Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Assignment 1: Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory
While cognitive behavioral therapy (CBT) and rational emotive behavioral therapy (REBT) have many similarities, they are distinctly different therapeutic approaches. When assessing clients and selecting one of these therapies, you must recognize the importance of not only selecting the one that is best for the client, but also the approach that most aligns to your own skill set.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. For this Assignment, as you examine the similarities and differences between CBT and REBT, consider which therapeutic approach you might use with your clients.
Learning Objectives
Students will:
• Compare cognitive behavioral therapy and rational emotive behavioral therapy
• Recommend cognitive behavioral therapies for clients
To prepare:
• Review the media in this week’s Learning Resources.
• Reflect on the various forms of cognitive behavioral therapy.
The Assignment
In a 1- to 2-page paper, address the followingCognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay:
• Briefly describe how cognitive behavioral therapy (CBT) and rational emotive behavioral therapy (REBT) are similar.
• Explain at least three differences between CBT and REBT. Include how these differences might impact your practice as a mental health counselor.
• Explain which version of cognitive behavioral therapy you might use with clients and why. Support your approach with evidence-based literature.
Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references..Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

NOTE ALL REFERENCES SHOULD BE 5 YEARS OR LESS

8

Cognitive Behavioral Therapy

SHARON M. FREEMAN CLEVENGER

This chapter provides a brief overview of cognitive behavioral therapy (CBT). This chapter begins with guiding principles and evidence-based research for CBT. Basic cognitive and behavioral techniques are presented that the advanced practice psychiatric nurse (APPN) can integrate into practice. A modification of CBT, schema-focused therapy is discussed, as well as application of models of CBT treatment for specific populations.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. The chapter concludes with a case study illustrating the use of CBT and postmaster’s and certification requirements.

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CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems (Beck & Dozois, 2011; Jakobsen et al., 2011; Karlin et al., 2010; Kliem, Kröger, & Kosfelder, 2010; Neacsiu, Rizvi, & Linehan, 2010). CBT is the first order of business and treatment of choice for most patients who need internal resources and coping skills enhanced. The therapist, together with the patient, structures each session and sets reasonable, measurable, specific goals so that both participants know when progress has been made. Goals include problems to overcome as well as positive changes that need to be made. Each session ends with homework assigned, which is then reviewed at the beginning of the next session. CBT is based on treatment plans that are clearly conceptualized and tested theories that guide the clinician through each action, session, and overall plan of care.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

BACKGROUND INFORMATION

Cognitive therapy “is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient” (Beck & Weishaar, 1986, p. 43). The basic premise is that depression is the result of cognitive distortions (CDs) and these distortions are learned errors in thinking. It is generally agreed that CBT evolved primarily from the work of Aaron T. Beck. Beck, originally trained in psychoanalysis, departed from psychoanalytic concepts as he studied Adler, Horney, and Sullivan. Beck concentrated on a person’s distortions in self-image, thereby creating a more systematic cognitive behavioral conceptualization of both psychiatric disorders and personality structure (Clark, Beck, & Alford, 1999). Through a series of studies on depression and suicidal thinking, Beck developed a systematic structuring of cognitive therapy with a blueprint of guiding principles and specific procedures to follow (Beck, 1976, p. 15).

During the 1970s, researchers began to apply behavioral theory to cognitive theories and strategies. Traditional behavior theory focused on guided experiments to shape measurable behaviors such as avoidance and suicidal ideation with little attention paid to the cognitive processes involved in the behavioral changes. For example, fearful responses were extinguished with exposure protocols. Meichenbaum (1977) and Lewinsohn (Lewinsohn, Hoberman, & Teri, 1985) began to incorporate these behavioral interventions within the cognitive theoretical structures and noted that this added depth, context, and deeper understanding to outcomes. Since then extensive research has demonstrated significant efficacy in the combined approach using cognitive techniques (i.e., cognitive restructuring) along with behavioral techniques (i.e., exposure therapy and relaxation training).

Cognitive therapy and/or CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). The model posits that dysfunctional (or maladaptive) thoughts relating to self, world, and/or others are rooted in irrational or illogical assumptions. The individual’s view of self and the world is central to the determination of emotions and behaviors and thus by changing one’s thoughts, emotions and behaviors can also be changed. In addition, CBT is structured hierarchically with cognitive processes understood in terms of primary and secondary thinking. Secondary thinking views the social and cultural world in determinate, positive, rational terms while primary thinking recognizes the indeterminate, negative, and irrational as a part of human action forever. Finally, CBT places significant importance on cognitive information processing and behavioral change. The resultant theoretical model combines features of traditional psychotherapy within a unique conceptual framework.

Clinical strategies are used to help the individual recognize the dysfunctional nature of their thinking patterns and to help the individual change their conclusions. Theoretical refinement of the model along with empirical testing has resulted in a consensus that it is the interplay among thoughts, feelings, and behaviors within one’s environment that results in psychopathology. Therefore it is imperative that interventions target all three foci in order to affect sustainable changes, cognition being the pivotal point.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

EVIDENCE-BASED RESEARCH

There have been many research studies validating the efficacy of CBT for both medical and psychiatric disorders as well as many mental health problems. See Table 8.1 for a selected list.

COGNITIVE TECHNIQUES FOR STABILIZATION

Specific techniques have been delineated that can be integrated by the APPN psychotherapist that assist in changing or modifying the patient’s thinking and behaviors. Cognitive therapy advocates guided discovery rather than directly challenging the patient’s views. There are times when it is necessary to be direct or even confronting such as in cases in which the therapist must intervene quickly. However, it is always best to be as collaborative as possible and to allow the patient to find the answers to their problems or dilemmas as much as possible. This minimizes debate and increases the sense of mastery and participation.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Socratic Dialogue

The Socratic dialogue (SD) is a technique described as “mutual discovery in which the therapist guides the patient through a series of questions and answers to elicit automatic thoughts and assumptions, and examine the logic and evidence that relates to them” (Leahy, 2001).Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

TABLE 8.1 Evidence-Based Research for CBT

Medical Disorder Citation
Tinnitus Andersson et al. (2005); Hesser et al. (2012)
Chronic pain Bogduk (2004); Skinner, Wilson, & Turk (2012); Thomas (2005); Thorn (2004)
Premenstrual dysphoric disorder (PMDD) Hunter et al. (2002); Lustyk et al. (2009)
Sexual dysfunction Hoyer et al. (2009); Nofzinger et al. (1993)
Chronic insomnia Espie, Inglis, & Harvey (2001); Mitchell et al. (2012)
Chronic fatigue syndrome McCrone et al. (2012); Price & Couper (1998)
Myocardial infarction Delisle et al. (2012)
Depression DeRubeis et al. (2005); Hollon et al. (2006); Jakobsen et al. (2011)
Anxiety and panic disorders Coull & Morris (2011); Heldt et al. (2005); James, Soler, & Weatherall (2005); Klinger et al. (2005); Ost, Thulin, & Ramnero (2004); Persons et al. (2005); Stanley, Diefenbach, & Hopko (2004)
Eating disorder Glisenti, Kevin, & Esben Strodl (2012); Leung, Waller, & Thomas (2000); Pike et al. (2003)
Personality disorders Bhar et al. (2012); Leichsenring & Leibing (2003); McMain et al. (2012)
Substance misuse disorders Sobell & Sobell (2011); Tyrer et al. (2003); Tyrer et al. (2004)
Marriage and couple problems Dattilio & Epstein (2005)
Posttraumatic stress disorders (PTSD) Bisson & Andrew (2005); Chard et al. (2010); Hinton et al. (2005); Karlin et al. (2010); Otto et al. (2003); Paunovic & Ost (2001); Taylor et al. (2001)
Self-injurious behaviors Riaz & Agha (2012); Tyrer et al. (2003)Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
Obsessive–compulsive disorder Benazon, Ager, & Rosenberg (2002); McLean et al. (2001); Olatunji et al. (2013); Piacentini et al. (2002); Rufer et al. (2006); Whittal, Thordarson, & McLean (2005)
Schizophrenia and schizophrenic symptom reduction Hofmann et al. (2012); Jones, Cormac, Silveira da Mota Neto, & Campbell (2004); Rector & Beck (2001, 2002); Turkington et al. (2004)
Health anxiety (Hypochondriasis) Bouman & Visser (1998); McManus et al. (2012)
Antisocial behaviors Kazdin, Marciano, & Whitley (2005)
Sexual offenders Yates (2003)
Borderline personality disorder (using a DBT approach) Binks et al. (2006); Kliem, Kröger, & Kosfelder (2010); Neacsiu, Rizvi, & Linehan (2010)

DBT, dialectical behavior therapy.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Socratic methods are radically different from psychodynamic schools and nondirective styles of therapy technique (Freeman, 2005). The former synthesizes the patient’s information and the therapist interprets it back to the individual encapsulating intentions, motivations, and conflicts (Freeman, 2005). Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay.The therapist’s interpretations are thought to lead the person to insight, integration, and eventual change. In contrast, SD involves the therapist asking specific questions derived primarily from restatement of the individual’s own words as the major technique leading the individual to self-discover insight leading to subsequent changes (Freeman, 2005).

TABLE 8.2 Socratic Dialogue

  1. History questions: How many children did you have in your first marriage? (non-SD)
  2. Memory questions: (remembering that the individual’s recall is influenced temporally, interference and “facts” being considered inconsequential) When did you first notice that your sleep patterns had changed?
  3. Translation questions: (asks the patient how the data refers to the individual) When you say you become anxious, explain to me what it feels like to feel anxious to you.
  4. Interpretation: (helps the patient identify relationships between facts and experiences) How does your sensitivity to criticism play out with your husband?
  5. Application: (asks the individual to apply previously mastered skills to a new situation) How can you use what you learned with your boss in your discussion with your son?Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
  6. Analysis: (requires breaking a problem into a number of parts) What evidence do you have to support this conclusion?
  7. Evaluation: (asks the individual to make decisions/judgments based on data) On a scale of 0 to 10, where would you rate your level of anxiety today? And how does that compare to 4 months ago?

There are basically seven types of questions involved in the SD: memory, translation, interpretation, application, analysis, synthesis, and evaluation. It is a series of well-placed questions that literally guide the patient to the expected response, rather than simply pointing out the answer to the individual. It is a much more powerful technique to have the individual find the answer for themselves than to direct the individual. Table 8.2 describes the types of questions used in the SD method of therapeutic interaction (Freeman, 2005).

Table 8.3 illustrates the basic rules for SD adapted from Freeman (2005) used in conjunction with the types of questions described on the following page.

DOWNWARD ARROW

This technique was first used by Beck in 1979 to refer to the technique of logical sequencing of reasoning. The individual is helped to uncover underlying assumptions in logic and sequence through careful questioning by the therapist asking, “If this is true, then what happens?”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. For example, Mrs. Jones, a successful attorney, was concerned that a staff member she was having problems with would undermine her practice if she terminated her even though she and this woman had not been able to work out their differences for months. The APPN asked her what specifically would happen if she fired Jane.

  Mrs. Jones: She would bad mouth me to her friends at the courthouse and that would give me a bad name!
              Therapist: And how would that affect your practice?
              Mrs. Jones: Everyone would believe her and I have a lot of clients that work at the courthouse!
              Therapist: And how many of those clients do you have at the courthouse?
              Mrs. Jones [thinking]: I guess about 15.
              Therapist: And how many clients do you have in your practice?
              Mrs. Jones: About 250.
              Therapist: And how many of the 15 at the courthouse would believe Jane and drop you?
              Mrs. Jones [laughing]: Okay, about 2 or 3 maybe.
              Therapist: So, if you fired Jane, 2 or 3 clients out of 250 would possibly drop you.
              Mrs. Jones: Yes, I guess I do this all the time! I’ve been making myself nuts over nothing!

IDIOSYNCRATIC MEANING

The therapist assists the patient to clarify statements and terms used so that both the therapist and the patient have a clear understanding of perceived reality.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

For example, Mr. Smith says, “When she makes those little faces it just puts me out! You know what I mean.” Therapist: “No, I don’t know what you mean. Please explain what you mean by ‘puts you out’.”

TABLE 8.3 Socratic Dialogue Basic Rules

  1. The techniques are embedded in the collaborative dialogue and are goal directed and specific.
  2. The therapist has a problem list that generates the plan of direction that begins the SD process. SD is not a series of drifting questions that “follow the patient.” Each question must be strategically placed in order to reach the predefined goal. This is where the concept of “guided discovery” comes from for the therapeutic interaction.
  3. The questions must be short, focused, and targeted. For example, “Do you experience difficulty agreeing with your husband?” “Is this similar to interactions with others?” “How does this play itself out in this situation?” “Can you think of another way to respond that may result in a less defensive response from him?”
  4. The questions must progress in a manner that keeps anxiety at a minimum for the individual.
  5. The SD questions should be framed in a way to elicit an affirmative response. For example, to a reluctant individual: “There are probably a lot of places you would rather be than here, right?”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
  6. The additional point to the above is that negative responses to questions mean that the therapist must reframe the question to gain an affirmative response. “Is it your idea to come to therapy today?” “No! I don’t want to be here!” “There are probably a lot of things you would rather be doing today than sitting here.” “Yeah! That’s for sure!”
  7. The therapist must monitor the patient’s reactions and moods on an ongoing basis. If a question increases a reaction, the therapist needs to address it immediately. “What just happened—I noticed a reaction—what was that?”
  8. The therapist must pace the questions to suit the individual’s mood, style, and content of information.
  9. The questions must be planned and in logical sequence. The therapist must have an internal map for the session and move the session in a planned direction toward the desired goal.
  10. The therapist must be careful to self-monitor and not “jump in” to offer interpretations or solve the patient’s problems. This is not only more respectful to the patient but it also allows for greater clarity.
  11. Self-disclosure should be extremely limited and only used with extreme caution and great care as to the motive for the disclosure. Comparing what the therapist did or does with what the patient did or does moves away from SD into discussion and possibly misjudgment.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
  12. The therapist may use everyday experiences as therapeutic metaphors. For example, this author uses Aesop’s Fables and other well-known story characters to make a point such as “sour grapes” that can elicit both content and affect.

TABLE 8.4 Cognitive Distortions

   All or nothing I’m either a success or a failure.
   Mind reading They probably think that I’m incompetent.
   Emotional reasoning Because I feel inadequate, I am inadequate.
   Personalization That comment must have been directed toward me.
   Global labeling Everything I do turns out wrong.
   Catastrophizing If I go to the party, there will be terrible consequences.
   Should statements I should visit my family every time they want me to.
   Overgeneralization Everything always goes wrong for me.
   Control fallacies If I’m not in complete control all the time, I will go out of control.
   Comparing I am not as competent as my coworkers or supervisors.
   Heaven’s reward If I do everything perfectly here, I will be rewarded later.
   Disqualifying the positive This success experience was only a fluke. The compliment was false.
   Perfectionism I must do this perfectly or I will be criticized and be a failure.
   Time tripping I screwed up my past and now I must be vigilant to secure my future.
   Objectifying the subjective I have this belief that I must be funny to be liked, so it is fact.
   Selective abstraction All of the good men are taken or gay.
   Externalization of self-worth My worth is dependent on what others think of me.
   Fallacy of the change of others You should change your behavior because I want you to and it will immediately make me happier/feel better.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
   Fallacy of worrying If I worry about it enough, it will be resolved.
   Ostrich technique If I ignore it, maybe it will go away.
   Unrealistic expectations I must be the best absolutely all of the time.
   Filtering I must focus on the negative details while I ignore and filter out all the positive aspects of a situation.
   Being right I must prove that I am right as being wrong is unthinkable.
   Fallacy of attachment I can’t live without a partner. If I was in a relationship, all of my problems would be solved.
   Fallacy of perfect effect If I do things perfectly, the results will be perfect.

LABELING OF DISTORTIONS

Individuals are helped to identify automatic thoughts that are “dysfunctional or irrational” as a type of self-monitoring for more accurate descriptives.

See Table 8.4 for examples of CDs. Patients are initially asked to choose four or five of their “favorite” CDs in their first session and to bring this information to the next session. This information is then integrated into future sessions as educational material as it is noticed in the patient’s verbalizations and/or written information. The patient is stopped and asked to “notice” what he or she has said (thought) and encouraged to reframe the information.

Other examples of distorted automatic thoughts are also “caught” and similarly restructured as needed.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

QUESTIONING THE EVIDENCE

This technique assists the individual in questioning the facts related to their cognitions and conclusions. This procedure investigates whether their information is based on facts or assumptions. For example, Mr. Hanson has been struggling with intimacy issues with his wife and reported that they had “finally” had sexual intercourse after 2 years of abstinence. He was very happy that this had occurred but was upset because he was sure she was not satisfied with the experience. Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay.The therapist stopped him at this point and asked him for his evidence to this fact. He said he just “knew.” The therapist did not let this statement stand as evidence and helped Mr. Hanson review the basis for his conclusion. After the review, Mr. Hanson reported that his wife had said that she was happy and felt “good.” The therapist said “So you think she lied to you?” Mr. Hanson said “No.” The therapist said, “Well either she lied to you or she felt happy, which do you think was true?” Mr. Hanson replied, “I guess she was happy.” He then smiled.

EXAMINING OPTIONS AND ALTERNATIVES

This technique involves the development of all possible alternative explanations in order to learn the skills in generating options rather than “only one way” thinking. For example Mrs. Umber was going to visit her son and daughter-in-law whom she did not get along with very well. She said, “I just can’t stand the idea of spending a whole week with them!” The therapist said, “How did you choose to spend the entire week?” Mrs. Umber said, “Well it is clear out on the coast so if we are going clear out there it doesn’t make sense to only go for a weekend.” The therapist said, “What are your options?” Mrs. Umber replied, “I am not sure what you mean.” “You are going to the coast for a week; do you have to spend the entire week with your son?” “I hadn’t thought about that,” said Mrs. Umber, “I guess I don’t, do I!” With that revelation she began to explore the possibilities of shortening her visit with her son and instead having a brief vacation with her husband in addition to the visit with her son.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

REATTRIBUTION

In individuals with the habit of accepting all or most of the blame for outcomes, this is an excellent technique for redistribution of responsibility. This is also helpful for individuals with personality disorders that place the blame squarely on the shoulders of others for most outcomes. Mrs. White: “I can’t believe he left me! I am such a loser!” Therapist: “You were married to him for 22 years and he had five affairs that you knew of. You yourself said that you were more there for him than any other woman would have been.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. How is that being a loser?” “I know, I just feel like a loser!” Therapist: “What was his part in this break up?” Mrs. White: “I guess he had some of it, but maybe if I wasn’t such a loser he wouldn’t have had all of those affairs.” Mrs. White has a way to go here but she has opened the door to the possibility that her husband played a part in the ending of her marriage. The therapist can now work with her in identifying the component parts of her husband’s responsibility and hers.

DECATASTROPHIZING

Catastrophic thinking is one of the hallmarks of anxious individuals. These individuals tend to focus on the most negative possible outcome of any given situation. Decatastrophizing allows for balance and realistic focusing by examining the “worst possible outcome” and developing a plan of action. For example, a young woman complains that she can’t sleep.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

 

              Women: I haven’t been able to sleep for 2 months! If I can’t get some sleep I won’t be able to stand it! I can’t live like this!
              Therapist: Take a deep breath and tell me what is the worst thing that would happen if you can’t sleep.
              Woman: I can’t live like this!
              Therapist: But what would happen if you continue to not sleep?
              Woman: I would walk around like a zombie!
              Therapist: Have you been to your doctor for sleeping medication?
              Woman: No! I am worried I would get addicted!
              Therapist: What would be worse, not sleeping or getting addicted?
              Woman: Not sleeping.
              Therapist: Do you think your doctor would let you get addicted?
              Woman: No, she has known me for years. She is really careful.
              Therapist: Would you let me call from here and get you an appointment today for an evaluation for medication?
              Woman: Yes. I guess I am really overreacting because I am so tired!

ADVANTAGES AND DISADVANTAGES

For individuals who appear to be stuck between two options, examination of the advantages and disadvantages of certain situations helps them to develop alternative perspectives. This breaks the “all-or-nothing” mindset and permits a more balanced view of the situation. For example, Mr. Black is wondering whether or not to accept a promotion at work that means more money but more travel and time away from his family. The therapist may help him outline a list of advantages and disadvantages in a cost–benefit analysis similar to what he may do at his job that looks familiar to him so that he can “weigh” out his choices by placing points next to each choice and then total the categories to help him decide.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

PARADOX OR EXAGGERATION

This type of technique should only be used by the very skilled therapist; otherwise the patient may view this technique as sarcasm or belittling. When used appropriately, the therapist takes an issue to the extreme to help the person see the absurdity of their sometimes overinflated viewpoints. One therapist had been working with a couple for a number of months. The couple had originally come in with issues related to his obsessive–compulsive tendencies for neatness and her tendency to be a free spirit. They had reached a number of compromises and were now very happy. Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay.At one point in the session they were talking about putting in a garden area and were having difficulty deciding how to organize the arrangements. The therapist said to the couple: “Oh my goodness! He wants the plants in rows and to be neat and orderly! Where on earth would he get an idea like that?” The couple realizing that this exactly matched his style immediately started laughing.

TURNING ADVERSITY TO ADVANTAGE

This technique is akin to making lemonade out of lemons. The individual is helped to identify how to use what appears to be a negative situation to his or her advantage. For example, being turned down for a job may open the individual up for more attractive possibilities that had not been investigated previously.

COGNITIVE REHEARSAL

Prior to making a behavioral change, it is sometimes less threatening to “practice” the new behavior through visualization and discussion. For example, this would include practicing assertiveness in a mirror or “talking through” a confrontation out loud prior to actually following through with the conversation.

AUTOMATIC THOUGHT RECORDS

The automatic thought record is a key component of CBT. The record was first introduced by Beck in 1979 to capture and analyze automatic thoughts both during and between sessions (Beck, Rush, Shaw, & Emery, 1979). The automatic thought record is used as homework after introducing the process within the therapy session. The individual completes the columns, identifying a troubling situation, resulting emotion, and thoughts associated with both. The therapist and patient work on clarification and development of “rational” responses in order to debate or challenge the original reaction. When practiced and repeated, the process of clarification and debate becomes internalized in the individual. See Appendix 8.1 for a copy of a form for an automatic thought record.

THOUGHT STOPPING

This is one of the simpler techniques in CBT. Basically the patient interrupts his or her stream of thought with a sudden stimulus such as snapping a rubber band on the wrist, saying “Stop it!” out loud, or some other real or imagined stimulus and then changes his or her stream of thought. The technique is most credible when demonstrated to the patient in session and then assigned as homework. OncCognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essaye a patient is given a loud stimulus in a session, such as “Stop it!” and then allowed to regain composure and report what his or her thought pattern is after the stimulus, the person realizes that this simple technique is very effective.

COGNITIVE RESTRUCTURING

The process of cognitive restructuring refers to the use of an automatic thought record combined with other cognitive techniques to effect changes in negative thinking patterns. The patient is asked to check in a few times a day at random times and write down what he or she is thinking. After keeping the automatic thought record for a week, the therapist and patient review the log and underline which thoughts are negative and identify the CDs the patient uses (see Table 8.4). Then the patient is asked to say the negative thoughts aloud to enhance awareness and to slow them down and say out loud to himself or herself the targeted negative messages whenever they occur during the next week. A list is then generated with the patient that counters those distortions. For example, one patient who was anxious about going to an upcoming social event became aware that her negative thoughts reflected her poor self-esteem: “I will have a terrible time since nobody likes me.” The positive comment developed to counter this was: “People usually like me.” The patient was asked that whenever she found herself thinking the negative thought in the next week that she practice thought stopping and substitute her positive statement from her list of positive statements that she carried with her. See Table 8.5 for steps in cognitive restructuring.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

TABLE 8.5 Steps in Cognitive Restructuring

  1. Tune in…keep a thought diary
  2. Focus on the words that are unhealthy
  3. Stop the messages
  4. Change the negative to positive

BEHAVIORAL TECHNIQUES

Assertiveness Training

Assertiveness training involves a combination of cognitive and behavioral practice. Prior to beginning an assertiveness training program, the advanced practice registered nurse (APRN) therapist needs to define the terms “assertive, aggressive, and passive.” For example, a person who is demanding, blunt, and self-righteous may perceive his or her behavior as assertive when in fact it is aggressive. In this type of a situation, the therapy starts by educating the individual in the importance of modifying the confrontational style. Most individuals with depressive disorders tend to exhibit more passive behaviors and would require education on assertiveness as opposed to aggressiveness in order to make the idea of assertive changes more appealing.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay The therapist may, for example, model assertive behavior, assist the patient within the session with role-play, and finally develop in vivo experiments that increase in complexity over time until the new behavior is internalized. A basic textbook for patients with assertiveness issues is Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky (1995). It is an excellent general workbook and reviews CBT techniques with helpful homework examples and information.

Behavioral Rehearsal

The behavioral component usually follows the cognitive training component and again includes behavioral experiments to gather more evidence or to develop more effective responses and styles. Rehearsal is usually practiced first in the therapy session itself often with role playing and then as often as possible outside of the session. The person then reports back in the following session for modification of the behavior if necessary. For example, Kevin, a 15-year-old male, often gets into arguments with his 6-year-old brother, Galen. The arguments usually stem from Galen “getting into my stuff” according to Kevin. After exploring the purpose of Galen’s behavior (obtaining attention from Kevin), Kevin was encouraged to increase positive exchanges when Galen was not expecting it. This was practiced in session until Kevin felt comfortable with the modified exchanges. Initially Kevin stated, “I can’t do that, I’d feel dumb being nice to him! He’s a kid!”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay In order to help Kevin feel more comfortable with specific things to say and do, the therapist and Kevin explored possible exchanges and then put them into “play” in the therapy setting. The rehearsal repeated until Kevin reported, “Okay, I can do that—that’s cool.” In situations where the APRN is assisting the individual using this technique, it is important to evaluate for safety as well as understanding of behavioral boundaries. In the example above, the therapist would problem solve possible outcomes to prepare Kevin for responses as well as set boundaries with him regarding potential aggressive interchanges.

Contingency Management

Contingency management is based on the systematic application of generally accepted principals of human behavior. An undesirable behavior is more likely to recur if it is immediately followed by some kind of reinforcer that is pleasurable (positive reinforcement). Positive reinforcers or rewards are more effective at changing behaviors than punishment (aversive reinforcement). An example of an aversive stimulus is punishing the child who does not behave. Negative reinforcers are those that increase the probability that a behavior will recur by removal of an undesirable reinforcing stimulus.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay For example, if the child behaves, the child does not get scolded. The use of contingency management is very useful for individuals with self-control problems because it provides a self-motivator for internal motivation of control. It generalizes well, which means it can be used in a variety of setting such as home, school, work, and social settings.

For example, in substance misuse settings, reinforcement is usually in the form of vouchers exchangeable in the form of groceries or other goods, services such as self-care, transportation, or health care, and sometimes local retail services. The reinforcers target abstinence behaviors such as attendance, adherence to treatment goals, compliance with medication, participation in therapy, abstinence from substances, and completion of therapy. It is important to evaluate the value of the reinforcer to the individual.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay The likelihood of the reward effectiveness increases with the perceived value of the reward. Lamb and colleagues discovered that higher payment amounts and the easier target criterion resulted in a higher likelihood of participants meeting the criterion (Lamb et al., 2004).

A contingency contract is a more formalized written agreement that is developed in collaboration with the person and/or significant other in order to explicitly state the positive and negative reinforcers for performing the desired behavior as well as aversive reinforcers for failure to perform the behavior. Suitable targets are those behaviors that are observable. See Table 8.6 for a checklist to assist the therapist in developing a contingency contractCognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. The steps below should be sequential because if secondary gains are not identified (see Item 4), the individual will not be able to accomplish the desired behavior. Often, secondary gains are unconscious and should be explored with the patient prior to beginning the subsequent steps.

TABLE 8.6 Checklist of Patient Outcomes for Contingency Contract

  1. Identify target behavior
  2. Explore reasons for behavior
  3. Verbalize knowledge of consequences of behavior
  4. Identify secondary gains from behavior, i.e., attention
  5. Keep diary of when problem behavior occurs
  6. Keep log of sequence and pattern of behavior (who, what, when, how, and why)
  7. Identify feelings that precede and follow behavior
  8. Keep diary of behavior and feelings
  9. Identify alternatives to behavior
  10. Write conditions under which desired behavior will occur and how behavior will be observed and measured
  11. Select positive reinforcers, i.e., weight loss and rewards
  12. Select aversive consequences for failure of desired behavior, i.e., chores
  13. Carry out plan for one week
  14. Practice desired behavior, step by step
  15. Keep diary of practice
  16. Involve family/friends in feedback/encouragement
  17. Identify other positive aspects associated with changed behavior
  18. Monitor ongoing weekly progress

Reprinted from Dykes and Wheeler (1998).

Bibliotherapy

The CBT therapist will often prescribe specific readings related to the individual’s difficulties. Readings and references can be given to the patient of the many CBT-based self-help books as an adjunct to in-session work. A full list of readings and CBT-based self-help books can be found on the Academy of Cognitive Therapy website at www.academyofct.org. The website is updated regularly to include the most relevant and up-to-date titles for both clinicians and patients.

Guided Relaxation and Meditation

Therapists often employ behavioral techniques aimed at reduction of autonomic nervous system responses to anxiety. These include deep breathing, relaxation training, meditation, and other exercises. These techniques help the individual to distract oneself from the upsetting thoughts, increase awareness of conscious control over breathing, heart rate, and other anxiety symptoms and thoughts. The individual may be assisted in “overbreathing” as a way to demonstrate control over “hyperventilation.” This technique should be used only by the experienced therapist. One very brief relaxation exercise is to have the patient breathe in deeply for 5 seconds, breathe out for 5 seconds while saying: “Relax … relax … relax” in a soothing tone. I recommend that patients practice this easy exercise a minimum of 10 times daily until they find they are able to do it almost automatically.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Social Skills Training

These skills are often taken for granted by many individuals. It is therefore important for the therapist to review and instruct on behaviors that will improve the potential for successful social interactions. For example, a therapist may notice that the patient looks at the floor or the ceiling during their conversation or when introducing themselves. The therapist may make use of this information by role-playing skills such as maintaining eye contact during an interview, shaking hands assertively, developing techniques for self-expression, and conveying opinions as well as overt changes such as appropriate language in public.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Shame-Attacking Exercises

This technique was first introduced by Albert Ellis, the father of rational emotive therapy (RET). In this type of therapy, the therapist engages the individual in exercises that emphasize his or her concern for what others think of him or her. For example, a person who is afraid of drinking soup in public may be assigned the task of going to a restaurant with a friend, ordering soup, and drinking it loudly while the friend makes note of how many people are really interested in what they are doing.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay They would then have their friend share the notes on the actual responses of the other diners as a way to disarm the person’s irrational belief that others are looking at him or her eat, slurp, and so on.

Homework

The hallmark behavioral technique in CBT is the use of homework assignments. Activities, some of which have been described above, are designed within the therapy session to be carried outside and practiced in between sessions. The self-help designed assignments reinforce and continue what has been learned and addressed within the therapy framework. This results in a truly collaborative process between the patient and the therapist. For example, the therapist may develop a homework plan for deep-breathing exercise practice, role-play practice on how to act in a certain social situations or in cases of alcohol misuse, practice ways to decline an alcoholic beverage.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay New, redeveloped, or revised rational responses are practiced until they replace previous, unhealthy responses. Homework also allows individuals to “try on” and experiment with new skills in order to give feedback to the therapist on which techniques work and which do not work. Techniques that do not work can then be modified or discarded as needed.

Psychoeducation

Psychoeducation is an integral component of all CBT techniques. In CBT, the educational component is skillfully interwoven within the specific therapeutic techniques that the therapist is choosing and supplemented with bibliotherapy if that is appropriate. For example, a couple came for marital therapy following the husband’s serial episodes of infidelity. The husband was not sure about whether to remain in the marriage or to leave his wife and two teenage sons so that he could continue to have serial affairs without guilt and restrictions. The therapist assigned two specific books to read: After the Affair by Janis Abrahms Spring (1997) and Not Just Friends by Shirley Glass (2003)Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay. In addition, the therapist used the SD to guide the husband through a cost–benefit analysis of each choice making sure to help him focus on the realities of the cost and benefit to the decision to leave versus the decision to stay. After completing the cost–benefit list, the therapist pointed out that he had not identified any costs to his sons as far as lessons learned from him about how men treat women and families with respect to responsibility (education). The next step was to help the patient self-identify that he had missed this component and discuss how he might be teaching his sons lessons that are unhealthy and explore his thoughts about this consequence. The focus on consequences became a focus of his therapy, not as a “blaming session” but a moment of education and self-identification of behavioral consequences of actions.

MODIFICATIONS OF CBT

Schema Therapy

Schemas develop early in life based on an individual’s experiences with others and their environment. Schemas are fundamental core beliefs or assumptions and are part of the perceptual filter people use to view the world. People are guided by templates, or schemas, through every action, reaction, and interaction based on their own developmental, personal, religious, familial, cultural, gender, and age-related experiences (Beck, Freeman, & Associates, 1990; Beck, Freeman, Davis, & Associates, 2003; Beck et al., 1979; Freeman & Freeman, 2005). Schemas are in a constant state of change and adaptation and become increasingly complex as one ages. Although schemas are alterable, the process of accommodation and adaptation may serve to help or hinder the individual when he or she applies the schema to new situations or functions that come his or her way.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay For example, those with an abandonment/instability schema would be plagued by thoughts about the unreliability of those available for support and connection and may have borderline personality traits while those with a social/isolation/alienation schema would have thoughts of being different from the rest of the world and might suffer from schizoid traits. Schemas are selected for recall or activated from memory and are used for interpretation of information, generation of affect, motivation, and action, and/or control (Beck et al., 1990; Freeman & Freeman, 2005). Understanding an individual’s schemas, belief systems, and underlying attitudes is essential in understanding the individual (Freeman & Freeman, 2005). See Table 8.7 for maladaptive schemas.

TABLE 8.7 Maladaptive Schemas

Young proposed that early schemas are more resistant to change than schemas that develop later in life (Young, 1991). He identified these schemas as Early Maladaptive Schemas. According to Young: “In comparison with standard cognitive therapy, schema therapy probes more deeply into the childhood origins of distorted thinking, relies more on imagery and emotion-focused techniques, and is somewhat longer-term” and is often combined with traditional cognitive therapy (Young, Klosko, & Weishaar, 2003).Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay For example, Young uses the CBT technique for identifying whether the patient is using an emotion that is adaptive or maladaptive to guide the patient’s decision making and cognitive processing and then assists to facilitate the identification of beliefs that block the process of change. Images are powerful forms of cognitions and long before we develop language, we develop memory encoded as pictures or images. Schema therapy is, and has been, a critical component of classical CBT.

Young uses many of the CBT techniques of guided imagery, imagery rescripting, imagery substitution, or even cognitive restructuring of images to reframe the view of an image to something more positive, less distressing, or even useful for a patient. See the website www.schematherapy.com for more information.

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Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a multimodal cognitive behavioral treatment developed by Dr. Marsha M. Linehan to work with subgroups of those diagnosed with borderline personality disorder (BPD), specifically those who abuse substances (Linehan, Tutek, Heard, & Armstrong, 1994). DBT works very well in the subset of Cluster B personality disordered patients, which includes those viewed as dramatic–emotional such as antisocial, borderline, histrionic, and narcissistic individuals (Linehan, Heard, & Armstrong, 1993). DBT has recently been modified for those who have both BPD and eating disorders (ED) (Linehan & Chen, 2005). Please see Chapter 14.

COGNITIVE TECHNIQUES FOR PROCESSING

Evidence-based CBT interventions for processing include those that involve exposure components through flooding, prolonged exposure, in vivo exposure, directed exposure, interoceptive exposure, and imaginal exposure. Exposure involves confrontation with the feared stimulus with prolonged excitation of the fear response until habituation and then extinction of the fear response in the presence of the trigger when it occurs.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay Deciding which exposure component to use depends on the person’s presenting problem as various methods for exposure have been developed. If the person suffers from panic anxiety, interoceptive exposure should be considered. This involves exercises such as stair stepping and head shaking that bring on panic-like symptoms. If the person does not suffer from panic, imaginal exposure through writing or talking about the trauma is appropriate.

Exposure or prolonged exposure involves the ongoing systematic activation of the fear response until extinction or desensitization occurs. The process may involve specific or nonspecific environmental cues in reality (in vivo) or through imaging. It can be likened to watching a scary movie over and over again until it no longer creates hyperarousal and fear.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay For example, when an individual experiences fear of an object, he or she tends to avoid it. Avoidance or escape from the phobic object results in a temporary reduction in anxiety. As a result the individual’s coping choice is reinforced through negative reinforcement. In prolonged exposure, the therapist uses a process of systematically desensitizing the individual to the avoidance pattern by gradually exposing the individual to the phobic object (either virtually or actually) until it can be tolerated without disabling anxiety.

Prior to beginning the desensitization process, the therapist and the individual explore alternative cognitive strategies such as distraction to cope with anxiety. This helps the individual build a set of tools to control fear. After the individual has mastered alternative responses, he or she is gradually exposed to the feared object. Someone who has a fear of contamination, for example, would be assisted in developing a fear hierarchy with individual situations rated on a scale of “10” (worst possible exposure) to “1” (very limited exposure). The therapist and the individual practice with increasingly unpleasant situations: a sink at a public restroom to a visibly contaminated or a smelly outhouse, for example.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay At each step in the progression, the patient is desensitized to the fear through the use of the coping technique. The person realizes that nothing bad happens to him or her, and the fear gradually extinguishes. For example, a person with a fear of attending classes may begin with driving around the school, then gradually moving up to touring a classroom both empty and filled, before actually signing up for and attending a class.

The patient is guided through mastery of relaxation sessions and then gradual mastery of each level of the hierarchy until he or she is ready to master the actual situation in vivo. For example, a psychologist, Dr. J, came to treatment for an inability to drive over bridges without significant anxiety after suffering a seizure while he was driving several friends in the car.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay Six months previously he had been diagnosed with a brain tumor after suffering a seizure. Dr. J had surgery and the tumor was removed without complications and he had not needed radiation or chemotherapy. He was now on anticonvulsant medication and reported that his surgeon felt he had a good prognosis and suffered no residual neurological deficits. See Table 8.8 for the hierarchy constructed and how this was paired with relaxation and imagery.

TABLE 8.8 Hierarchy for Driving Fear of Bridges

  1. Thinking about going in the car if he has to go across a bridge
  2. Imagining driving across the bridge (pick a specific bridge)
  3. Getting into the car with the idea you are going driving
  4. Drive the car for about 2 to 3 minutes with image of the bridge
  5. Riding in the car to a bridge with a friend driving, do not drive over the bridge
  6. Riding in the car with a friend driving and going over a small bridge
  7. Driving the car with a friend and getting off the exit before the small bridge
  8. Driving the car with a friend and going across the small bridge
  9. Driving the car alone and going across the small bridge
  10. Driving the car alone and going over a slightly larger bridge
  11. Repeat with larger bridges

After constructing this hierarchy, Dr. J practiced deep-breathing exercises in sessions guided by the therapist along with a safe-place exercise (see Appendix 1.7 for safe-place exercise). He was asked to practice these exercises at home during the week every day for 15 to 20 minutes. At his next session, he was asked to visualize himself at 1 in his hierarchy of fears, thinking about going in a car over a bridge with as much vividness and detail as possible, as if he was “right there” but imaging himself as confident and calm, dealing with the situation as he would like to. He was asked to stay with the fear thought for about 1 minute and then was asked to rate his anxiety on a 1 to 10 scale with 10 being the worst and he responded that it was a 2. He was then asked to repeat a calming affirmation “I am calm and at ease” while picturing himself handling the situation in a calm and confident manner while deep breathing. Returning again to Item 1 on his hierarchy, he was now able to proceed and was asked to spend about a minute in his safe place scene so that he could get fully relaxed. Then 2 was imaged in the same way, repeating the fear and alternating with the safe place (about a minute each). If the client experiences greater than a 4 on a 0 to 10 scale with the fear, he or she should stay in the image for only 10 seconds and retreat to the safe place until he or she is relaxed. Continue guiding the client step by step in imagination from the safe place to the fear. It may be necessary to add another step that is intermediate if the client has difficulty proceeding. The person should be comfortable with the previous step before going onto the next one. The APRN must remain sensitive to the individual’s response pattern in order to prevent traumatization or increasing anxiety. Dr. J was able to work through this exercise and could then transfer this learning in vivo.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

APPLICATION OF CBT TO COMMON PSYCHIATRIC DISORDERS

CBT has been applied and developed for specific problems and populations such as depression, anxiety, personality disorders, and substance misuse patients.

Cognitive Model for Depression

The cognitive model of depression emphasizes the cognitive triad to illustrate depression generation and maintenance. The premise is that individuals develop and then maintain a negative self-view, and this attitude extends to the world, their experiences, and on into the future. As a result they perceive themselves as worthless, abandoned, and inadequate. As depression takes hold, the individual feels overwhelmed with demands and seemingly impenetrable barriers, preventing the individual from realizing his or her goals. The world takes on a gray cast devoid of pleasure and is viewed pessimistically.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

CBT focuses on altering the person’s view of himself or herself, the situation, and the resources around him or her (Shaw, 1977). Therapy is structured, active, and reality based as well as time limited. The individual is taught to take certain specific steps to combat his or her depressive views. These steps include identifying and monitoring automatic thoughts, critical examination of evidence, substitution of objective interpretations for their automatic negative attributes, and recognizing connections between thoughts and feelings.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

For those who have been traumatized, numerous negative cognitions may be present, particularly those who have suffered from interpersonal violence. These include thoughts about self-blame, guilt, shame, low self-esteem, danger, defectiveness, and unworthiness (Briere & Scott, 2006). It is important that the client is able to describe his or her thoughts and perceptions related to the trauma. This can be accomplished through the narrative as well as through journaling about the event. The journaling can be assigned as homework occasionally during the course of therapy so that the client writes about a specific topic, recalling in as much detail as possible the event. The person is then asked to read it aloud to the therapist the following week. Using the Socratic method described above, the APPN can ask open-ended questions that allow the client to examine his or her interpretations about the experience. Briere and Scott list typical questions that might include:Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

“Did you have any thoughts while it (the traumatic event) was happening? What were they?”

“Given, the situation, do you think there was anything else you could have done?”

“So, that made you feel that you were to blame/responsible/bad/stupid/seductive. Can we go over what happened and see what made you think that?”

“Did you want him/her/them to rape/beat/abuse/hurt you? Do you remember ever wanting that?”

“You say that you were hurt/raped/beaten because you asked for it/were deductive/didn’t lock the door/were out late. Can we go over the evidence for that conclusion? Maybe it’s more complicated than that?”

“If this happened to someone else, would you come to the same conclusion?”

“It sounds like you believe what he/she said about that. Was he/she a person you would believe when he/she said something?”

“Why do you think he/she did that? Did he/she get anything out of it?”

(Briere & Scott, 2006, pp. 112–113)

Through the use of brain imaging techniques, researchers have discovered that cerebral blood flow in specific brain areas responded with equal vigor to both CBT treatment and pharmacologic treatments for both depression and anxiety disorders (Furmark, Tillfors, & Marteinsdottir, 2002; Goldapple et al., 2004; Nakatani et al., 2003; Paquette et al., 2003).

Cognitive Model for Anxiety

Anxiety is actually an adaptive survival strategy. When the body experiences or perceives a threat to survival, it prepares for flight, fight, or fleeing through activation of the autonomic nervous system. The nervous system activation is experienced as increased heartbeat, muscle tension, increased blood flow, and diaphoresis (to cool the body). If there is an actual threat, the individual is prepared to respond adaptively. If there is no threat, the individual interprets the symptoms as anxiety with the accompanying psychological response called “fear.” Anxiety symptoms that seem to come out of nowhere cause the individual to fear the onset of this uncomfortable experience. The individual scans the environment and may or may not locate something to attribute to the symptom activation. As more and more attributions of threat occur (e.g., bridge, heights, and public speaking)Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay, the person becomes more and more alert to potential activation. This sets the person up for a “fear of fear” response. The anxious individual distorts innocuous events, exaggerates the potential for harm, and develops behaviors that interfere with adaptive coping strategies. As the cycle increases in velocity, the individual believes that he or she is unable to cope and is therefore helpless against the anxiety symptoms. The best illustration of the efficacy of CBT for anxiety comes from the work of Barlow and Clark on the treatment of panic disorders (Barlow & Cerney, 1988; Clark, 1986; Clark, Salkovskis, & Hackmann, 1994). They observed the constellation of cognitive symptoms that team with behavioral symptoms to create a panic reaction/response in an individual. Through extensive research, they demonstrated that combining cognitive techniques to modify fearful cognitions along with specific behavioral approaches reduced or eliminated the panic response/reaction in most individuals (Barlow & Cerney, 1988; Clark, 1986; Clark et al., 1994).Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Cognitive Model for Personality Disorder

One of the hallmark treatments of personality disorders is CBT. Cognitive theorists and psychoanalysts have both agreed that it is imperative to identify and then modify “core” problems when treating individuals with personality disorders. The difference between the two theories lies in the perspective of the structure of personality disorder. Psychoanalysis believes that the structures are unconscious and therefore are mostly unavailable to the individual while the cognitive theories believe that the products and processes are within the realm of awareness and therefore more accessible. Dysfunctional behaviors, thoughts, and feelings, according to cognitive theory, are in large part due to the function of certain schemas (rules or patterns we have developed for living). These schemas consistently bias our judgments and create a tendency to skew our views, creating situations in which we tend to make cognitive errors and draw faulty conclusions (Beck et al., 2003; Freeman, Davis, & DiTomasso, 1992).Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

It is rare that an individual presents for treatment of his or her personality disorder. Instead the individual usually comes into treatment at the behest of some significant other or other external pressure. The individual may also come in for treatment of a secondary result of the outcomes of his or her behavior patterns such as depression, relationship difficulties, anxiety problems, or other issues. Often these individuals will see their problems as independent of their own behavior and describe themselves as victims with little to no idea as to how they got into these difficulties, how they contribute to their problems, and/or how to change. Others in their lives are well aware of the self-defeating elements of their behaviors (such as overdependence, lack of empathy, self-centeredness, inhibition, and drama) and may express frustration, dismay, or even incredulousness that the individuals do not see it themselves (Beck et al., 2003; Freeman et al., 1992). For additional information on this very interesting topic, the readers are referred to the current leading resource on the subject (Beck, Freeman, Davis, & Associates, 2003).Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Cognitive Model for Substance Misuse

The community reinforcement approach (CRA) has been developed for use with patients who abuse substances. Contingency management is a key component and interventions include social, recreational, familial, and vocational reinforcers in order to help the person through the process of abstinence and maintenance. Additional components in CRA include (1) functional analysis of substance use, (2) social and recreational counseling, (3) employment counseling, (4) drug refusal training, (5) relaxation training, (6) behavioral skills training, and (7) reciprocal relationship counseling. The National Institutes of Drug Addiction Therapy Manual recommends a reinforcement model that typically includes vouchers for behavioral outcomes such as clean urine drug screens, participation in treatment, and completion of the treatment program (www.drugabuse.gov/pdf/CRA.pdf). Vouchers are used as opposed to cash or saleable items to avoid triggering the individual’s craving response to cash (cash is usually associated with the ability to purchase substances). See Table 8.9 for therapist resources and websites for specific populations.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

CASE EXAMPLE

Bethany is a 44-year-old woman who has been married for 20 years to her step-uncle who raised her after her parents died and is 40 years her senior. She has no children and works as an attorney. She described her parents as distant, paying minimal attention to her while she was growing up. Her mother and father died when she was 15 and the loss was considered “a surprise and shock.” She has one brother whom she describes as “distant” and seldom available to her. Her brother lives at a significant distance from her, making contact difficult. She has occasional affairs, but they are less frequent and less pleasurable than they used to be.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany has had more than 10 years of treatment with medications as well as a variety of psychotherapeutic techniques for her self-reported depression and attention deficit disorder (ADD). Her Beck’s Depression Score at intake was 51 (out of 63 possible) and her Quick Inventory of Depression Symptomatology was 23 (out of 27 possible), both of which are in the severe range. She denied suicidal ideation or intent. There was no evidence of hallucinations, delusions, or cognitive impairment. She reported significant sleep problems with daytime somnolence. She stated that she used to be very productive, creative, and happy; however, she has not felt that way for a very long time.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay She was extremely tearful during the interview reporting feeling overwhelmed, hopeless, and exhausted. She felt extreme guilt that she had not been the kind of wife her husband deserved and wondered why he puts up with her. She was concerned she would lose her job due to her inability to concentrate and low productivity level. She felt unappreciated at work by her supervisor who told her she was the “least productive” member of the firm. Bethany stated that she had no energy, restless sleep, irritability, indecisiveness, and felt like a “total failure at life.” She has only one close female friend who has been unaware of her affairs.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany is very attractive and maintains good physical condition (however, she does not verbalize satisfaction with her self) and experiences moderate to severe pain related to fibromyalgia and arthritis. Treatment included several long-and short-acting opiate pain relievers as well as gabapentin (an anticonvulsant used for neuropathic pain relief).

Her diagnosis from previous and current psychiatrists included major depression, recurrent, severe ADD, nonhyperactive type. Medication attempts had included more than 10 different antidepressants (all noneffective) as well as several stimulants for treatment of her ADD. Laboratory tests were ordered including thyroid function tests, liver and kidney function tests, B12 and folate levels, electrolytes, and a complete blood count.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

TABLE 8.9 CBT Therapist Website Resources for Specific Populations

Population Specific Approaches and Website References for Additional Information
Addiction http://www.nida.nih.gov/TXManuals/CBT/CBT1.html
Therapy Manuals for Drug Abuse: Manual 2: A Cognitive-Behavioral Approach: Treating Cocaine Addiction. The manual includes chapters detailing history of CBT, components of CBT, applications of CBT to cocaine dependent individuals, relapse prevention, follow-up, and empirical support for the use of CBT in treating substance dependence as well as measures to evaluate competence in therapists using CBT.
Depression http://www.psychologyinfo.com/depression/cognitive.htm
Brief overview of treating depression by Psychology Information Online developed by Donald J. Franklin, PhD. Reviews the thoughts, feelings, and behaviors common to depressive diseases as well as the therapeutic interventions used in CBT to reverse the depressive cycle. Automatic thoughts are outlined as are specific ways to cope more effectively.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
Child sexual abuse http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135
Substance Abuse and Mental Health Services Administration Model Programs: Trauma Focused Cognitive Behavior Therapy Model Programs http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135
Anxiety and social anxiety http://www.socialanxietyinstitute.org/ccbtherapy.html http://www.anxietynetwork.com
Dr. Thomas Richards, director of the Social Anxiety Institute, has posted several excellent monographs on treating anxiety disorders with CBT on his websites. He discusses the cognitive, behavioral, and physical components common to these disorders in easy to understand terms. The reader is “walked” through the guidelines of the CBT process of treatment and referred to additional resources.
Obsessive–compulsive disorder http://www.ocdonline.com/definecbt.php
This website outlines the basic CBT treatment of obsessive–compulsive disorder. The explanation also includes a brief explanation of the integration of behavioral techniques used within the CBT framework to augment the total CBT therapeutic armament, thereby strengthening the overall treatment effect.
Eating disorders http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448
This website discusses CBT treatment of eating disorders, specifically self-image components, incorrect beliefs about the disorder, behavioral changes that the individual will be making (such as meal diaries), developing mastery over mood and other facets of their lives, and other very important components of the eating disorder spectrum. The outline also discusses expectations of treatment, length of treatment, relapse, and follow-up.
Chronic pain http://www.springerpub.com/prod.aspx?prod_id=45957
Cognitive Therapy With Chronic Pain Patients by Winterowd, Beck, & Gruener, Springer Publishing.
http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/caudill.htm&dir=trade/self&cart_id=456893.3089
Managing Pain Before It Manages You by Margaret Caudill
Both of these volumes are excellent adjuncts to the CBT clinician working with individuals with chronic pain conditions. They contain full explanations of the physiology of pain, the cognitions association with chronic pain as well as behaviors common to chronic pain sufferers. In addition they contain the techniques used in CBT to alter the thoughts, feelings, and behaviors that cripple chronic pain sufferers.
Schizophrenia http://www.psychologyinfo.com/schizophrenia/cognitive.htm
There is a misconception that CBT cannot be used with persons who are “too dysfunctional.” This is incorrect. In fact, CBT is very effective with individuals who are cognitively impaired. The therapist simply uses a greater number of behavioral techniques in these cases. In cases with individuals with schizophrenia, the therapist is often working with the family members in addition to the patient. Dr. Donald Franklin has a very brief discussion on his website of this type of treatment.
General information Wright, Basco, and Thase (2006).
Learning Cognitive-Behavior Therapy. American Psychiatric Publishing, Inc. Washington, DC http://en.wikipedia.org/wiki/Cognitive_behavior_therapy
Online encyclopedia definition and description of CBT available at: www.appi.org/pdf/wright

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The initial interview focused on eliciting her current impression of her problems, her view of her treatment history, and underlying beliefs regarding both of these issues. It was important to determine the psychodynamic impact regarding her lack of improvement over the past decade in order to evaluate the effect this had on her expectations for change, hope for improvement, and impact on motivation for another type of intervention. Care was taken to create a timeline of symptoms both historically and temporally. Information was documented using her own words whenever possible. Patient-generated metaphor, life rules, and conclusions were noted regarding her perception of her illness and its impact on her function, cognition, and outlook.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

For this patient, it was clear that several factors could be contributing to her depressive symptomatology. These factors are outlined below:

  1. 1.  Chronic pain. It is well known that patients with chronic pain disorders are susceptible to depression due to feeling trapped in the pain, a lack of hope for improvement, and lack of sleep that disrupts normal sleep architecture. In addition, this patient was being treated with narcotic pain relievers at a significantly high dose. Narcotic pain relievers are notorious for problematic side effects that include somnolence, insomnia, and confusion. Somnolence and insomnia create severe lack of energy and motivation that can be mistaken as depressive symptoms.
  2. 2.  Stimulant use for ADD. Stimulant use, prescribed or not, has known side effects that include nervousness, insomnia, depression, and drowsiness. These medications can fuel an already existing depression and add an anxious quality.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay
  3. 3.  Chronic severe depression. The patient’s temporal course of severe depression would make it very likely that she would develop the negative cognitive set as described above. A person’s expectation of treatment failure is a significant predictor of treatment outcome. Her disappointment in previous psychotherapeutic interventions as well as pharmacologic interventions makes it likely that she does not trust that treatment, or treatment professionals, will be able to help her.

Formulation and Treatment Plan

The first step in any case formulation and treatment plan is an accurate diagnosis. The evaluation of Bethany’s symptoms included exploration of hypomanic episodes to rule out a cyclical mood disorder such as bipolar disorder. Two episodes of spending in excess that included reduced need for sleep were uncovered in the previous 12 years. Each of the episodes was memorable to Bethany but did not create a severe hardship on herself or her husband, thereby meeting the criteria for hypomania as opposed to mania. Given this information, it was determined that Bethany did not suffer from Major Depressive Disorder. Her diagnosis was changed to Bipolar II Disorder, which is not as amenable to traditional antidepressant therapies. It was also determined that Bethany did not suffer from an Axis II Personality Disorder as determined through an assessment of function and behavior prior to the first depressive episode. Once the diagnosis was in place, a full medical and medication evaluation was completed using the patient report and documented medical information.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay It was determined that the medications previously prescribed for Bethany were negatively impacting her level of depression as well as increasing her feelings of pessimism about medication and health care professionals’ ability to help her. To minimize the impact of narcotic analgesics on her depressive symptoms and energy levels, a consultation was sought with her pain management team with Bethany’s consent and cooperation. A narcotic medication taper was agreed to by Bethany, her pain team, and therapist to limit the dose to the lowest effective dose for pain while minimizing cognitive impairment of confusion, lack of concentration, and somnolence. Given that the patient had never experienced symptoms of distraction and lack of concentration prior to the time her depression became severe, it is most likely that her problems were due to hypomania and agitation. Therefore, it was agreed that the medications for ADD would gradually be tapered and discontinued.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Finally, she was prescribed a course of lamotrigine, which is indicated for bipolar disorders that are primarily depressive in quality. Patients who are severely incapacitated by depressive cognitions and symptoms are not as likely to respond to cognitive interventions until the depressive symptoms begin to abate. She was educated in the expectations for the new medication for effect and side effect. She was also educated in realistic expectations of medication for control of her symptoms specifically that the medication would not be a “magic” solution. In order for her to experience maximum benefit, the APPN felt that she would have to “undo” the automatic thoughts and beliefs that perpetuated the depression. Providing her with a realistic introduction is the first cognitive intervention in her treatment plan. It says, “This is treatable, this is what to expect, this is what the pill will do, AND this is what you will need to do.” (NOTE: These steps are not always contained within the cognitive therapy model of treatment.)Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

It should be noted that her decision to marry a man 40 years her senior who is/was her father figure was most likely due to her low self-esteem and need for a father figure after her father’s death. Her frequent affairs also point to an underlying personality disorder that is most likely fueled by the hypomania. She gains powerful feelings from attracting men and this gives her short-term relief from her otherwise empty life. Because stabilization is the most important first goal, these issues should not be addressed immediately as they would push the patient rather quickly out of therapy. If and when she wishes to bring these issues up in therapy they can be dealt with, but only at that time. It is important for the therapist to remember that it is the patient’s goals, not the therapist’s, that set the agenda in therapy.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Course of Therapy

The initial session included the components of assessment, preparation for therapy, introducing the patient to cognitive therapy, problem conceptualization, and initial goal development. The second session reinforced the above and integrated the information obtained from collateral sources which refined the treatment plan. Medication changes were begun in the second session once it was clear that the patient understood the rationale for each of the changes recommended. Each session subsequent to these two sessions included a medication and symptom check prior to beginning the psychotherapy component of the session. Sessions typically begin with a review of any homework (out of session practice, or experiments). Initial interventions for Bethany were behavioral in content, given the level of cognitive impairment she was suffering. For example, Bethany’s level of physical inactivity was affecting her energy, self-concept, and negative cognitions. A daily exercise program was negotiated with Bethany that included 20 minutes of walking each morning.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Subsequent sessions focused on uncovering specific irrational automatic thoughts as they appeared in the session. Once a thought was identified, the therapist repeated the thought and discussed it with the patient. For example, “Everyone thinks I am such a slug!” Bethany was asked “Everyone? Virtually everyone thinks you are a slug?” Her response was “Well, no not everyone, almost everyone.” This was explored further and it was determined that the only one who had complained about Bethany’s activity level was her boss. Another example of Bethany’s use of overgeneralization was “There is nothing normal in my life!” and “Why do these things always happen to me?” Bethany was interrupted each time she used an overgeneralization. The thoughts were challenged in a respectful, exploration friendly manner until Bethany was stopping herself in therapy by saying “I don’t mean ‘always,’ I mean most of the time.”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Decatastrophizing techniques were used when Bethany began escalating, beginning when a small discrete problem, “I couldn’t find my keys for a couple of minutes!,” is changed from “My mind is a mess! I can’t remember anything! I am never going to be able to convince my boss that I can do my job!” The APPN modeled slowing down and evaluating the pattern of escalation by beginning with the activating event (losing the keys). Another technique that was useful with Bethany was the use of Socratic questioning, for example, asking, “What might be another explanation?” Questions framed in this way helped Bethany to break down errors in thought such as all-or-nothing thinking. Exaggerations in thinking were assessed using a scaling technique when Bethany expressed dichotomous categorical thinking processes. Breaking down categorized variables such as “I didn’t get any sleep at all!” into “on a scale of 1 to 100, where would you rate your sleep last night?”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Interruption of Bethany’s tearfulness was difficult during the early sessions due to the depth of her depression. In order for interruption to be considered respectful and helpful as a technique to (a) de-escalate and (b) evaluate, Bethany was introduced to the technique early in the relationship. The introduction included the component that “In order for me to really understand what you are saying, I will be interrupting you at times to ask questions. In order for me to help, I need to make sure I have a clear understanding of what you are telling me.” Allowing Bethany to dissolve into tears perpetuates her current method of dealing with her depressive thinking. Interruption coupled with Socratic questions and scaling helped Bethany experience disruption of her escalation, which reinforces her ability to interrupt the process on her own.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Therapy Monitoring and Use of Feedback Information

Bethany’s progress was monitored through use of the Beck Depression Inventory (BDI) and the Quick Inventory of Depression Symptomatology-Clinician Rated (QIDS-C). Bethany scored 51 (out of a possible 63) on the BDI and 23 (out of a possible 27) on the QIDS-C at the time of initial assessment. The scores fall into the severe range of depression. Repeat measures were taken at biweekly intervals. Using the standardized instruments was a helpful adjunct to clinical judgment in psychotherapy in that it provided concrete evidence of improvement of symptoms.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany’s self-reports during her first two return visits were “I am still a mess! I am not any better at all!” Use of the instruments supported the cognitive approaches utilized including using evidence to challenge her self-defeating thinking patterns. The evidence was introduced in a respectful manner using a method of cooperative inquiry. “Let’s look at the scores on your reports. They indicated that your depression is still in the severe range but there are some changes. It looks like you are moving in the right direction.” With assistance in evaluating each of her symptoms rather than her overall experience, Bethany began to express hesitant optimism that she was improving. During the first month, her scores decreased from 51 and 23 to 38 and 15 on the BDI and QIDS-C, respectively.

Once Bethany began to experience an improvement in her mood along with hope for additional improvement, she moved into a more active role in the therapy sessions. The APPN then was much more active during her first four sessions, given her severe disabling symptoms and her weight. Her sleep gradually improved and her daytime somnolence began to abate. With the increase in energy, she was able to walk 5 minutes a day beginning week 5 of therapy. Initially the exercise increased the pain of her fibromyalgia, which is an expected response. The therapist warned her that this was to be expected and did not indicate that she was harming herself. According to Bethany, several of her health care practitioners had told her that the best treatment for fibromyalgia was exercise but she had never felt motivated enough to begin a program.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Getting Bethany to take an active part in her health care (via exercise) was a key component in her therapy. Exercise served multiple purposes: (a) it helped reduce the pain experience, (b) it increased her body’s tolerance for physical activity, (c) it increased her energy and motivation level, (d) exercise increases release of the body’s endorphins and serotonin, both of which improve mood, and finally (e) reduced her weight, which motivated her to continue the program of activity and therapy.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

At this point, Bethany was introduced to two other components in her treatment: the daily thought record (DTR) and her activity/mood diary. She was assigned the book Mind Over Mood by Padesky and Greenburg (1985) as her resource and for supportive information both in and outside of the sessions. Bethany had experienced success in challenging her automatic thoughts in the therapy setting and this information was used to reinforce DTR homework as a productive and helpful adjunct to her sessions. The APPN also used the DTRs that are suggested by Padesky and Greenburg including daily written entries indicating the person’s (a) situation, (b) current mood rating, (c) automatic thoughts, (d) evidence that supports the hot thoughts, (e) evidence that does not support the hot thoughts, (f) alternative or balanced thoughts, and finally (g) post-exercise mood rating.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany’s affect remained labile in the sessions with tearfulness during periods when she talked about feeling overwhelmed and useless. She would point this out and dichotomize her perception of the episode as “I am so tired of feeling like this all the time! I am never going to stop crying all the time!” Her expressions “all the time” and “never get better” were highlighted to help her evaluate the tearful episodes rationally. This type of situation lends itself to the use of scaling techniques. This technique breaks down “all-or-nothing” thinking into a continuum to help the patient experience her perception in a more balanced way.

For Bethany this meant asking her “When you say ‘all the time,’ help me to understand how much of the time is ‘all the time.’ Is it 100% of the time (holding my hands about 2 feet apart), 50% of the time (moving my hands closer together), or another percentage of time?”Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany’s response was to stop crying, think deeply for a few minutes during which the APPN remained quiet and then she said “I am not sure … maybe 50%.” The perception of all the time was broken down even further now that she was considering that “all the time” did not mean “100% of the time.” To help her evaluate her perception with more data, the therapist asked: “When you came in the first day you said you would cry about four to five times a day for an hour or two each time. That means you were crying between 4 and 10 hours a day. Let’s take the first variable. How many times a day are you crying?”

 

              B: Maybe once or twice.
              APPN: So you have reduced the number of times you are crying from 4 or 5 to 1 or 2. That is about 60% to 75%. And each time you have a crying episode, how long are you crying?
              B: Oh, only about 10 minutes, sometimes as much as 20 minutes, but never more than that.
              APPN: It sounds like the duration of crying is pretty significantly reduced! As much as 80%. Let’s go back and look at what you said earlier, “I cry all the time.” What do you think about crying now?
              B: I get it. I am doing it again! [laughs]. It is still so easy to bury myself by automatically thinking the worse that can happen. When I stop and look at things realistically, I know I am doing much better now. I have to practice stopping myself!

Documented baseline measurements help with the process of examining the evidence. Capturing the patient’s own words, especially if there are measurable data points, is critical in the process of examining the evidence of progress when a patient has a bad moment or a bad day. Using the data to confront in a kind and respectful manner reinforces hope of recovery, which is one of the cornerstones of motivation to maintain change.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Concluding Evaluation of the Therapy’s Process and Outcome

At this point in treatment, Bethany has been in therapy for 6 months, beginning with a weekly session for eight sessions and tapering to one session a month. She continued to use the DTR for tough times and felt more confident with the process of challenging her automatic thoughts. The most difficult times for Bethany include those times when her pain flares up, usually during periods of unusual activity. Her overall pain ratings have fallen from her initial daily ratings of “8 or 9” to baselines of “4 to 6.” A reduction in pain experience of 50% is considered successful in a pain management program. Bethany is happy with the change in baseline and is more functional. She walks twice a day, 10 minutes each time which is a 100% increase in activity from her first session.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Bethany had a good response to the lamotrigine, which managed her hypomania very well. It is important with patients who have a disruptive underlying psychiatric problem amenable to medication that the medication is integrated into the therapy treatment plan. The APPN reinforced to Bethany that the medication would help stabilize her moods but would have no effect on the automatic thoughts, habits, and other destructive forces that had fueled her severe depression. The first 10 to 15 minutes of each session were devoted to evaluation of medication effectiveness, side effects, and dose response until she stabilized. Again, this is not a usual component of traditional cognitive psychotherapy; however, psychopharmacological education needs to be integrated into the treatment plan if the therapist is also the prescribing practitioner. See Chapter 9 for further information about integrating prescribing with psychotherapy.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

POSTMASTER’S CBT TRAINING AND CERTIFICATION REQUIREMENTS

Competency standards for CBT have been outlined by Jesse H. Wright, MD, PhD; Donna Sudak, MD; David Bienenfeld, MD; and Judith Beck, PhD (2001) for the American Association of Directors of Psychiatric Residency Training (AADPRT). A supervision checklist is also available as designed by Wright and colleagues (www.appi.org/pdf/wright). The academy of cognitive therapy (ACT) offers certification for licensed mental health professionals in CBT and evaluates applicants’ knowledge and ability before granting certification. The standards of the academy are designed to identify and credential clinicians with the necessary training, experience, and knowledge to be effective cognitive therapists. ACT requires 40 hours of course work, completion of a compiled list of assigned readings including at least one core text on CBT theory and methods, a written case formulation, case supervision, and the submission of audio or videotaped sessions that are reviewed and rated by experienced cognitive therapists. In addition, the practitioner must have significant practice experience treating individuals with CBT with a variety of diagnoses. APPNs who wish to pursue CBT certification can find the requirements on their website at www.academyofct.org.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

CONCLUDING COMMENTS

CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems. CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). The underlying premise of CBT is that dysfunctional (or maladaptive) thoughts relating to self, world, and/or others are based on irrational or illogical assumptions. CBT places significant importance on cognitive information processing and behavioral change. Therapy is structured, active, and reality based as well as time limited. The individual is taught to take certain specific steps to combat their dysfunctional or maladaptive views. These steps include identifying and monitoring automatic thoughts, critical examination of evidence, substitution of objective interpretations for their negative, dysfunctional attributions, and recognizing connections between thoughts and feelings. It would be incorrect to say that severely impaired individuals, such as individuals with schizophrenia, cannot be treated with CBT. For these individuals, the therapist uses a greater number of behavioral techniques, for example, than cognitive techniques. For higher functioning individuals, the therapist uses more cognitive techniques. For any individual, therapy is a collaborative process taking schemas, ability, and physiology into account when deciding the plan of action.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

DISCUSSION EXERCISES

  1. Discuss the importance of assisting the individual to identify his or her own cognitions, behaviors, and other factors that contribute to the individual’s problems.
  2. What is the role of homework in cognitive therapy? Why is homework important?
  3. What are some common types of distorted thinking styles in a person with an anxiety disorder? What techniques would be helpful for this problem?
  4. According to cognitive theory, what is the basis for depressive disorders?
  5. Would you refer an individual with severe anxiety to a cognitive therapist? Why or why not?
  6. Describe two cognitive techniques and two behavioral techniques. In what types of situation would you choose each?
  7. Develop a written contingency contract for yourself for a behavior that you would like to change.
  8. Fill out the automatic thought record for a recent situation that you found disturbing.

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APPENDIX 8.1

 

Adapted from Gilson, Freeman, Yates and Freeman (2009), with permission.

|

(Wheeler)

Wheeler, Kathleen, PhD, APRN-BC, FAAN. Psychotherapy for the Advanced Practice Psychiatric Nurse, Second Edition, 2nd Edition. Springer Publishing Company, 20131211. VitalBook file.

The citation provided is a guideline. Please check each citation for accuracy before use.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

  • Chapter 8, “Cognitive Behavioral Therapy” (pp. 313–346)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Note: You will access this text from the Walden Library databases.

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay

 

Note: For this week, view Behavior Therapy and Cognitive-Behavioral Therapy only. You will access this media from the Walden Library databases.

Beck, A. (1994). Aaron Beck on cognitive therapy [Video file]. Mill Valley, CA: Psychotherapy.net.

 

Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 50 minutes

Eysenck, H. (n.d.). Hans Eysenck on behavior therapy [Video file]. Mill Valley, CA: Psychotherapy.net.

 

Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 50 minutes.

Optional Resources

Ellis, A. (2012). Albert Ellis on REBT [Video file]. Mill Valley, CA: Psychotherapy.net.

 

Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 50 minutes.Cognitive Behavioral Theory Versus Rational Emotive Behavioral Theory Essay