Cognitive Therapy in Action

by Ivy-Marie Blackburn, Vivien Twaddle

Overview

Cognitive therapy is the established method of helping people to overcome states of depression, anxiety or other emotional conditions. Not only do the authors explain the theory behind the treatment but this was the first collection of case studies to be published outside of the United States.
With an introduction to the development and application of cognitive therapy, the book goes on to outline how it can work for a therapist or counsellor. Covering cases from depression and panic disorder to bulimia and obsessive-compulsive disorder, giving details of the process of the therapy in each case.
This is an invaluable practical guide to how cognitive therapy works for clinical psychologists, students, social workers, nurses and psychiatrists.

Product Details

ISBN-13:	9780285640054
Publisher:	Souvenir Press
Publication date:	04/01/1996
Sold by:	Barnes & Noble
Format:	eBook
Pages:	320
File size:	3 MB

About the Author

Ivy-Marie Blackburn and Vivien Twaddle are eminent members of the Cognitive Therapy Centre in Newcastle.

Read an Excerpt

Cognitive Therapy in Action

A Practitioner's Casebook

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By Ivy-Marie Blackburn, Vivien Twaddle

Souvenir Press

Copyright © 1996 Ivy-Marie Blackburn and Vivien Twaddle
All rights reserved.
ISBN: 978-0-285-64005-4

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CHAPTER 1

The Evolution of Cognitive Therapy

WHAT IS COGNITIVE THERAPY?

Cognitive therapy is the field of applied psychology that is unified by a belief in the central role played by mediating knowledge structures or thinking processes in explaining and changing human behaviour. While acknowledging a reciprocal interaction between cognition and emotion, the many diverse orientations within cognitive therapy tend towards viewing cognition from the point of view of its contributory role in influencing emotion, although a few have begun to explore emotion as a primary source of information and meaning in its own right. All orientations draw heavily on a broad repertoire of cognitive and behavioural techniques, and some are expanding into experiential methods.

This chapter attempts to explore some of the historical roots of this evolving field of psychotherapy. It splits the discussion into two main sections, which broadly represent the first and second twenty years of the lifespan of cognitive therapy to date. It attempts to illustrate the intrinsic and ongoing dialectical growth process that continues to enhance cognitive therapy's utility and range of application. And while considering what is quite unique about this type of psychotherapy, we address emergent integrating issues.

THE FIRST TWENTY YEARS, 1960s–1970s

The theoretical (and practical) underpinnings of cognitive therapy were shaped by a variety of sources both within the general field of psychology and within applied clinical observation and practice. From the general field, three major strands of thinking stand out: the phenomenological approach and its contention that the view of one's self and of the world is central to the determination of behaviour (Adler, 1936; Horney, 1950); structural theory, which expounds the concept of hierarchical structuring of knowledge to include primary-and secondary-process thinking (Piaget, 1972); and the academic field of cognitive psychology which, while integrating both assumptions, stresses the importance of cognition in information-processing and behavioural change (Williams et al., 1988).

From the clinical field, a number of workers have been influential: George Kelly, whose model (1955) of personal constructs expounded the idiosyncratic ways of construing and interpreting the world in the context of behavioural change; Arnold (1960) and Lazarus (1966), whose theories of emotion attributed a primary role to cognition in emotional and behavioural change; Ellis (1962), whose Rational–Emotive Therapy encapsulated the principle of the primacy of cognition for clinical intervention and emphasised the control that can be brought to bear over patterns of thinking and behaviour. From the behavioural field, Bandura's Social Learning Theory (1977) was important in attempting to explain the development of new behavioural patterns in terms of the cognitive aspects of observational learning. In doing so, it shifted behaviour therapy into the cognitive domain, as did Meichenbaum's (1977) self-instructional learning model and Mahoney's early work on cognitive control of behaviour (1974).

But it was Beck's model that really took the clinical literature by storm. This heuristic cognitive model was developed as a reaction to the theoretical excesses and practice limitations of classical psychoanalysis and to the rigidly restrictive nature of radical behaviourism. The model became the cornerstone of cognitive methodology and conceptualisation in the 1970s and, indeed, it continues to have its place at the forefront of empirical and clinical endeavour today. Much of cognitive therapy's development since his 1967 thesis (Beck, 1967) uses this 'grandfather' of models as a benchmark. For this reason we use it as a main reference point for the rest of this section.

Early cognitive conceptualisations

Cognitive therapy's focus on phenomenology necessarily accorded the content of a patient's experience a position of central importance in clinical understanding and intervention. Indeed, content–focused frameworks, such as Meichenbaum's self-instructional training (1977) and Ellis's rational–emotive therapy (Ellis and Greiger, 1977), were some of the first to appear in the cognitive therapy literature. One of the prominent more recent examples is that proposed by Beck and Emery (1985), which focuses on content issues of danger and vulnerability in patients with anxiety disorders; the negative triad which appears in Beck's conceptualisation of depression is another.

The advantages of this type of clinical framework became clear very early on. Such frameworks provided a working understanding of the immediate cognitive phenomenology influencing affect and behaviour in a manner that patients could easily relate to. Their straightforward and concretely descriptive focus made them workable for less traditional clinical subjects such as those with personality disorders and psychotic presentations, children and people with learning disabilities. However, their weakness was that they did not address the non-accessible cognitive processes and structures indicated in emotional and behavioural disorders (Craik and Tulving, 1975; Goldfried et al., 1984). There was also an issue of parsimony: different content-based models were required for different emotional disorders and, apart from the problem that such disorders are not mutually exclusive, there was the additional difficulty that patients with the same disorders did not necessarily share a common content.

The limitations, therefore, led to tripartite cognitive models which attempted to embrace the idea of different 'levels' of cognition. Beck's was the clearest and most influential. His framework distinguished between automatic thoughts (content), faulty information-processing (process) and dysfunctional assumptions (structures, or schemata). In doing so it advanced the cognitive understanding of patients' problems beyond that of content. The model views informational content as the products of information-processing. Automatic thoughts represent that part of conscious knowledge which is not the result of directed (logical) thinking, but which occurs out of the blue. They are synonymous with Meichenbaum's 'self statements' and Ellis's irrational beliefs (Meichenbaum, 1977; Ellis and Greiger, 1977).

Schemata are the deep, relatively stable, cognitive structures which reflect fundamental beliefs about oneself, the world and others. They represent complex patterns of thoughts that determine how experiences are perceived and conceptualised. They operate as a type of transformation mechanism that shapes incoming data so as to fit and reinforce preconceived notions. This 'distortion', or manipulation, of experience is maintained through the operation of characteristic information-processing mechanisms: arbitrary inference, selective abstraction, over-generalisation, magnification and minimisation, personalisation, labelling/mislabelling and dichotomous thinking (Beck et al., 1979).

The model encapsulated the idea of a cognitive diathesis, or vulnerability, which represented a major issue in the academic and clinical literature – for instance, Seligman's developing ideas of a vulnerable attributional style in the onset of depression (Alloy, 1988). Beck proposed that the idiosyncratic dysfunctional schemata form the basis of vulnerability to specific emotional disorders. When 'activated' by stressful events that reflect those in which they were originally laid down, the schemata produce the cognitive shift that leads to the systematic bias in how an individual notices, interprets, integrates and remembers data. Schemata are considered unconscious in the sense that they are 'ideas we are unaware of ... because they are not in the focus of attention but in the fringe of consciousness' (Campbell, 1989).

The extent of the disruptive effect that a particular schema has on an individual is dependent on several factors: the strength with which the schema is held; how much the schema is essential to a person's sense of personal integrity and safety; the amount of disputation the individual engages in when a particular schema is activated; previous learning with regard to the importance and essential nature of the schema; and how early the schema has been internalised (see Freeman, 1992). Beck argued that the schema returns to its previous dormant state once the stressor is removed. This has been given as the reason why some patients can rapidly return to health at the beginning of therapy – it happens, presumably, because the therapist and his or her explication of a model that 'makes sense' has reduced the stress (Freeman, 1992). This return to a state of dormancy has also been used to account for the observation that previously depressed patients are no different in schematic profile from never depressed individuals, as measured by the Dysfunctional Attitude Scale (Weissman, 1979; Hamilton and Abramson, 1983; Silverman et al., 1984).

This observation led to more complex explanations of vulnerability: Teasdale addressed the issue with his differential activation hypothesis (Teasdale, 1988), by proposing that depressed affect increases the accessibility of negative interpretative categories and constructs associated with previous experiences of depressed mood. Teasdale incorporated ideas from extensive studies of the effect of mood on memory (Blaney, 1986; Fennell et al., 1987), and its relationship with a range of other cognitive processes such as interpretations of ambiguous situations, self-efficacy expectations, evaluations of self and future probability and negative events (Bower, 1981; 1983). In effect, Teasdale challenged Beck's view that dysfunctional schemata are activated as a result of a precise fit between an environmental stressor and the content domain of the particular schema. By contrast, Teasdale argued that this activation occurred as a result of the depressed affect per se reactivating negative constructs that had been most frequently and prototypically associated with previous experience of depression as a whole. The clinical implication of this is that a particular stressor should necessarily activate a wider range of constructs than those proposed by Beck. Biological and other psychological factors were also introduced, to complicate the picture further. So, paradoxically, in its attempt to embrace the complexities of cognitive operations, Beck's model was criticised for over-simplification.

Since Beck's model first appeared in the literature, a main avenue of investigation has been to discover which types of negative interpretative structure are most important in relation to the development of emotional disorders. It appears that they are those relating to the self. Individuals with pervasively dysfunctional self-referent schemata seem more likely to be vulnerable to developing non-transient depressive disorders (Teasdale, 1988). Several cognitive psychology paradigms have illustrated the importance of these self schemata: the Stroop test, incidental recall, colour-naming tasks (Kuiper and Derry, 1982; Segal et al., 1988).

Methodological assumptions

Cognitive therapy soon came to be associated with a set of explicit assumptions, or guiding principles, which have become the defining characteristics of the approach. There are, broadly speaking, eight of them.

1 The centrality of the cognitive conceptualisation The models came to be conceptually driven in that, rather than being a shot-gun technique-orientated approach with no theme or focus – as the early myth had it – they stressed the importance of a clear treatment conceptualisation guiding a series of organised and focused treatment strategies.

2 The phenomenological emphasis The phenomenological approach to psychopathology naturally led to the patient's idiosyncratic subjective experience becoming the central focus of the therapeutic exchange. And this became one of the most distinctive early aspects of cognitive therapy. Seeing the 'world through the patient's eyes' naturally meant relying heavily on his own reports of his experience, and taking it at face value; the point of variation across therapists and conceptual models was the focus that each put on the different aspects of that experience (content, process, structure).

3 The collaborative nature of the therapeutic relationshipThe emphasis on phenomenology required a context of collaboration: the patient and therapist working together in an atmosphere of negotiation – a direct descendant of Kelly's notion of patient and therapist as 'personal scientists' (Kelly, 1955). Beck and colleagues (1979) coined the phrase 'collaborative empiricism', which encapsulated the idea of a team approach in which the patient provides the raw data to be investigated with the therapist's guidance. The objective of such a relationship is to develop a milieu in which specific cognitive change techniques can be applied most efficiently (1979, p. 49). And for the most part this was the focus of the clinical relationship, which was considered primarily as the context for the execution of techniques. Only later was the relationship to be viewed as an intervention tool in itself.

Beck's model originally viewed difficulties in the therapeutic relationship, such as 'incapacitating transference', as technical problems to be identified and examined in the same fashion as any other cognitive behavioural data. The emphasis was on minimising its occurrence in therapy. This stance was common in all the models of the time, more attention being given then to technique than to the relationship between therapist and patient per se (Meichenbaum, 1985; Rehm, 1977). Documented prerequisite therapist characteristics for developing a collaborative therapeutic milieu include both non-specific ones such as non-possessive warmth, accurate empathy and genuineness (Beck et al., 1979; Beck and Emery, 1985; D'Zurilla, 1988), and specific ones such as good educational skills in instructing, challenging and reinforcing patients' efforts at change in a reciprocal, non-superior fashion, along with openness and directness for fostering an atmosphere of equality and partnership (Dobson and Block, 1988; Beck and Emery, 1985; Rothstein and Robinson, 1991).

4 Active involvement of the patient With a collaborative type of relationship the process of therapy naturally evolved into a highly interactive one. The models heavily emphasised actively engaging the patient in devising and experimenting with strategies for cognitive and behavioural change. Both therapist and patient came to have a role in selecting therapeutic targets and negotiating how such targets should be approached. This was, and still is, a more or less unique aspect of cognitive therapy.

A study by Vallis et al. (1988) is of interest here. They compared therapist competency ratings of cognitive therapists and general non-specific therapists, using the Mattarazzo checklist of therapist behaviours (Mattarazzo et al., 1965). They observed among the most competent cognitive therapists a greater frequency of brief questions necessitating 'yes/no' answers, and of interruptions. These are classed as 'errors' in communication on this scale, but in cognitive therapy such questions and interruptions are regarded not as errors but as a critical part of the active collaboration between patient and therapist. This nicely illustrates that what is deemed to be competent in one system of psychotherapy may not be so judged within another.

5 The use of Socratic questioning and guided discoveryThe type of questioning used within cognitive therapy became known as Socratic dialogue. Rather than interpreting the patient's thoughts and actions, the therapist's role was to raise questions about thoughts, feelings and actions, so encouraging the patient to discover things for herself: a process of guided discovery. This was in sharp contrast to communication via interpretations. Apart from running the risk of 'mind-reading' and of misunderstanding the patient, interpretations were considered to risk putting her in a compromising position – in that it is simpler to agree than to disagree, or to seem ungrateful or difficult. The Socratic questioning format of cognitive therapy allowed the patient to maintain integrity and the therapist to gather the most accurate data – accuracy being an important prerequisite for developing hypotheses, the building blocks of cognitive conceptualisation.

6 Explicitness of the therapist From the idea of negotiation, or collaboration, followed the requirement that the therapist share explicitly the model, his or her own working hypotheses and ideas on conceptualisation. It also entailed admitting mistakes and agreeing to disagree, and so on. There was to be no place for 'private' therapist models within the cognitive therapy paradigm, as this would sabotage the collaborative stance.

7 The emphasis on empiricism The models have always been heavily empirical: creating and testing out the working hypotheses emerging from the collaborative guided-discovery process via a number of techniques, broadly categorised as cognitive (focused primarily on modifying thoughts, images and beliefs) and behavioural (focused primarily on modifying overt behaviours). The categories are not, of course, mutually exclusive. For instance, a behavioural technique such as assertiveness-training has cognitive components to it: it can be used to accomplish cognitive changes, such as adjustment in expectancies regarding the consequences of assertion, as well as changes in interpersonal behaviour itself.

(Continues...)

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Excerpted from Cognitive Therapy in Action by Ivy-Marie Blackburn, Vivien Twaddle. Copyright © 1996 Ivy-Marie Blackburn and Vivien Twaddle. Excerpted by permission of Souvenir Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Contents

Title Page,
Preface,
Acknowledgements,
1 The Evolution of Cognitive Therapy,
2 The Empirical Status of Cognitive Therapy,
3 A Case of Depression,
4 A Case of Generalised Anxiety Disorder,
5 A Case of Panic Disorder,
6 A Case of Obsessional-compulsive Disorder,
7 A Case of Bulimia Nervosa,
8 A Case of Long-term Problems,
9 Epilogue,
References,
Index of Subjects,
Index of Authors,
Copyright,