If I take it again later and better my score, that will probably E Effective new belief work out fine also, and in the big picture, my happiness doesn’t depend entirely on following the career path I’ve imagined.” ELLIS & GLORIA https://www.youtube.com/watch?v=tcq4RMzSyng  ALBERT ELLIS’ REBT – CRITIQUE May ignore deeply held cultural beliefs Takes irrational thoughts one by one and disputes them individually Could there be core beliefs that drive the multiple individual ones? In the case of the GRE anxiety Is the anxiety specific to the GRE situation? Does this person have a fear that any failure will have catastrophic consequences? What might be the core belief underlying this fear of failing, experienced in multiple situations?  A A R O N B E C K ’ C T, C B T Originally developed to conceptualise and treat depression Cognitive Triad: Thoughts about the self, the external world, and the future Negative thoughts about all three produces depression Like Ellis’s approach, the goal is to increase the client’s logical thinking Dysfunctional Thought Record Column A: A brief description of the event/situation Column B: Automatic thoughts about the event/situation: usually the irrational thought Column C: Emotions Column D: An adaptive response: identify the distortion in the automatic thought, challenge it, formulate an adaptive response Column E: Outcome: emotion after identifying an adaptive response and the extent to which the automatic thought is still believed  AARON BECK – LABELING Vocabulary to work on Column D Discredit illogical thoughts by labelling them Common thought distortions, labels: All-or-nothing thinking (e.g., there is only one way to see this) Catastrophizing (e.g., it’s the worst and it’s the end!) Magnification/minimization: (my mistake is massive, and my success could be achieved by anyone) Personalization (e.g., this only happens to me! It’s something about me) Overgeneralization (e.g., it’s always like this) Mental filtering (e.g., yes but the good things don’t really count) Mind reading (e.g., I know what they are thinking!) Our beliefs are hypotheses Testing beliefs exposes them as illogical Possibility of backfire Q U E S T I O N I N G A U T O M AT I C THOUGHTS What is the evidence that the automatic thought is true? Not true? Is there an alternative explanation? What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? What’s the effect of my believing the automatic thought? What could be the effect of changing my thinking? What should I do about it? If my friend was in the same situation and had this thought, what would I tell him/her?  E X A M P L E AU T O M AT I C T H O U G H T R E C O R D Date/ Situatio Automatic Emotion(s) Adaptive Outcome Time n Thoughts Response What actual What thought(s) and/or What emotion(s) (sad, (optional) What cognitive How much do you now believe each event or stream image(s) went through anxious, angry etc.) did distortion did you make? automatic thought? of thoughts, or your mind? you feel at the time? daydreams or Use questions at the bottom What emotion(s) do you fell now? recollection led How much did you How intense (0-100) was to compose a response to the to the believe each one at the the emotion? automatic thought(s). How intense (0-100) is the emotion? unpleasant time? emotion? How much do you believe What will you do (or did you do?) each response? What (if any) distressing physical sensations did you have? Nov 27, My He’s angry at me. Sad (50), scared We have been getting Original thought (35) along well. He has 2 pm husband (90) (45) forgotten to call before didn’t call He’s cheating on and often it was because Angry (5), sad (45), lonely when he me. (80) Anxious (40), sad something important (30) said he He wants to came up at the office. (50), jealous (60) There could be many would. leave me. (100) Angry (40), sad reasons why he hasn’t I will call him to find out for Something (90), lonely (85) called yet. It might not sure. Pounding terrible has Afraid (30), have anything to do with us. (70) heart, happened to him anxious (45) tense (75) shoulders AARON BECK –BELIEFS AS HYPOTHESES We live as if our beliefs (Column B) were true Our beliefs are hypotheses Test them Power of behavioural experiments Testing beliefs exposes them as illogical  CRITIQUE OF COGNITIVE THERAPY How to truly determine what is “logical” Do problems always arise from illogical thinking? Is thinking logically (column D) always enough to improve how people feel? Can column D come from a failure to see true shortcomings, defensiveness? Can people sustain the discipline necessary to apply logical thinking to all discrete situations? Is there always a happy ending?  CRITIQUE OF COGNITIVE THERAPY The cognitive work does not explain therapeutic improvements Demonstrated in dismantling studies Same therapy in 2 groups, one with and one without cognitive work In mediation analyses The cognitive processing (or change) must be shown to precede the improvement in symptoms Is it all exposure? Is there a reciprocal relationship btw symptoms and changes in cognition?  A P P L I C AT I O N S O F C O G N I T I V E T H E R A P Y: M I N D F U L N E S S Mindfulness and acceptance-based therapies are considered “third wave” therapies (after first wave - behaviourism, and second wave – cognitive) Rather than engaging in experiential avoidance, an individual can engage in acceptance: engaging with mental processes and allowing them to run their course without fighting against them Mindfulness “refers to being able to pay attention in the present moment to whatever arises internally or externally, without becoming entangled or ‘hooked’ by judging or wishing things were otherwise” (Roemer & Orsillo) Mindfulness is “an innate human capacity to deliberately pay full attention to where we are, to our actual experience, and to learn from it. This can be contrasted with living on automatic pilot and going through our day without really being there” (Hick, 2008). “The short definition of mindfulness... is (1) awareness, (2) of present experience, (3) with acceptance” (Germer). Mindfulness is “the awareness that arises out of intentionally attending in an open and discerning way to whatever is arising in the present moment” (Shapiro).  MINDFULNESS Mindfulness is a way of relating to your thoughts Not focused on changing the thoughts but rather on changing the way people relate to their thoughts Contemplative engagement with one’s own thoughts rather than dispute and refutation Experiential avoidance (remember existential therapy) is replaced with acceptance The idea is that fighting with our thoughts brings psychological distress Experiential avoidance is the foundation of many psychological disorders PTSD Generalised anxiety disorder Depression MINDFULNESS &INTERNAL EXPERIENCE Baer’s five-factor model Observing Paying attention to inner experience Describing Putting words on this experience Acting with awareness Be aware of one’s own behaviour/environment Non-judging Avoid passing judgment on inner experience Non-reacting Don’t try to change inner experience  S E L F - C O M PA S S I O N Approach developed to manage painful experiences Kindness vs judgement Apply kind treatment rather than harsh judgment during difficult times Common humanity Suffering is part of being human Mindfulness Attend to painful internal experiences without trying to change them or overidentifying with them Accept them for what they are: thoughts A C C E P TA N C E A N D C O M M I T M E N T THERAPY “A” Acceptance of inner experience Also a way of relating to inner experience Stop battling inner experience, acknowledge it, accept it “C” Commitment to personal values First step is connecting, or reconnecting with personal values Then, remain true to these values in day-to-day behaviour “T” Take action consistent with values Connect way of thinking with way of living A C C E P TA N C E A N D C O M M I T M E N T THERAPY Accepting internal psychological experience Move from FEAR to ACT Fusion with inner thoughts, Accepting one’s own inner feelings and behaviours experiences for what they are, and Evaluation of self and one’s own nothing more inner experiences Choosing directions in life based Avoidance of unpleasant inner on one’s core values, which will experiences (e.g., distraction) enhance meaning and purpose Reason-giving relying on Taking action in ways that are rationalizations that sound consistent with one’s own values legitimate but perpetuate unhealthy approaches to life A C C E P TA N C E A N D C O M M I T M E N T THERAPY VALUES Family & Intimate Relations: what kind of parent/spouse/sister/uncle/etc. do you want to be? What kind of partner do you want to be? Social Relationships: what sort of friend do you want to be? How would you like to act towards your friends? Employment: what kind of work is valuable to you? What qualities do you want to bring as an employer? Education / Personal Growth: what kind of skills would you like to develop? What would you like to learn more about? Recreation: how would you like to enjoy yourself? What relaxes you? Spirituality: what kind of relationship do you want with God/nature? Citizenship: how do you want to contribute to your community? Physical Wellbeing: how do you want to look after yourself? D I A L E C T I C A L B E H AV I O U R THERAPY Originally developed as a treatment for borderline personality disorder (BPD) In BPD, difficulties with emotion regulation are a core problem Struggle to control the intensity of feelings Emotion regulation stem for 2 sources Biological predisposition, supported by twin studies Invalidating interpersonal environment Teaches the person that only extreme emotional displays will get attention, including suicide D I A L E C T I C A L B E H AV I O U R T H E R A P Y Core DBT practices: Problem solving  Think through stressful situation rather than react with extreme emotion  Assess consequences of impulsive action  Devise strategies for best possible outcome Validation  Persuasively communicate that clients’ feelings are an important and sensible reaction to their situation  Different than empathy which simply states the existence of the feeling Dialectics  Resolve simultaneous, contradictory feelings held by the client and arrive at the truth of their emotions  Therapist accepts the client while also pushing for change  D I A L E C T I C A L B E H AV I O U R THERAPY Four specific skills training modules: Emotion regulation – identifying, describing, and accepting rather than avoiding negative emotions Distress tolerance – development of self-soothing techniques and impulse control Interpersonal effectiveness – develop appropriately assertive social skills to preserve relationships: protect relationships from emotional outbursts Mindfulness skills – encouraging clients to fully engage in their present lives and internal experiences without avoidance or evaluation R E C E N T A P P L I C AT I O N S : M E TA C O G N I T I V E T H E R A P Y Metacognition = thinking about thinking In traditional cognitive therapy, the irrational belief is caused by an event In metacognitive therapy, the “activating event” can be a thought itself The cause of unhappiness is our thoughts about our thoughts Cognitive Attentional Syndrome Brooding, ruminating thinking style Positive thoughts about worry: worrying helps me prepare for the future Negative thoughts about worry: this worry will destroy me! Metacognitive therapists make thinking about thinking the primary focus Has been applied primarily to anxiety disorders, including obsessive-compulsive disorders, posttraumatic stress disorder, generalized anxiety disorder, and schizophrenia. Thinking about delusional thoughts rather than accepting them right away R E C E N T A P P L I C AT I O N S : COGNITIVE THERAPY FOR MEDICAL PROBLEMS The way patients think about injury, illness, or condition can be powerful, especially when irrational How will they be affected? How will family and friends react? How will treatment work? The therapy is exactly the same as regular cognitive therapy, but focuses on irrational thoughts about the illness Increasing logical thinking can improve mental and physical health Has been successfully applied to a variety of medical problems  R E C E N T A P P L I C AT I O N S O F C O G N I T I V E T H E R A P Y, C O N T I N U E D Schema Therapy Addresses maladaptive schemas about the self and relationships with others formed during childhood, often resulting from poor parenting Rejecting, unloving, abusive, etc. The schemas match the treatment they received as children Unlike other cognitive therapies, pays attention to the “roots” of the cognitions and helps clients see that those cognitions are false (e.g.) “people who are important to me will leave me” (e.g.) “people in my life will hurt me” (e.g.) “I must be a terrible, unlovable person” (e.g.) “I’m incompetent and will never succeed in life” Uses the therapeutic relationship The client will act out these schemas with the therapist  R E C E N T A P P L I C AT I O N S O F C O G N I T I V E T H E R A P Y, C O N T I N U E D Schema Therapy Intended for clients who have borderline personality disorder or other long-standing, complex clinical issues, such as long-term depression and complex eating disorders Very similar to Brief Psychodynamic therapies Implicitly assumes the impact of unconscious forces Treats the deep-seated belief as an irrational thought with disputing, etc.  HOW WELL DOES IT WORK? Strongly supported by empirical evidence Works for a range of disorders Improvements provided by cognitive therapies As rational beliefs increase, the chances of psychological problems drop Most important rational beliefs are those related to self-acceptance Mindfulness-based therapies Found to have positive effects in meta-analyses that focus on specific problems like eating disorders, psychosis, and weight loss VIDEO OF D I A L E C T I C A L B E H AV I O R THERAPY https://www.youtube.com/watch?v=nFwAiO22g4Y