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  #11  
Unread April 18th, 2005, 09:15 PM
James Pretzer James Pretzer is offline
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Default Changing dysfunctional cognitions vs changing the relationship to the cognitions

Good point. I like Hayes' idea that we need to help clients change their relationship to their dysfunctional thoughts and I agree that this has been implicit in Beckian CT. Perhaps if we look at it more explicitly we'll find more effective ways to doing this.

However, my understanding is that Hayes argues emphatically that we should not try to challenge the content of dysfunctional cognitions, just focus on changing their relationship to the cognitions. I must admit that I don't quite understand his reasoning on this point. Does anyony understand why he's convinced that we shouldn't try to change dysfunctional cognitions?
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  #12  
Unread December 7th, 2005, 02:26 PM
dieter (ClinPsych) dieter (ClinPsych) is offline
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Default Re: Is it important to change the client's dysfunctional cognitions?

My understanding of the ACT rationale is that even trying to change dysfunctional cognitions will dignify them in an undue way and reinforce "cognitive fusion" (i.e. taking thoughts/memories/images as literal truth). The whole thrust of ACT interventions is on undermining the client's "enmeshment" with his/her own thoughts and cognitive restructuring, therefore, is regarded as counterproductive.
Also, cognitive restructuring work, implicitly or explicitly, "colludes" with the client's control agenda (here: control of content of thought in order to control content/topography of emotional experience and associated behaviour) while ACT is focused on finding ways to "get on with life in a direction that is determined by the client's personal values" in the continued presence of aversive private experiences (i.e. thoughts, affect/mood, body sensations). In other words, in ACT the client's agenda of : "In order to lead the life I want to lead I will have to change my feelings/body sensations through changing my thoughts first" is sought to be replaced by the new agenda: "I will put my energy into actively trying to lead the life I want to lead while accepting that certain private experiences (cognitions,affect/mood/body sensations) may or may not be present.

In yet other words: Much like in DBT (opposite action principle) the idea is
1.that affect/mood/cognitive states will change if behaviour changes
2.the long-term satisfaction/dissatisfaction with life does depend more on one's actions than on cognitive content
3. trying to control private experiences (and cognitions in particular) is likely to produce paradoxical negative effects and leads to a rather maladaptive (ego-centric) fixation with these experiences at the expense of participating in one's actual life/context/environment
4. Therefore radical acceptance (achieved through building of mindfulness skills and cognitive defusion exercises rather than disputation and intellectual discussion) is more likely to produce a "fading" effect and flexibility in handling one's private experiences

In my personal practise I sometimes use cognitive restructuing techniques in order to "prime" mindfulness/acceptance work as it sometimes helps clients to just consider the possibility that their cognitions are not "made" of the same "stuff" as their actual/physical context.

(Sorry, that this reply took many months to be written)
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  #13  
Unread December 12th, 2005, 09:55 PM
James Pretzer James Pretzer is offline
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Default Re: Is it important to change the client's dysfunctional cognitions?

I think ACT (and DBT) makes some good points and raises some important issues. However, I have some problems with the way in which the differences between CT and ACT are discussed by some ACTers. On several occasions when I've heard Steve Hayes speak, his comments have been framed as though (1) it is obvious that CT consists only of cognitive restructuring, (2) cognitive restructuring doesn't work, (3) therefore CT doesn't work and we should abandon it. In a recent (and very lively) debate on the Academy of Cognitive Therapy listserv, Steve made the point that we should draw a distinction between the principles of ACT and his presentation style. It may be that some of the apparent contradictions between ACT and CT are due to Steve's communication style rather than to inherent contradictions between the two approaches.

I'd argue that cognitive restructuring can reinforce cognitive fusion and collude with the client's control agenda, but that it need not do so. In fact, it seems to me that cognitive restructuring implicitly draws a distinction between the thinker and the thought and explicitly questions whether the client's thoughts/memories/images are "true". It may well be that "rational responses" may be contraindicated when the client is trying to use them to control internal experience. Certainly I wouldn't agree to an agenda of "In order to lead the life I want to lead I will have to change my feelings/body sensations through changing my thoughts first." At most, I might investigate whether helping the client change his or her thoughts is a useful way to help them achieve their goals.

If ACT's agenda is "I will put my energy into actively trying to lead the life I want to lead while accepting that certain private experiences (cognitions,affect/mood/body sensations) may or may not be present", then it has the same agenda that I have with most of my clients. I spend a lot of my time working to get clients to go ahead and do what makes sense despite aversive thoughts, feelings, or physical sensations. It's not that I've abandoned CT, it's that CT never said that humans should eliminate all unpleasant thoughts, feelings, or sensations and never said that one should control all internal experience by changing one's thoughts (or in any other way).

At the recent ABCT convention, Steve complained that CT is a "moving target" i.e. whenever he thinks that he has identified something unique about ACT, Cognitive therapists say "Oh, we do that too." Well, from what I've heard, it sounds as though Steve has had a very narrow view of CT and hasn't grasped the breadth of CT interventions. He's focused on radical acceptance more intensely than most of us have, but actually CT's been using acceptance-based interventions for a long time. He's emphasized values more than we have, but it's not as though values are something new that we never thought of before.

There may be some very useful things CT can learn from ACT but I doubt that we'll need to abandon CT.
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  #14  
Unread January 12th, 2006, 06:39 PM
alexandra_k alexandra_k is offline
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Default Re: Is it important to change the client's dysfunctional cognitions?

Lol! What’s in a name? You can say that ‘cognitive therapy’ is in contrast to ‘behaviour therapy’ and then the behaviourists can talk about how distressing emotional responses can result from conditioning without cognition, and the cognitivists can cite studies where changing cognition results in a change in distressing emotional state. Or you can say that ‘cognitive behaviour therapy’ takes the insights from both. If you want to know what is distinctive about cognitive therapy (as opposed to other varieties of therapy) then I would have thought the focus on changing the clients cognitions was the most salient feature. And ACT’s focus on acceptance is what is distinctive about that. But in practice… Wise to be a little eclectic I would have thought.

The ‘disputation’ vs ‘socratic’ approach is interesting to me. I agree with JustBen’s point that terms are bandied about without their meanings being made clear. While we shouldn’t hold off using the terms until necessary and sufficient conditions are forthcoming it would help matters somewhat if people could gesture towards what they mean by those terms and also provide some concrete examples of differences in the approaches thus going someway towards operationalising them. I mean… Is it that ‘disputation’ tends to me met with resistence while ‘collaborative empiricism’ tends to result in the client being happily engaged? If this is the difference then I’m sure everyone would agree that ‘collaborative empiricism’ is preferable (and is ultimately likely to be more productive) than ‘disputation’. It is an interesting point that Socrates was made to drink Hemlock because people felt upset in response to his method of questioning…

How do you feel when I tell you that you have lots of irrational thoughts? How about maladaptive thoughts? How about thought distortions? Perhaps… It is the labelling of the clients thoughts as ‘irrational’, ‘maladaptive’, and / or ‘distorted’ that functions to get the client on the back foot resisting the therapists attempt to change them. Is it thought that you need to ‘unsettle’ the client before they will be prepared to work towards change?

The trouble with truth… Is you have to clarify what you mean by truth. Truth might be correspondence with reality, truth might be coherence with the clients web of beliefs, truth might be what is useful (pragmatic). The sad fact is that the rationality that people exhibit in general is far from ideal. All of us are prone to a variety of ‘irrational’, ‘maladaptive’, and / or ‘distorted’ thoughts. Yet not all of these thoughts are the focus of therapy (not should they be). Rather… It is a certain subset of the clients thoughts that are targeted by the therapist and these thoughts do not seem to be inherently more ‘irrational’, ‘maladaptive’, and / or ‘distorted’ than countless other thoughts that we exhibit in our daily lives that are not considered problematic. Hence… It would seem to me that cognitive resturucturing is less about ‘truth’ than it is about how unhelpful the therapist judges some of the clients thoughts to be. And perhaps the Socratic approach… Involves questioning so that the client can figure out for themselves what thoughts are unhelpful to them rather than being provided with a list of thoughts that the therapist has already decided are targets for change.

>… Hayes argues emphatically that we should not try to challenge the content of dysfunctional cognitions, just focus on changing their relationship to the cognitions.

I don’t think… We choose what thoughts will pop into our heads. If I direct you ‘don’t think about oranges’ then you will find yourself thinking about oranges in order to understand what I’m asking you to do (it is an ironic process). I wouldn’t have thought that cognitive restructuring would mean that those thoughts just don’t present in the clients conscious experience anymore. If anything, cognitive resturucturing might be more likely to have them recur to the client. What it seems to aim to do, however, is to reduce the ‘assent’ that the client feels when the thought occurs to them. We think a lot of things that we do not believe. At least… I do.

But my guess would be… It is coming up with the more helpful alternative thoughts… Alternative thoughts that the client may be able to bring themselves to believe that would be the most profitable. But judging the utility of thoughts / beliefs… Perhaps the thought is to emphasise that the client needs to be the judge of that...
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  #15  
Unread February 27th, 2006, 03:01 AM
Michael Vurek
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Default Re: Is it important to change the client's dysfunctional cognitions?

As a recent explorer of ACT and a long-time fairly traditional CBT therapist I follow this discussion with delight. I have always found mindfulness and acceptance practices in cognitive restructuring, and now I think I can still see cognitive restructuring in ACT. What is currently interesting to observe is my own shifting between guided exploration and broadening of a client's thoughts or beliefs, and guided practice of "acceptance technologies" depending on what's happening in the context of the session or course of treatment. From my CBT training I try to keep an eye on our collaborative conceptualization, and from recent undertandings of DBT and ACT I watch for my own experiential avoidances.

Please excuse the length of the following. It is an outline I recently did for myself in preparation for training in some basic CBT skills.

Doing thought records, in any of a variety of forms, facilitates and is facilitated by mindfulness. We can learn how to observe, describe and write down automatic thoughts, without judgment, and just noticing with curiosity how they are linked to states of mind.

For “facts that support the hot thought” I tend to use the language “what is true” or “what I need to accept”. The point is the same, I believe: to state in objective, factual terms what grains of truth reside in the hot thought. There is more opportunity to practice when we shift "emotional mind" thoughts back up to the automatic thoughts section. It can also be interesting to discern the difference between the emotions associated with these facts, and the ones associated with the hot thoughts - often sadness instead of hopelessness; disappointment instead of anger; etc.

For “facts that don’t support the hot thought” I tend to use the language “what else is true” or “what data lies outside the emotional mind view of the situation”. I emphasize that the practice is designed to “broaden” our view, not necessarily “correct” it. The balanced thought becomes what is true, and what is also true.

The thought record becomes another skill, built of several sub-skills, which the client can take or leave, once they have some sense of it.

Continuums are a parallel tool, giving clients the opportunity to validate the energy associated with the emotion and hot thought, which is the gap between how we want things to be and how they are. We also identify the more complex and variable nature of how things are when we look objectively, rather than via the absolute nature of hot thoughts or rigid beliefs associated with negative states of mind.

I enjoy the natural progression into action plans and experiments. Action plans speak to conditions and behaviors that are associated with the “true” side of thought records or continuums. When our actions or the conditions of our lives are inconsistent with our values, we seek to make changes. It helps to have structure to guide those changes, and a means for predicting the predictable problems that will arise in the process.

Experiments seem to emerge from balanced thoughts (that are logical/reasonable, but not credible) and identified values or aspirations. Values and aspirations emerge from lines of constructive Socratic questioning. Predictions are often about the pain that is naturally inherent in the new behavior – pain that may have been greatly intensified by years of “experiential avoidance”. Beliefs become mile-markers. We can observe how they shift, or gain/lose credibility, over the time of experimentation.

I’m exploring the clinical value of working with core beliefs and schemas. I know that I am interested and curious about them, and encouraging that curiosity can be helpful to clients. There are various “teaching points” regarding observable habits of mind, specifically its propensity to create short-cuts for understanding experiences. We can learn how these short-cuts are 1) conditioned by events and our response to those events; and 2) become “facts” that subsequently influence/distort future responses to unique and new experiences. There is also the very moving experience of clients contacting their schemas with kindness and compassion. It seems to evoke a rich sadness, and may lead to extending kind and compassionate curiosity about other contents and habits of mind.
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  #16  
Unread April 4th, 2011, 12:57 PM
James Pretzer James Pretzer is offline
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Default Despite theoretical debates, sometimes cognitive changes have major benefits

A recently-published study examined the role of cognitive change (change in catastrophic misinterpretations of bodily sensations) in the treatment of panic disorder. Participants were 43 adults diagnosed with panic disorder who received 12 weeks of panic control treatment (a CBT approach developed by Barlow and colleagues). Researchers assessed panic disorder severity weekly and assessed catastrophic misinterpretations, agoraphobia, and peak anxiety prior to sessions 1, 3, 6, 9, and 12. They found that change in catastrophic misinterpretations was associated with later reduction in overall symptom severity, frequency of panic attacks, distress and apprehension, and avoidance. The researchers note that their results showed better outcomes when cognitive change preceded symptomatic improvement.

This, of course does not suggest that a purely cognitive approach to treating panic disorder would be a good idea. First, behavioral experiments can be an important part of achieving cognitive change. Second, if you achieve cognitive change and don't follow up with in-vivo exposure to avoided situations and avoided sensations, you aren't likely to achieve lasting improvement. However, it does provide fairly clear evidence that achieving cognitive change can be an important part of effective treatment.
Teachman, B. A., Marker, C. D., & Clerker, E. M. (2010) Catastrophic misinterpretations as a predictor of symptomatic change during treatment for panic disorder. Journal of Clinical and Consulting Psychology, 78, 964-973.
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  #17  
Unread May 22nd, 2011, 04:40 AM
Fionnula MacLiam Fionnula MacLiam is offline
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Default Re: Is it important to change the client's dysfunctional cognitions?

I'm surprised that Longmore & Worrell's paper hasn't come up in this discussion:

Longmore & Worrell, 2007, Do we need to challenge thoughts in CBT?, Clinical Psychology Review, 27, 173-187

available at http://www.actmindfully.com.au/upima...hts_in_CBT.pdf

(Although, I thought Behavioural Experiments are specifically designed to test thoughts & beliefs, as they don't generally fulfill criteria for exposure.)
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  #18  
Unread June 9th, 2011, 01:35 PM
James Pretzer James Pretzer is offline
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Default Re: Is it important to change the client's dysfunctional cognitions?

The Longmore & Worrell (2007) article is a good one. Thanks for calling it to our attention. I'd encourage anyone interested in this topic to take a look at it. I'd also encourage them to think for themselves when considering the conclusions that Longmore and Worrell draw.

Both the title of the article and the opening line of their Conclusion focus on the question "do we need to challenge thoughts in CBT?" and specifically, do we need to use "logical, rationalist methods" to challenge dysfunctional thoughts and beliefs? This is a legitimate question to ask, but does anyone argue that CBT must must challenge dysfunctional thoughts or that we must use "logico-rational" strategies in doing so?

I can think of quite a few authors who argue that it is useful for therapists to directly challenge dysfunctional thoughts and beliefs and who argue that the strategies that Longmore & Worrell categorize as "logico-rational" can be a useful way of doing so but I can't think of anyone who argues that use of these strategies is necessary for CBT to be effective or that use of these strategies is sufficient for CBT to be effective.

This is an important point. Quite a few studies (many of which are summarized by Longmore and Worrell) show that behavioral interventions, cognitive interventions, and a combination of cognitive and behavioral interventions are equally effective in treating a number of different problems. If anyone was saying that cognitive interventions are more effective that behavioral interventions or if anyone was saying that cognitive interventions are necessary for treatment to be effective, the data would show that they are wrong. However, I'm not aware of anyone who takes that position.

CBT is distinguished by a variety of intervention techniques for altering dysfunctional cognitions. Some of these techniques rely on logical analysis (such as examining the evidence for and against a thought or identifying cognitive distortions) and some of them are behavioral in nature (such as behavioral experiments or in-vivo exposure). CBT also uses many interventions that are shared by other therapeutic approaches. Many who have criticized CBT talk as though we assume that "logico-rational" interventions are necessary and/or sufficient for treatment to be effective. However, that is not our view. We argue that specific "logico-rational" interventions often are useful, but that is quite different from arguing that they are necessary, sufficient, or superior to other interventions.

Cognitive Therapy's stance is that with most problems we need to use both cognitive and behavioral interventions. With moderate to severe depression we advocate using behavioral interventions first (increasing activity and involvement in potentially reinforcing activities), then using a combination of "logico-rational" and behavioral interventions to modify dysfunctional cognitions and dysfunctional interpersonal behavior. With phobias, we advocate addressing fears cognitively, through teaching skills for coping with anxiety, and through in-vivo exposure. The same applies with many other problems. The available research shows that cognitive interventions are no more and no less effective than behavioral interventions. Some of the art in CBT lies in choosing which interventions to use with a given client as well as when and how to use them.

Do we need to challenge thoughts in cognitive behavior therapy? No, we don't need to. However, the empirical evidence shows that, in general, cognitive and behavioral interventions are equally effective with a number of problems and clinical experience shows that cognitive and behavioral interventions work well together.
Longmore, R. J. & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy?, Clinical Psychology Review, 27, pp.173-187.
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  #19  
Unread July 26th, 2011, 10:04 AM
James Pretzer James Pretzer is offline
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Default Do rational responses and behavioral experiements have different effects?

It has been argued that different CBT interventions operate through different mechanisms of change. For example:

Bennet-Levy, J. (2003). Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments, Behavioural and Cognitive Psychotherapy, 2003, 31, 261
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