PSY 245

CLINICAL PSYCHOLOGY-II

 Assoc. Prof. Dr. BAHAR BAŞTUĞ

 Clinical Psychologist
Cognitive-Behavioral Theory
and Therapy
Welcome

 Back in the 1970s, most behaviorists didn’t

want to think about cognition. Some
behaviorists included cognitions from the
beginning.
Joseph Wolpe allowed clients to use imagery in the
desensitization. He accepted a form of cognition
into his therapeutic work. However, Wolpe
criticized Michael Mahoney’s use of a technique
referred to as “mirror time” or “streaming”.
Streaming involved having the client free-
associate while looking at himself in a mirror.

Pressure from the behaviorists did not reduce the

“cognitivists” motivation, instead, increased it.
 Now, most practitioners just refer to CBT as
an approach that integrates both behavioral
and cognitive therapies.
Whenever you experience an unpleasant
feeling or sensation, try to recall what
thoughts you had been having prior to this
feeling. Aaron Beck
Historical Context and
Biographical Information
Cognition as an important focus dates back to at
least Socrates. Socratic questioning is to discover
an individual’s method of reasoning.

Wundt used introspection as a method of studying

humans in his first psychological laboratory.

Watson and Skinner rejected the introspection.

Historical Context and Biographical
Information II
There are three key figures and streams of
thought linked to the history of cognition in
counseling and psychotherapy.
– Albert Ellis and Rational Emotive Behavior
Therapy
– Aaron Beck and Cognitive Therapy
– Donald Meichenbaum and Self-Instructional
Therapy
Historical Context and Biographical
Information III
 Ellis developed REBT and focused on
irrational thinking.

 Beck developed cognitive therapy and

focused on maladaptive thinking.

 Meichenbaum focused on inner speech and

developed self-instructional training.
Albert Ellis: Rational-Emotive
Behavior Therapy
Ellis was born in Pennsylvania, in 1913 into Jewish
family. He had a similar childhood to Adler. He was the
eldest of 3 children. His father was often away from
home. His mother was egosentric and bipolar. He
hospitalized 8 times between 5-7 ages due to kidney
problem.

After being rejected his first 8 novels, he graduated

Columbia Univ. Clinical Psy programme. K. Horney
analyzed him. He formulated his approach after
discovering in his psychotherapy practice that
psychoanalysis was ineffective.
Albert Ellis (1913 –2007)
Ellis summarizes five basis components of his
theory:
1. People have irrational ideas and personal
philosophies.
2. These irrational ideas cause people great
distress and sadness.
3. These ideas can be set down to a few basic
categories.
4. Therapists can find these irrational categories
easily in clients’ reasoning.
5. Therapists can teach clients how to give up
their irrational beliefs.
Ellis credits Adler’s pioneering acceptance of
cognition; he also notes that his “rational
psychotherapy” is based on the
philosophical writings of ancient Greek and
Roman stoics, particularly Epictetus. The
first CBTist in the Western world was the
philosopher Epictetus (c. 50–138 ..). He
was born a slave in Phrygia, in what is now
central Turkey.
Albert Ellis: Rational-Emotive Behavior
Therapy

Ellis initially referred to his approach as rational

psychotherapy,

later changing the name to Rational-Emotive

Therapy.

In 1993, he inserted the word behavior, thus

creating Rational Emotive Behavior Therapy
(REBT).
Aaron Beck and Cognitive Therapy
A. Beck was born in 1921 in Rhode Island. His
family was Russian Jewish immigrants. Older
brother and sister died of influenza, he saw
himself as a replacement child. He had physical
problem during childhood, similar to Adler and
Ellis. Because of hospitalization, when he
restarted the school, he believed he wasn’t
smart. He overcame this negative thougths,
obtaining a medical degree from Yale Univ.
Aaron Beck and Cognitive Therapy

Beck was psychoanalytically trained. Early in

his career he was interested in validating
Freud’s theory of depr, but he ended up
rejecting Freud’s theory.

Many psychoanalists ignored Beck for

questioning Freud. However, over time,
Beck’s work on depr was recognized as
empirically valid, and his theory of depr
represents one of the best-known.
Aaron Beck and Cognitive Therapy

Beck’s approach has been known as cognitive

therapy. He reasoned that psychological
problems can be mastered by sharpening
discriminations, correcting misconceptions
and learning more adaptive attitudes.
Introspection, insight, reality testing, and
learning are basically cognitive processes.
Aaron Beck and Cognitive Therapy
Beck is a soft-spoken, gentle man who works
with clients in a collaborative manner. Beck
is not interested in convincing clients of
their irrational beliefs. He uses collaborative
empiricism. In collaborative empiricism, he
works together with clients to help them
discover the maladaptive nature of their
automatic thoughts and core beliefs.
Ellis emphasizes the forceful eradication of
irrational thoughts, Beck emphasizes the
collaborative modification of maladaptive
thoughts.
Donald Meichenbaum and Self-Instructional
Strategies

Meichenbaum followed the path of behavior

therapy into the field of cognitive therapy.
He noticed that people on the streets in NY
city would sometimes talk to themselves.

He focused on impulsive schoolchildren and

hospitalized adults with SCH. He discovered
that both schizophrenics and children could
improve their functioning after being taught
to talk to themselves or to think aloud.
Donald Meichenbaum
Donald Meichenbaum and Self-
Instructional Strategies

 Meichenbaum integrated the work of Soviet

psychologists Vygotsky and Luria with
Bandura’s vicarious learning model and the
operant conditioning principle.
Donald Meichenbaum and Self-
Instructional Strategies
 Meichenbaum’s focus was on self-
instructional training (SIT), which he
referred to as a form of cognitive behavior
modification.
 He later developed stress inoculation
training, a specific approach for helping
clients manage difficult stressors. He is
openly empathic and emotionally oriented.
Donald Meichenbaum and Self-
Instructional Strategies
More recently, Meichenbaum shifted toward
an empirically constructive model. He is also
redefining cognitive therapy as an
integrational approach.
Meichenbaum’s progression—from behavior
therapy, to cognitive behavior modification,
to cognitive-behavioral therapy, to
constructivist cognitive-behavioral therapy
—reflects a trend toward integration.
Theoretical Principles
 CBT is a critically minded, empirically based
treatment approach that doesn’t advocate a
specific treatment approach.

 In addition to classical and operant

conditioning, CBT is based on two additional
learning theories:
– Social Learning Theory
– Cognitive Appraisal Theory
Social Learning Theory (SLT)
was developed by Albert Bandura (1925 –
present).
Social Learning Theory (SLT)

SLT includes stimulus-influence components

(classical conditioning) and consequence
influence components (operant
conditioning), but it also adds a strong
cognitive mediational component.
Social Learning Theory (SLT)
It emphasizes two main cognitive processes:

1. A significant portion of human learning is

observational. Bandura documented the
power of observational or vicarious
learning as a source of behavior change.
This process has come to be known as
modeling. It includes covert mental
processes that cannot be observed by
experimenters.
Social Learning Theory (SLT)
2. Reciprocal interactions occur between the
individual’s behavior and the environment.
Bandura postulates that individuals have
thoughts about the future, behavioral
consequences and goals. Because of these
reciprocal interactions, individuals are capable
of self-directed behavior change. In opposition
to Skinner and Watson, Bandura sees free will
and self-determination as possible.
 Social Learning Theory (SLT)

One of the most important social learning theory

concepts is self-efficacy.

SELF-EFFICACY is defined as an individual’s

belief or expectation that he or she can adequately
complete a specific situation or task.

“The conviction that one can successfully execute

the behavior required to produce an outcome.”
Bandura
Social Learning Theory (SLT)
 Higher self-efficacy is associated with
success.

 Lower self-efficacy is associated with

negative self-talk, giving up easily and
reduced concentration.
Social Learning Theory (SLT)

A primary purpose of therapy is to help clients

develop and strengthen self-efficacy. A client who
comes to therapy to quit smoking may initially
have little confidence in his ability to quit. If
therapy is to be successful, it will be necessary to
enhance the client’s smoking cessation self-
efficacy. The therapist teaches the client self-
monitoring procedures, PMR, and strategies for
coping with uncomfortable feelings associated
with nicotine withdrawal.
Cognitive Appraisal Theories

The essence of cognitive theory can be summarized in

one sentence that Ellis attributes to Epictetus:
“People are disturbed, not by what happens,
but by what they think of what happens.”
Skinner: Behavior is a function of its consequences.
S-R theory
Now: Behavior is a function of what organism thinks
about its consequences.
S-O-R theory
Cognitive Appraisal Theories

 Cognitive theory emphasizes the individual

organism’s processing of environmental stimuli as
the force determining his or her specific response.
Rational Emotive Behavior Therapy
REBT views humans as neither inherently good nor
inherently bad. Ellis considers humans to have the
potential for thinking both rationally and
irrationally. Humans have a strong tendency to
think in mistaken, and irrational ways and this is
the primary source of human distress.
Ellis used an A-B-C model.
“A” = the “activating event” that has occurred in an
individual’s life;
“B” = the individual’s belief about the activating
event;
“C” = the consequent emotion and behavior linked to
the belief.
Rational Emotive Behavior
Therapy
Cem’s Activating Event: His wife is late for
dinner.
Cem’s Belief: His wife doesn’t love or respect
him any more. She’s probably having an
affair.
Cem’s Consequent Feelings: Anger, sadness,
hurt, resentment, and jealousy;
and Behavior: yelling and accusing her of
having an affair.
Rational Emotive Behavior
Therapy

Ellis refers to this sort of belief as an irrational belief=iB.

The purpose of REBT is to help substitute a rational
belief = rB for a current iB, which will result in more
positive and more comfortable new feeling =F
Rational Emotive Behavior
Therapy
The main purpose of confronting is to dispute (D)
the irrational belief. “Is it true that your wife must
always be home right on time to prove her love for
you?”

Ellis’s dispute of Cem’s irrational belief will have an

emotional effect (E) on Cem. This effect will be
the development of a set of alternative, rational
more effective beliefs. If therapy is successful,
Cem will experience a new feeling (F).
Rational Emotive Behavior
Therapy
 The ABCDEF Cognitive Model (Ellis)
– A = Activating event
– B = Belief about the activating event
– C = Consequent emotion and behavior linked to
the belief
– D = Disputation of irrational belief
– E = Effect
– F = Feeling
Beck’s Cognitive Theory

The theoretical principles of Beck’s cognitive

therapy are similar to Ellis’s REBT.
Similarities:
1.Cognition is at the core of human suffering.

2. The therapist’s job is to help clients modify

distress-producing thoughts.

Beck criticizes Ellis’s use of the term

irrational.
Beck’s Cognitive Theory

 Components of Beck’s cognitive theory:

– Development of inaccurate/negative beliefs.
– Self-schema
– People develop systematically distorted
irrational thoughts.
– This results in biased information processing
cognitive content consistent with specific
mental disorders.
– Modification is possible via cognitive therapy.
Beck’s theory includes the following
characteristics:
1. In the process of living, individuals are exposed to
a variety of life events, some of which trigger
automatic, maladaptive thoughts.
2. These maladaptive thoughts are characterized by
their faultiness; they are too narrow, too broad, too
extreme, or simply inaccurate.
3. An individual’s maladaptive thoughts are usually
derived from deeply held maladaptive core beliefs
(=schemas or dysfunctional attitudes).
4. Individuals acquire these core beliefs during
childhood.
5. These automatic thoughts, core beliefs, and their
associated emotional disturbances, can be
modified via cognitive therapy, the procedure does
not require exploration of a client’s past.
 According to Beck, cognitions are based on
attitudes or schemas, developed from
previous experiences. If a person interprets
all his experiences in terms of whether he is
competent and adequate, his thinking may
be dominated by the schema, “Unless I do
everything perfectly, I’m a failure.”
Consequently, he reacts to situations in
terms of adequacy even when they are
unrelated to whether or not he is personally
competent.
Beck’s Cognitive Theory

Beck’s core beliefs = Adler’s life style

Beck’s automatic thoughts = Adler’s basic

mistakes.
Beck’s Cognitive Theory
Beck uses a different procedure for modifying clients
thoughts. Cognitive therapists use collaborative
empiricism to help clients discover inaccurate or
maladaptive thoughts.

Collaborative empiricism emphasizes:

joint work of client and therapist,
Socratic questioning and
different techniques.

This approach requires the therapist to work within the

client’s frame of reference, trying to see the world through
the client’s eyes.
In the Socratic questioning, therapists ask
questions that help clients focus on (1)
awareness of automatic thoughts and core
beliefs, (2) evaluation of the usefulness and
accuracy of automatic thoughts and core
beliefs, and (3) possible strategies for
modifying automatic thoughts and core
beliefs.
Meichenbaum and Self-Instructional
Theory

Meichenbaum’s self-instructional model is based on

internal speech or verbal mediation. His model is
reciprocal: interactive relationship between the
individual and the environment.
Preparation: Inner speech that occurs before the
stressful event
Coping: Inner speech that occurs during the stressful
event
Aftermath: Inner speech that occurs after the stressful
event
Theory of Psychopathology

In REBT, psychopathology is a direct function of

irrational beliefs. Ellis’s theory of
psychopathology is consistent with Horney’s
“tyranny of the shoulds.”

The REBT approach to psychopathology is direct,

straightforward, and sometimes offensive.
Ellis had a list of 12 basic irrational beliefs
that cause emotional suffering. He later
added a 13th, other REBT writers have
added additional irrational beliefs. Ellis
decided that all irrational beliefs could be
boiled down to the three very basic beliefs:
1. “I must do well and be approved by
significant others, and if I don’t do as well
as I should or must, there’s something really
rotten about me.” That irrational belief
leads to feelings of depr, anxiety, despair
and self-doubting. It’s an ego must.
2.“You other humans with whom I relate, my
original family, my later family, my friends,
my relatives, and people with whom I work,
must, ought, and should treat me
considerately and even specially.” That’s
anger, that’s rage, that’s homicide, that’s
genocide.
3.“Conditions under which I live, my
environment, social, economic or political
conditions, must be arranged so that I easily
and immediately have a free lunch, get what
I command. Isn’t it horrible when those
conditions are harsh and when they frustrate
me? I can’t stand it! I can’t be happy at all
under those awful conditions and I can only
be miserable or kill myself!” That’s low
frustration tolerance.
Theory of Psychopathology

Beck’s theory of psychopathology is similar to

REBT. Ellis focused on three basic irrational
beliefs, Beck emphasizes the client’s cognitive
distortions or faulty assumptions and
misconceptions. These distortions, triggered by
external events produce automatic thoughts,
which are linked to underlying core beliefs or
schemas. Beck has described several different
types of cognitive distortions. In his work, Beck
listed seven.
Cognitive distortions:
Personalization (self-referencing),
Dichotomous or Polarized Thinking,
Labeling and Mislabeling,
Magnification and Minimization,
Overgeneralization,
Mind Reading.
Cognitive triad
Beck theorized that specific automatic thoughts and
core beliefs were indicative of specific mental
disorders. As a consequence of his research on
depr, he concluded that a particular cognitive triad
characterizes depressive conditions. Beck’s
cognitive triad consists of
• Negative evaluation of self:
• Negative evaluation of the world or events:
• Negative evaluation of the future:
THE PRACTICE OF CBT

1. Access clients’ irrational or maladaptive

thoughts.

2. Instruct clients in more adaptive or more

rational thinking.

3. Support clients as they apply these new and

developing skills in their lives.
Cognitive therapy requires extensive training
and supervision to achieve competence.

CBT begins with initial contact between

therapist and client. During this contact
terapists focus on developing the therapeutic
relationship and on educating clients about
CBT.
Assessment Issues and Procedures

Primary goals:

1.Diagnosing that best describes client

symptoms.

2.Developing a formulation that can be used

for treatment.
 Cognitive therapists use a wide variety of
assessment strategies:
– Collaborative Interviewing
– Setting an Agenda
– The problem List
– Self-Rating Scales
– Cognitive-Behavioral Self-Monitoring
– Case Formulation
Collaborative Interviewing

In opposite to other theories, some

CBtherapists consider the therapeutic
relationship secondary. CBT focuses on
remediation the problems and existing research
on whether the alliance contributes to positive
outcome is mixed.
Collaborative Interviewing

CBT emphasizes collaboration. The therapist

is not the expert on whom all therapy success
depends. The client and therapist join together
and use collaborative empricism to guide
assessment and treatment.
Setting an Agenda

CBT is agenda-driven. To set an agenda in the

first few minutes of every session is crucial.
The Problem List
The major task is to set a clear and detailed problem list.
Operational definition: simple, concrete and descriptive.
Benefits of generating a problem list:
1.It gives therapists a chance to show interest in client
problems.
2.Antecedents and consequences are identified and
initial hypothesis about client’s core beliefs can be
generated.
3.As therapists use Socratic questioning, clients become
oriented to CBT.
Examples of questions to explore client problems:
• What was going through your mind just before you
started to feel this way?
• What does this say about you?
• What does this mean about you . . . your life . . .
your future?
• What are you afraid might happen?
• What is the worst thing that could happen if this
were true?
• What does this mean about the other person(s) or
people in general?
• Do you have images or memories in this situation?
If so, what are they?
Self-Rating Scales

At the beginning of therapy and throughout

the therapy process, CB therapists use of
self-rating scales.
Beck Depression Inventory (BDI)
Beck Anxiety Inventory
Beck Hopelessness Inventory
Penn State Worry Questionaire
Cognitive-Behavioral Self-Monitoring

It is important to teach clients to pay attention to

their automatic thoughts. Cognitive self-
monitoring is effective to help clients increase
awareness of automatic thoughts, emotions and
behaviors.

“Thought Record.” To use a Thought Record,

clients are instructed to jot down the basic
information immediately after experiencing a
strong emotional response:
Cognitive-Behavioral Self-Monitoring

(1) date and time of the emotional response,

(2) situation that elicited the emotional
response,
(3) behaviors the client engaged in,
(4) emotions that were elicited,
(5) associated thoughts that occurred during
the situation,
(6) any other related responses.
Thought Record Sample
Situation Emotion Automatic Cognitive Rational Outcome/ New
Thoughts Distortion Response Feeling

Briefly describe Specify and State the Classify the Replace the Rate the feelings
the situation rate the emotion automatic cognitive automatic again
linked (Sad, thought that distortion thought with to see if the
to the unpleasant Anxious, accompanied present a more rational rational response
feelings. Angry) on a the within (or modified them.
0-100 scale. emotion. the automatic adaptive)
thought. response.

Home alone Sad: 85 “I’m always Dichotomous Being home Sad: 45

on Saturday alone. No thinking on Saturday
night one will ever and night is better
love me. No catastrophizing than being
one will ever with
want to be someone I
with me.” don’t like.
Just because
I’m not in a
relationship
now doesn’t
mean I’ll
never be in
one.
Case Formulation
 Case formulation is a bridge from assessment
to treatment. It helps clinicians develop a
treatment plan.
 Four elements:
1. Creating the problem list.
2. Identifiying mechanisms underlying the problems.
3. Identifiying precipitants activating current
problems.
4. Consideration of the origins of the client’s current
problems. ???
Psychoeducation

CB therapists educate clients about

psychological (CBT) rationale, problems and
procedures. Educating clients is not as a
lecture. CB therapists prefer using stories,
demonstrations and life examples.

«Bump in the night»: about how cognition

influence emotion.
Methods for Exploring and Identifying
Automatic Thoughts and Core Beliefs

• CBT work often focuses on helping

clients develop an awareness of their
automatic thoughts and core beliefs.

• Many techniques exist for helping

clients become more tuned in to their
cognitions.
Methods for Exploring and Identifying
Automatic Thoughts and Core Beliefs
• Guessing the Thought: therapists take a guess at
the underlying thought.

• the Downward Arrow

• To uncover underlying core beliefs.
• Chasing cognitive distortions: Beck identified 7
cognitive distortions.
• Conducting a cost-benefit analysis (to mind reading)
• Applying the double standard technique (to dichotomous
thinking)
Specific Therapy Techniques

 The following techniques come from Ellis

and Meichenbaum.
Vigorous and Forceful Disputing
A Favorite Technique from Albert Ellis
This technique stems from Ellis’s view that an individual can
begin to lightly adopt a rational belief (e.g., “I want people
to like me, but I can live happily if they don’t”) while at
the same time strongly holding onto an opposing irrational
belief with more intensity (e.g., “But I really absolutely
need their approval and have nothing to live for if I don’t
get it!”).
Ellis’s homework assignment essentially amounts to repeated
practice at more and more forceful cognitive disputing
procedures. If clients can build a forceful and rational
counterattack against their irrational beliefs, they’ll be able
to minimize and hopefully eliminate their irrational
thinking.
Stress inoculation training
 Meichenbaum uses it for a variety of clinical
problems.
 SIT includes three phases:
 Conceptualization: a collaborative relationship,
Socratic questioning, educate about stress.
 Skills acquisition and rehearsal: specific skills are
taught, practiced in office and in vivo.
 Application and follow-through.
Thinking in Shades of Gray

This technique is derived from Burns. It

involves taking automatic thoughts,
assumptions, or conclusions about a
specific performance and placing them on a
concrete, measurable scale.
«Black-white» rating scale: 96-100 complete
success, below 95 complete failure

«Shades of gray» rating scale: 96-100

complete success, 85-95 partial success, 75-
84 marginally acceptable, 0-74 complete
failure
Cultural and Gender Considerations
 CBT focuses on symptoms as manifest within
individuals. This position is often considered
culture and gender blind.

 For most cognitive-behavioral therapists,

culture and gender are not primary
significance.
Evidence-Based Status
 There are two main lists published that
catagorize psychological treatments as either
(a) well established, (b) probably efficacious,
or (c) possibly efficacious.
 One list focuses on treatments for adults, and
the other list focuses on treatments for
children and adolescents.
 CBT approaches dominate both of these lists.
Evidence-Based Status
 CBT is well-suited to the modernist
research paradigm.

 Some CBT practitioners emphasize that a

positive therapy relationship is essential.
Concluding Comments
 There’s little doubt about the efficacy of CBT.

 Philosophically and empirically, it is a logical

and effective form of treatment for many
disorders.

 It’s possible that new approaches to

counseling and psychotherapy might even be
more effective than CBT.