Cognitive Behavioral Therapy

COGNITIVE BEHAVIORAL THERAPY

Key Figures: Albert Ellis, Aaron Beck

Theory: Maladaptive behavior is associated with patterns of thinking and response which do not result in mentally healthy outcomes.

Treatment: The goal of Cognitive Behavioral Therapy is to change or substitute these patterns with more realistic and useful thoughts and responses.

Relevance: It is used to treat depression, anxiety disorders, phobias, and other forms of mental disorders. Medication is often used in conjunction with this approach to treat mood disorders and more severe forms of mental disorders. Schools of psychotherapy associated with this discipline are Rational Emotive Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.


BECK (Cognitive Therapy)

Identification of automatic thoughts similar to preconscious. Depressed individuals this internal dialog is negatively oriented resulting in low self-esteem and negative self-concept. Cognitive Therapy and Beck Depression Inventory utilize Clients Thought Patterns (Cognitive Schema).

Beck's Cognitive Therapy is most effective for treating phobias and depression. The client's difficulties are a result of a distorted construction of reality in three levels:

1. View of Self
2. View of Experiences
3. View of the Future

Beck believes that when a client changes his or her thinking, biochemical changes occur in the brain which results in the client feeling better and less depressed.

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Individually based theory and therapy models

Person Centered Therapy

Theoretical Foundations
■ Focus is on the person and not the presenting problem

■ Humanism
        o Philosophical movement that emphasizes worth of the individual and the centrality of human values
        o Attends to matters of ethics and personal worth
        o Gives credit to the human spirit
        o Emphasis on creative, spontaneous, and active nature of humans
        o Optimistic
        o Human capacity to overcome hardship and despair

■ Non-Deterministic        o Beliefs that it is oversimplification to view people as controlled by fixed physical laws.
        o Encouragement of therapy that considers individual initiative, creativity, and self fulfillment

■ Self Actualization        o Innate process by which a person tends to grow spiritually and realize potential

■ The Experiencing Person        o Important issues must be defined by the client
        o Special concerns are discrepancies between what a person thinks of himself and the total range of things he experiences


Techniques

■ Listening
■ Accepting
■ Respecting
■ Understanding
■ Empathic Responding

Attachment Theory

Attachment theory explores the relationships between humans using psychological, ethological and evolutional theory. John Bowlby, a British psychoanalyst and psychiatrist who lived from 1907 to 1990, created the original theory. The central tenet is the belief an infant needs to develop a relationship with one or more primary caregivers for normal emotional and social development to occur.

Bowlby believed in four basic, distinguishable characteristics in attachment. First is Proximity Maintenance. This is the desire to be close to the people to which we are attached. Second is Safe Haven. This is safety or comfort seeking with the attachment figure when feeling threatened or fearful. Third is Secure Base. Secure Base implies the attachment figure is a place the child can use and return to when exploring the surrounding environment, comforted that there is a place of security that acts as a touchstone, if needed, in which to return. Fourth is Separation Distress. This is the occurrence of anxiety when the attachment figure is not present.

Bowlby associated infant behavior with seeking proximity to an attachment figure (trusted caregiver) in situations of stress. The trusted caregivers establish Proximity Maintenance. Infants then become attached to caregivers who respond to them and are constant in their lives, especially from ages six months to two years, because they create a Safe Haven. As children approach the age of two, the child uses the attachment figures (caregivers familiar to them) as a Secure Base. The infant who is attached has an adaptive response of Separation Distress or Separation Anxiety when the attachment figure departs. This mechanism is an apparent survival mechanism for the child.

Initial criticism of Bowlby’s research came from the psychoanalytic community because of the departure from the predominant theory of the time. Later criticism came out of other disciplines after extensive empirical research surrounding the development of infant/child close relationships. However, the basis concepts associated with the theory have remained and serve as the foundation of theory, as well as the formulation of policy and practice in the arenas of social policy as it relates to children and childcare to enhance the attachments in early childhood.

Mary Salter Ainsworth, an American Developmental Psychologist who lived from 1913 to 1999, focused her work on emotional attachment. Through her research, she developed attachment patterns observed in infants: secure attachment, anxious/avoidant attachment and anxious/resistant attachment. She observed infants who experienced distress when their mother departed and sought comfort upon her return, referring to this as Secure Attachment. Ainsworth observed a lack of distress upon a mother’s departure from her infant and avoidance at her return, called Anxious/Avoidant Attachment. Ainsworth’s third category of observations involved a pattern of proximity to the mother in the initial minutes alone, followed by high levels of distress at mother’s departure, seeking comfort upon her return, followed by rejection at the closeness. She referred to this third category as Anxious/Resistant Attachment.

A fourth category was later theorized, called Disorganized Attachment, theorized by Mary Main and Judith Solomon. Disorganized Attachment resembles the Anxious/Avoidant infants/children, but had significant ambivalence upon reunion with the caretaker, both approaching and avoiding. Bowlby described this as pulling away with anger while seeking to be close.

MSE- Consciousness, Speech, Mood and Affect

MSE - Consciousness, Speech, Mood and Affect

The mental status exam can cover a myriad of areas and each mental health professional will need to decide what is important. Professionals from different disciplines are likely to be interested in areas relative to their specialty and area of expertise. For example, a neuropsychologist will be interested in neurological processes as they relate to behavior. Hence, the MSE conducted by a neuropsychologist might be detailed in assessment of attention, concentration, language, memory, etc. A psychiatrist on the other hand, may focus more on issues related to thought processes, mood and anxiety level. Of course, this is not clearly defined, as many areas of mental health treatment are cross-disciplined. The point is, one “good” MSE does not necessarily look like another. It can be adapted to one’s theoretical orientation as well as the specific information that is required at the particular time. As a rule, the interviewer must adapt to the situation based on information and observation. He must think on his feet, so to speak. Below is a brief case example.

A 25-year-old Hispanic female is brought into your office by her mother. The mother reports that her daughter is depressed. You speak to the girl alone and find that she is indeed depressed. In the course of the interview, you note that she uses an occasional word that you have never heard before. Since she is a Spanish-speaker, and you do not speak Spanish, you assume she is substituting occasional Spanish for English words. However, these words do not “sound” like Spanish, so (in passing) you ask about them. After discovering that these are made up words, you decide to pursue more detailed inquiry into language, thought processes and thought content.

Along the way, you must follow the clues brought up in the interview. In the above case, the client may have been exhibiting neologisms (made up words- often related to thought disorder and psychosis) or she could have been creating her own private language (for a variety of non-pathological reasons), or she might simply have some articulation problems related to organic brain damage. The interviewer should be “curious” about everything that comes up in the interview.

Some areas of inquiry are easily identified. If the interviewee is clearly drowsy, somnolent, or stuporous, this becomes primary to other areas of inquiry. However, if a person is alert and responsive, it is not necessary to conduct a Glasgow Coma Scale.

Mood and Affect are areas commonly evaluated in almost all mental status examinations. Mood is a “sustained” emotional state, such as: depressed, euphoric, elevated, anxious, angry, and irritable. Affect is more the observable emotional state at the time of the interview. These include descriptors such as: flat, blunted, restricted, and inappropriate.

In inquiry about mood, affective clues are important. Facial expression, quality of voice (timber pitch, intensity) eye contact and muscular tension (among others) all give clues as to mood. Of course, self-report is one of the best ways to evaluated mood. One interesting and useful bit of information for clarifying the difference between anxiety and depression is to use Brenner’s Definitions. A pervasive feeling that something bad “has happened” is indicative of depression. If one has a pervasive feeling that something bad is “going to happen,” this indicates anxiety.

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Bandura's Social Learning Theory

Bandura's Social Learning Theory
Albert Bandura, born in Canada in 1925, is a psychologist in the behavioral movement who has been referred to as a founder of the cognitivist movement because of his movement from strict behavioral psychologist to seeing personality as being formed by environment, behavior and the individual?s psychological processes.
Bandura developed the idea of reciprocal determinism. He believed the pure behaviorist model of environment (variables that can be observed, measured and manipulated) cause behavior was too simplistic. He suggested behavior also causes elements in the environment, making the relationship of environment and behavior reciprocal, with elements of each interacting with one another. He called this phenomena reciprocal determinism. He later took this a step further, adding a cognitive element, one of imagery, moving him from the behaviorist movement into the foundation of the cognitive movement.
Bandura is best known for his study known as the Bobo Doll Studies. He made a film of a young woman, one of his students, attacking a Bobo doll (an inflatable clown that returns to an upright position when knocked down). In the film, she attacked it both verbally and physically. He showed the film to kindergartners. The children liked the film and were later let into a room to play. In the room was a Bobo doll. Observers noted the children mimicking what they had seen on the film, indicating observational learning. No requirements for rewards, punishments or approximations to learning the new behavior were needed for the behavior.
Bandura established steps involved in the modeling process for learning. Attention is required. If attention is limited, such as by illness, emotional state, physical state, or environmental limits, the ability to attend to what is modeled is limited and learning is hampered. If attention is enhanced, such as with drama, prestige, delivery (by credible or entertaining source) or like the subject, more attention is paid.
Retention is required for effective modeling. The individual must be able to remember what was seen or to what was attended. Imagery and verbal descriptions assist in bringing forth what is needed to duplicate it in behavior.
Reproduction is part of effective modeling. Prior to duplicating the behavior, the thoughts are not more than daydreaming. The images and language must be translated into action, which requires the individual to reproduce the behavior. If an individual watches the quarterback on a football, but is not able to throw a football, he has not engaged in reproduction. On the other hand, if he has thrown a football and has the basic skill set, he may improve his performance through imitation of what he observes in those who are more proficient that he is. Beyond observation of another performing a desired skill, one can imagine his or herself performing the desired skill in the mind?s eye before performing the skill and improve performance by the internal observation and practice of the performance in the arena of imagery or imagination.
Motivation is another element of modeling because without the will or desire to do the behavior, the individual will not do it. He may do it because of past reinforcement, promised reinforcement or vicarious reinforcement. Bandura holds that negative motivations are also reasons one may elect to do or not do a modeled behavior, such as past punishment, promised punishment or vicarious punishment.
Stepping out of a pure behavioral perspective, Bandura believed in self-regulation as the other element in human personality. He suggested three elements in this process. First, self-observation in which one looks at the self and behavior and monitors each. Second, judgment in which one compares the self with some standard, traditional, performance or another. Third, self-response in which if one does well with the set or desired standard, one is rewarded, or if done poorly, one is punished in some way. Rewards or punishments may be tangible (favorite meal) or covert (emotions of achievement, self-worth, shame). Out of this result, he believed those who struggle with poor self-esteem or self-concept elicit this from elements of self-regulation: self-observation (have an accurate reflection of self), standards (set reasonable ones) and self-response (use of self-reward and celebration of success without dwelling on failure).