Cognitive Behavioral Therapy Techniques PDF

Cognitive Behavioral Therapy Techniques I. CBT and cognitive reappraisal A. Neurological correlates B. Positive vs. negative reappraisal C. The feeling tone of thoughts − Follow your bliss D. Importance of grounding reappraisal in reality E. Future gain reappraisal tactic 1. Viewing failure as fe...

Cognitive Behavioral Therapy Techniques I. CBT and cognitive reappraisal A. Neurological correlates B. Positive vs. negative reappraisal C. The feeling tone of thoughts − Follow your bliss D. Importance of grounding reappraisal in reality E. Future gain reappraisal tactic 1. Viewing failure as feedback 2. Reframing our view of stress 3. Reframing our view of work F. Counterproductive effect of defensive pessimism II. Behavioral activation therapy − Mapping your life Cognitive behavioral therapy (CBT) • There are many different subtypes of CBT, encompassing a large number of different psychotherapeutic techniques • Commonality is that they share a focus on changing maladaptive thinking − Newer variants of CBT, such as mindfulness therapies (which will be covered in detail in upcoming lectures), focus more on changing one’s relationship to maladaptive thinking • In this lecture, we will look at neuropsychological research on various CBT techniques that aim to help people − Minimize negative and self-defeating thoughts − Cultivate positive and goal-consistent thoughts Cognitive Reappraisal of Emotion Cognitive reappraisal or cognitive restructuring: CBT technique used to identify and change the way situations, experiences, events, ideas, and/or emotions are viewed in order to change their affective impact • Large number of studies support its effectiveness in increasing positive emotions and reducing negative emotions • Standard technique used in CBT, an evidence-based therapy that is among the most commonly used in psychotherapy today Ø Ex: Tugade & Fredrickson (2004) study in which participants were asked to prepare an impromptu speech that would be evaluated by others • In original “threat” condition, participants were told that their performance would be evaluated, and that the evaluations would be used to predict their academic and social success • In the cognitive reappraisal condition, participants were told to try to get psyched-up for the task and to think of the task as a challenge to be met and overcome Results: • Those in the cognitive reappraisal condition evidenced relatively shorter durations of cardiovascular reactivity and relatively greater experiences of positive emotions • This was true regardless of whether the participants were high or low in resilience Neuroimaging Studies of Cognitive Reappraisal More recent research has focused on the neural mechanisms underlying cognitive reappraisal • Existing models generally agree that reappraisal recruits control regions, primarily in the prefrontal cortex, to modulate emotional responding in the amygdala • However, there are competing views regarding − Precisely which control regions are involved − How exactly they exert control over the amygdala, i.e., what neural pathways are involved • To complicate matters, the particular regions and pathways activated probably vary depending on the particular type of appraisal strategy used (e.g., reinterpretation vs. distancing) Ø Meta-analyses of 48 neuroimaging studies, the majority of which used negative reappraisal to lower negative emotions in response to negative stimuli, found that reappraisal (Buhle, Silvers, Wager et al., 2014) • Dampened activity in the amygdala • Activated the following regions: − PFC, including dmPFC, dlPFC, vlPFC: executive functions, cognitive elaboration − Lateral temporal cortex: semantic and perceptual representation − Posterior parietal cortex: sustained attention ➜ This suggests that negative cognitive reappraisal works by changing the meaning that we give to a particular stimulus or situation, which reduces amygdala activity, making the potentially stressful stimuli feel less salient Ø Other meta-analyses have found that the following also play important roles: • Orbitofrontal cortex (OFC): evaluation of emotional salience, selection of behaviors (Cutuli, 2014) • Anterior cingulate cortex (ACC): emotional state interpretation, motivated behavior • Anterior insular cortex (AIC): conscious appraisal of bodily states to trigger emotion regulation processes ➜ Emotion regulation is modulated by a rich net of interconnections between all of the above regions and the amygdala, and many of those connections have been found to play a role in cognitive reappraisal (Pico-Perez, Alemany-Navarro, Dunsmoor et al., 2019) In addition, some EEG studies have found that using cognitive reappraisal correlates with specific types of electrical activity changes in the brain Ø For instance, a reduction in magnitude of late positive potential (LPP) was found in response to negative stimuli when applying emotion regulation instructions (Hajcak & Nieuwenhuis, 2006; Foti & Hajcak, 2008) • LPP is a type of event-related potential that begins around 400–500 ms after the onset of a stimulus and is largest over parietal scalp sites • LPP was enhanced for pleasant and unpleasant pictures in passive viewing block • Reappraisal resulted in a reliably reduced LPP • Degree of LPP modulation was positively related to reductions in the selfreported emotional intensity that followed application of emotion regulation instructions Note that negative voltage charges are plotted as upward deflections Caveat: Reappraisal may be • Adaptive when stressors are uncontrollable (when the person can regulate only the self) • Maladaptive when stressors can be controlled (when the person can change the situation) Ø Study on depression (Troy, Shallcross, & Mauss, 2013) found that • For participants with uncontrollable stress, higher cognitive-reappraisal ability was associated with lower levels of depression • In contrast, for participants with controllable stress, higher cognitivereappraisal ability was associated with greater levels of depression Is Positive or Negative Reappraisal More Effective? Ø fMRI study by Waugh, Zarolia, Mauss et al. (2016) addressed this question • Two conditions − Decrease Negative condition (negative reappraisal) o “The situation is not as bad as it first seemed” o “He/she is back to normal now” − Increase Positive condition (positive reappraisal) o “He will be grateful that he had this experience” o “Their relationship will be stronger than before” • Participants were briefly trained in reappraisal strategy • In fMRI scanner, negative emotions were induced using images from IAPS • Reappraisal strategy was applied • After every trial, participants also rated their level of positive and negative affect and arousal Results: • Both forms of reappraisal shortened duration of responses in the amygdala, insula, and superior temporal gyrus and lengthened responses in prefrontal regions • While negative reappraisal also decreased intensity of amygdala activation, positive reappraisal did not • In contrast, the intensity of activity in the medial prefrontal cortex—an area involved in cognitive control of emotion— increased only in the positive reappraisal condition − Suggests that positive reappraisal may involve more engagement with the emotional stimulus relative to negative reappraisal − Means that using positive reappraisal may require more active cognitive effort into thinking about the potential meanings associated with a particular stimulus • While it may seem that such increased cognitive engagement with the negative images would increase negative emotions, this was not the case ➜ Participants actually reported the largest increase in positive emotion and decrease in negative emotion following positive reappraisal, when they were apparently engaging more deeply with the negative stimuli Height (intensity) and width (duration) of activation differences between the regulation (Decrease Negative and Increase Positive) and non-regulation (Look Negative) conditions The Feeling Tone of Thoughts Research studies on reappraisal of negative thoughts in general indicated that participants’ self-ratings of mood tend to correlate highly (in a negative direction) with neurophysiological measures of negative emotions, such as − Increase in activation of the amygdala − Reduction of activity in control centers in the prefrontal ➜ People’s emotions are a good indicator of whether a particular appraisal tactic might be effective (Waugh, Zarolia, Mauss et al., 2016; McRae, Ciesielski, & Gross, 2012 ) ★ The newer variants of CBT (i.e., mindfulness therapies) that focus more on awareness of emotions and the physical body and their relationship to thoughts use techniques that are in line with these findings Thoughts and emotions are inextricably linked, but in the newer variants of CBT, you use emotions to help guide your thoughts, rather than using thoughts to guide your emotions as in traditional CBT • View that emotions are a foolproof guidance system telling you whether you are thinking a thought that is in line with your own best interests Ø How does it feel when you criticize someone? How does it feel when you are praising someone or something out of a genuine sense of appreciation? ☞ Becoming more aware of the “feeling tone” behind thoughts makes it much easier to choose the positive thoughts and let go of the negative • One way to become more aware of the feeling tone behind thoughts is to reach for the “best feeling thought” that one can access at any given moment (on a deep, not superficial level, of course!) - It’s about becoming more aware of your emotions and giving yourself permission to feel good/prioritizing feeling good: v “Nothing is more important than that I feel good.” - This also means focusing more on how you feel and less on what other people may think ☞ “Mental health is getting to the point where you don’t give a rip what anyone else thinks or says or does” ☛Follow Your Bliss* ² When you first wake up in the morning, set an intention to think good feeling thoughts − Actually you don’t even have to deliberately try to think positive thoughts − During the night, your negative thoughts relax − If you don’t actively pick them up by choosing to think about them, you will be able to feel that path of least resistance and thus to get on that positive track ² Try to sustain it for as long as you can − As you move through the day, look for opportunities to appreciate things − And if you feel like criticizing someone or something, play with your puppy or kitty or sing a song till that feeling goes away ² Think of it as a game, a challenge − You might not even make it till breakfast the first day, but keep working at it, so that next day, you might be able to maintain it through breakfast, and then through your early morning work, etc. ² See if there are important things you can learn − For instance, you might find that if you avoid checking Facebook, you might be able to maintain that positive state longer (From Abraham-Hicks) *Origin of phrase: • In his final interview, twentieth century scholar of mythology Joseph Campbell was asked by Bill Moyers whether he ever had the sense of “being helped by hidden hands”: v “All the time. It is miraculous. I even have a superstition that has grown on me as a result of invisible hands coming all the time – namely, that if you do follow your bliss you put yourself on a kind of track that has been there all the while, waiting for you, and the life that you ought to be living is the one you are living. When you can see that, you begin to meet people who are in your field of bliss, and they open doors to you. I say, follow your bliss and don’t be afraid, and doors will open where you didn’t know they were going to be.” Grounding Reappraisal in Reality Ø Another reappraisal study using design similar to Waugh et al. (2016) investigated specific reappraisal strategies • Participants asked to use positive or negative reappraisal strategies and given examples of each • Negative emotions were induced using images from IAPS • After every trial, participants also rated their level of positive and negative affect and arousal • In addition, skin conductance was measured to assess reappraisal outcomes • Lastly, participants were asked to describe specific reappraisal tactics that they used − A tactic coding system based on tactics reported in previous studies was applied − The effectiveness of each type of strategy was analyzed (McRae, Ciesielski, & Gross, 2012) Results: • Positive reappraisal led to greater increases in positive affect and smaller decreases in skin conductance than negative reappraisal • Participants who tried to challenge the reality or authenticity of what they saw showed smaller increases in positive emotion than participants who used other tactics, such as changing how they viewed future consequences of the situation − Reality challenge: o “The pictures were fake or from a movie” − Change future consequence: o “The situation depicted in the picture will improve over time” Ø In similar vein, another earlier study had found that those who use the technique of suppression – i.e., denying or trying not to feel one’s emotions • Experience and express less positive emotion and greater negative emotion • Have worse interpersonal functioning • Report lower overall levels of well-being (Gross & John, 2003) Ø Examples: ☛Future Gain Reappraisal Tactic − How has dealing with this situation made you a stronger person? − How can you learn something from this situation? − How might this setback potentially result in an even better final outcome? One big factor determining whether you see a situation as stressful or as a challenge is your beliefs about the eventual outcome Ø Ex: A romantic break-up may open you to the possibility of meeting your real Prince Charming who has all the positive qualities of your old significant others – and more! v This tactic in a way epitomizes what optimism is all about: seeing challenges as stepping stones to success, rather than as insurmountable obstacles Ø Classic study of female breast cancer survivors found that one of key factors that distinguished them from those who died was their view that their lives had been altered for the better after developing the disease - Two-thirds of survivors (including many who had been given poor prognosis for recovery) reported this - Supposed “benefits” included o Realizing what was truly important in life and reordering priorities o Giving fuller expression to their feelings o Developing a greater appreciation of the preciousness of life (Taylor, Lichtman, & Wood, 1984) Ø Similar findings have been observed in individuals who were coping effectively with a variety of illnesses, including HIV, AIDS, and heart disease This reappraisal strategy is also about perceiving failure as feedback that will allow you to • Learn what you need to learn to succeed • Develop clarity about what you want ☞ If nothing else, negative emotions tell you what you really want because you’re never so clear about what you want as when you’re experiencing the absence of it The Path of Failure: Abraham Lincoln • Age 22: Lost job • Age 23: Defeated for state legislature • Age 24: Failed in business • Age 27: Nervous breakdown • Age 34: Ran for congress and defeated • Age 39: Defeated again • Age 46: Ran for senate and defeated • Age 47: Defeated for nomination for vice president • Age 50: Defeated again for senate • Age 51: 16th US President Reframing Our View of Stress And here are a few more research studies demonstrating how our view of stress in particular can dramatically change how it affects us Ø Study: In the midst of a banking crisis and massive restructuring, bank managers were asked to watch one of two videos 1) Video that depicted stress as debilitating to performance 2) Video that provided details on ways in which stress enhances the human brain and body, by increasing cortisol, focus of attention, etc. ➜ Participants who had viewed the “enhancing” video experienced a significant drop in stress levels and health problems and a significant increase in work efficiency (Crum, Salovey, & Achor, 2013) Ø Medical students asked to perform a novel surgical task ➜ Those who scored high on Emotional Intelligence (EI) experienced greater levels of subjective stress, as well objective stress (as indicated by increased heart rate), compared to those with lower EI − They also showed better after-task recovery (Aurora, Russ, Petrides et al., 2011) Dark gray lines = enhancing condition Medium gray lines = control condition Light gray lines = debilitating condition “Soft” skills = new ideas, focus, engagement, collaboration “Hard” skills = quality, quantity, efficiency, accuracy In a Gallup World Poll, those who were stressed but not depressed reported being energized and satisfied with their lives • This is the opposite of the lethargy reported by those who were depressed but not stressed (Ng, Diener, Aurora et al., 2009) Championship athletes, successful entertainers, motivated students, and great teachers and leaders all thrive and excel when aroused by a challenge (Blascovich & Mendes, 2010) Working through difficulties helps you to progress towards your goals and grow as a person Ø Shawn Achor study in which highly successful businesspeople were asked to list the five experiences that most shaped who they are today • Nearly all the experiences they wrote down involved great stress ➜ Few people grow on vacation! Ø New York Times article on Harvard MBA grads 15 years after graduation (Duhigg, C., 2019) • Majority were not happy campers: complained about jobs that were unfulfilling, tedious, or just plain bad; disaffected children; and billable hours in divorce court… “If you spend 12 hours a day doing work you hate, at some point it doesn’t matter what your paycheck says.” • However, there were a few people seemed to have wound up with jobs that were both financially and emotionally rewarding − Most of these had something in common: they tended to be the ones who failed to get the jobs they wanted when they graduated, who had been passed over by the big prestigious companies − They were forced to scramble for work and they learned from their own setbacks … and wound up richer, more powerful, and more content than everyone else! ➜ Ø Pick any biography and you’ll see the same thing: stress is not just an obstacle to growth; it can be the fuel for it Ø Study on preschoolers found that • Those who were the most outgoing, socially competent, and well liked - Showed high activity in brain circuit that triggers stress hormones on first day of school - Showed decline in stress hormone levels as the year went on • Opposite pattern was found in preschoolers who were unhappy and socially isolated (Goleman, D., 2005) ☛ Be Grateful for Challenges Remember that happy people aren’t just people who have somehow managed to arrange their lives so that they never encounter difficult situations or people • Without challenges and difficulties, we cannot grow and mature ➜ Be grateful for challenges Reframing Our View of Work Csikszentmihalyi found that people actually have more peak experiences (moments of highest happiness and fulfillment) at work but say they prefer leisure time • Suggests that our association of effort with pain and leisure with pleasure is so deep-rooted that it distorts our perception of the actual experience! • But this severely limits our potential for happiness because in order to be happy, we must not only experience positive emotions but also recognize them as such ☞ We need to learn to reframe our work and our education as a privilege rather than as a duty (Ben-Shahar) ☛ Take a moment before you start a challenging assignment to think about why you are doing it, why you should be enjoying it Ø Study on hospital cleaners (Wrzesniewski & Dutton, 2001) • Group A - Viewed their work as a job, boring and meaningless - Saw their work merely as removing the garbage and dirty linen • Group B - Viewed their work as contributing to the patients’ well-being and smooth functioning of the hospital - Engaged in more interactions with nurses, patients, and their visitors, taking it upon themselves to make the patients and hospital staff feel better ➜Group B hospital cleaners were happier than Group A and happier than doctors who didn’t experience their work as meaningful ☞ How we perceive the work can matter more than the work itself ☛ Crafting your work: • What potential meaning and pleasure exists in what you do? A word on defensive pessimism… Some people actually use fear of failure to motivate themselves to succeed v “Oh, no, I’m going to FAIL that class!” • This is known as defensive pessimism • Does this work as a motivational strategy? ➜In the short run, it can In the long run, it’s a recipe for burnout, low self-esteem, and unhappiness Ø Research indicates that after three years in college, defensive pessimists report - Lower grade-point averages - More physical and psychological symptoms (Cantor & Norem, 1989) Age and Reappraisal Multiple studies have shown that the effectiveness of reappraisal increases with age Ø One fMRI study on individuals aged 10-22 found that • Used same basic paradigm as studies discussed above • Reappraisal success increased with age, as gauged by self-report rating of negative affect • Activity in prefrontal during reappraisal also increased with age • However, there was no difference in amygdala activation (McRae, Gross, Weber et al., 2012) Ø On the other hand, a more recent study, using a similar paradigm with participants aged 10.5-23, found that • Older individuals showed greater drops in negative affect and greater decreases in rostrolateral prefrontal-amygdala connectivity after reappraisal • In addition, reduced amygdala response persisted when the older participants viewed the aversive stimuli again after about 30 min − This effect was mediated by activity in the rostrolateral PFC (Silvers, Shu, Hubbard et al., 2015) Behavioral Activation Behavioral activation • Another technique that forms a cornerstone of cognitive–behavioral therapy • Considered to be one of the most effective and widely-used treatments for emotion dysregulation For depression: Clients are asked to • Rate the degree of pleasure and accomplishment they feel during specific activities • Establish and maintain regular routines that encompass activities that receive a high score, rather than leave them to chance • These activities may include ones that provide - Pleasant experiences - Social support - Experiences of mastery • Therapy would start with relatively easy goals and work up to more challenging ones ☛Behavioral Activation For depression or stress/anxiety: • An hourly self-monitoring chart is used to track activities and the impact on mood they create for a full week • Behavioral activation helps clients to develop an understanding of the relationship between actions and emotions, with actions being seen as the cause of emotions • Particular emphasis is placed on evaluation of effects of rumination • Attending to experience is taught as an alternative to rumination • Additionally, focus is given to quality sleep, and improving social functioning ☛Mapping Your Life Negative rituals may also be introduced – time during which you refrain from doing certain things, e.g., create an Internet-free time zone each day • Can be combined with CBT reframing techniques - Instead of thinking of it as “spending less time on your phone,” think of it as “spending more time on your life” ★ Students engaged in behavioral change projects often report that the most effective way to get themselves to study harder is not rewards, punishments, or even social support, but to limit specific time-killing activities, like Facebook, texting, and internet surfing ☛Start Small Start with very small steps if you are trying to motivate yourself to do something or to change a habit Ø If you are dreading having to do that exercise routine, just tell yourself you will put on your exercise shoes and do a few jumping jacks Ø If you know you have a habit of stress eating and polishing off giant bags of chips, take smaller portions and tell yourself you can always get more later if you want to do that Ø If you want to spend more time reading, leave a book on your bedside table Ø If you want to cook more, lay out a shopping list for that recipe you’re eager to try Ø If you want to spend less time on YouTube, always watch in incognito mode to defeat the evil algorithms tracking your preferences to keep you glued to your screen! Ø fMRI study on behavioral activation therapy for depression Patients with major depressive disorder (MDD) • Were given an average of 11.5 sessions of Brief Behavioral Activation Therapy for Depression (BATD) • Then completed a forced-choice reaction time task while in fMRI pre- and post-treatment − A bullseye target stimulus was occasionally embedded within alternating blocks of sad and neutral pictures − Participants had to press one button for target images and another button for non-targets as quickly as possible Results: fMRI revealed that behavioral activation was associated with functional changes in structures that mediate responses to rewards (i.e., targets in study), including: • Paracingulate gyrus (during reward selection) • Right caudate nucleus (during reward anticipation) • Paracingulate and orbital frontal gyri (during reward feedback) ➜ Behavioral activation improved functioning of unique reward structures (Dichter, Felder, Petty et al., 2009) Video Reference Video excerpted from: • Secrets Of Self Made Millionaires by Brian Tracy https://www.youtube.com/watch?v=KAGn_k1jHsY