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Unread September 24th, 2004, 10:14 PM
Sharkey Sharkey is offline
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Default Re: Third Wave Behavior Therapies and CT

I think that your reply underlines some of the problems that I, as an experienced cognitive therapist, am currently grappling with. I would like to make the following points:

1. Firstly, Cognitive Therapy (CT) is defined as a psychotherapy by its emphasis on changing cognitive all the seminal publications and subsequent ones and prove me wrong on this. The fact that cognitive therapists have , from very early on, routinely integrated techniques from other approaches should not detract from this point. When this type of integration has been applied in a theoretically consistent way it has been used in the service of belief change. However ( and this criticism has been made by John Teasdale and others) very often cognitive therapists have been using interventions that simply do not make sense in terms of the cognitive model...two-chair dialogues, mindfulness meditation, and other mainly experiential interventions. When CT has not used CT techniques to target problems, like simple phobias for example, this seems to me because the theory is simply limited (not, as it appears from your argument, that CT continues to be CT even if it is BT)

2. You say that the targeting of cognitive content continues to be warranted in the treatment of depression "because it works and works well". The best of the research trials show that at least 40 per cent of recipients fail to respond to CT. Thus, our search for better treatments should not stop. To continue to emphasise the targeting of cognitive content in the treatment of depression when we now have 10-15 years of research findings suggesting that it is the cognitive process of rumination that is the main feature of depressive cognition seems to me to be irresponsible. Furthermore it raises the question as to why a therapy that seems to have been so clinically liberal in the past (even if this was theoretically incoherent in many ways) seems now to have have lost clinical flexibility when it comes to an apparently indisputable empirical finding.

Can Cognitive Therapy become a dinosaur?

Last edited by Sharkey; September 25th, 2004 at 03:02 AM.
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Unread November 11th, 2004, 06:12 PM
James Pretzer James Pretzer is offline
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Default Is CT defined by interventions designed to change cognitions? (Part 1)

Your idea of looking back to seminal works and also at subsequent ones is a good one (though my point isn't to prove you wrong). Certainly, trying to change the content of cognitions is a very important part of CT and one can build a good argument that it is a defining characteristic of CT. However, even in early publications, the emphasis was not solely on changing cognitions. In Cognitive Therapy and the Emotional Disorders, Beck (1976, pp. 214-215) wrote:
“In the broadest sense, cognitive therapy consists of all the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals. The emphasis on thinking, however, should not obscure the importance of the emotional reactions which are generally the immediate source of distress. It simply means that we get to the person’s emotions through his cognitions. By correcting erroneous beliefs, we can damp down or alter excessive, inappropriate emotional reactions.
The ‘experiential’ approach exposes the patient to experiences that are in themselves powerful enough to change misconceptions. The interactions with other people –snip- may help a person to perceive others more realistically and consequently to modify his inappropriate maladaptive responses to them. –snip- Similarly, a patient, in response to his psychotherapist’s warmth and acceptance, often modifies his stereotyped conception of authority figures. –snip- Sometimes the effectiveness of psychotherapy is implemented by motivating a patient to enter situations he had previously avoided because of his misconceptions.
The ‘behavioral’ approach encourages the development of specific forms of behavior that lead to more general changes in the way the patient views himself and the real world. Practicing techniques for dealing with people who frighten him, as in ‘assertive training,’ not only enables him to regard other people more realistically but enhances his self-confidence.”
In Cognitive Therapy of Depression (Beck, Rush, Shaw & Emery, 1979, p. 117) the chapter on behavioral techniques preceeds the one on cognitive techniques and it clearly asserted that CT includes much more than the application of cognitive techniques:
“The cognitive therapy of depression is based on the cognitive theory of depression. By working within the framework of the cognitive model, the therapist formulates his therapeutic approach according to the specific needs of a given patient at a particular time. Thus the therapist may be conducting cognitive therapy even though he is utilizing predominantly behavioral or abreactive (emotion releasing) techniques.”
This also makes it clear that if the therapist is using interventions that don't make sense in terms of the cognitive model, they aren't doing good CT. This applies if one is using a "non-cognitive" technique in a way that doesn't make sense conceptually or if one is using a cognitive technique in a way that doesn't make sense conceptually. Using thought sheets inappropriately isn't good CT. Using mindfulness training or gestalt "empty chair" techniques can be good CT if it is done in a way that makes sense conceptually.

It is important to remember that the “seminal works” were written 25 or 30 years ago and that CT has evolved a bit since then. For a contemporary statement of CT’s view, consider the following excerpts from the chapter that Dr. Beck and I wrote of the second edition of Major Theories of Personality Disorder (Clarkin & Lenzenweger, 2004):
“Cognitive Therapy is based on the proposition that much psychopathology is the result of systematic errors, biases, and distortions in perceiving and interpreting events. These cognitive factors are seen as resulting in dysfunctional responses to events which, in turn, may have consequences which serve to perpetuate the dysfunctional cognitions. Theoretically, the focus is strongly on the interaction between the individual and his or her environment rather than emphasizing either individual or situational factors in isolation (for a detailed example see Pretzer, Beck, & Newman, 1990). Individuals' interpretations of events are seen as playing a central role in many forms of psychopathology, and these interpretations are seen as being the product of the interaction between the characteristics of the individual and the nature of the events the individual encounters. However, in discussing treatment, much more emphasis is placed on individual factors (such as dysfunctional beliefs) than on situational factors (such as negative life events) because therapist and client are more able to modify individual factors than situational ones.
In considering the role of cognition in psychopathology, Cognitive Therapy uses the term "cognition" broadly to refer to much more than verbal thought of which the individual is self-consciously aware. "Cognition" is treated as synonymous with information processing and no a priori assumption is made that all important aspects of cognition are verbally mediated, are easily accessible to the individual's awareness, or are subject to the individual's volitional control. In fact, much cognition occurs outside of awareness simply because the individual is not paying attention to it. Many of the processes involved are automatic and occur without a need for awareness or volitional control. Cognition is not necessarily verbally-mediated. It can also be mediated by mental imagery or can involve more abstract modes of information processing
Also, while the Cognitive model assumes that the individual's interpretation of events shapes his or her emotional response to the situation, we also argue that the individual's emotional state has important effects on cognition. A large body of research has demonstrated that affect tends to influence both cognition and behavior in mood-congruent ways (Isen, 1984). A number of studies have demonstrated that even a mild, experimentally induced depressed mood biases perception and recall in a depression-congruent way (see Watkins, Mathews, Williamson, & Fuller, 1992). This means that a depressed mood increases the likelihood that the individual will focus on negative aspects of the situation and preferentially recall negative experiences which occurred in the past. While this phenomenon has not been investigated extensively for most other moods, it appears that many moods tend to bias perception and recall in a mood-congruent way. Thus, as an individual's level of anxiety increases, attentional processes appear to be biased in favor of signs of threat (Watkins, et al., 1992). This phenomenon lays the foundation for a potentially self-perpetuating cycle where the individual's automatic thoughts elicit a particular mood, the mood biases perception and recall in a mood-congruent way, this increases the likelihood of additional mood-eliciting automatic thoughts, which elicit more of the mood in question, which further biases perception and recall, and so on until something happens to disrupt the cycle.
It is important to notice that the Cognitive model does not assert that cognition causes psychopathology. We view cognition as an important part of the cycle through which humans perceive and respond to events and thus as having an important role in pathological responses to events. However, we view it as a part of a cycle and as a promising point for intervention, not as the cause.
The Cognitive model of psychopathology emphasizes the effects of dysfunctional automatic thoughts; dysfunctional schemas, beliefs and assumptions; and dysfunctional interpersonal behavior. Therefore, each of these are important targets for intervention in Cognitive Therapy. The initial goal of Cognitive Therapy is to break the cycle or cycles which perpetuate and amplify the client's problems (see Figure 3). This could potentially be done by modifying the client's automatic thoughts, by improving the client's mood, by working to counteract the biasing impact of mood on recall and perception, and/or by changing the client's behavior. In theory, these interventions could break the cycle or cycles which perpetuate the problems and thus could alleviate the client's immediate distress. However, if the therapist only does this, the client would be at risk for a relapse whenever he or she experienced events similar to the ones which precipitated the current problems. In order to achieve lasting results, it would also be important to modify the schemas, beliefs, and assumptions which predispose the client to his or her problems and to help him or her plan effective ways to handle situations which might precipitate a relapse.
Our view is that many dysfunctional cognitions persist because: a) many individuals are unaware of the role their thoughts play in their problems, b) the dysfunctional cognitions often seem so plausible that individuals fail to examine them critically, c) selective perception and cognitive biases often result in the individual's ignoring or discounting experiences which would otherwise conflict with the dysfunctional cognitions, d) cognitive distortions often lead to erroneous conclusions, e) the individual's dysfunctional interpersonal behavior often can produce experiences which seem to confirm dysfunctional cognitions, and f) individuals who are reluctant to tolerate aversive affect may consciously or non-consciously avoid memories, perceptions, and/or conclusions which would elicit strong emotional responses.
This view suggests that cognitive interventions should be directed towards identifying the specific dysfunctional beliefs which play a role in the individual's problems and examining them critically while correcting for the effects of selective perception, biased cognition, and cognitive distortions, and helping the individual to face and tolerate aversive affect. Logical or intellectual analysis of dysfunctional cognitions is usually not sufficient to accomplish substantive change. Individuals often find that within-session interventions can be intellectually convincing but that to be convinced "on the gut level", and to have the change in cognitions be manifested in their behavior, it is usually necessary to test the new cognitions in real-life situations. These "behavioral experiments" (see Beck, Rush, Shaw & Emery, 1979, p. 56 or Freeman, et al., 1990, pp. 76-77) are often much more convincing than any amount of intellectual insight. When dysfunctional cognitions are strongly supported by interpersonal experience, it may be necessary to accomplish changes in interpersonal behavior and/or in the individual's environment in order to challenge the cognitions effectively.
It is our view that many dysfunctional behaviors persist because: a) they are a product of persistent dysfunctional beliefs, b) expectations regarding the consequences of possible actions encourage behaviors which actually prove to be dysfunctional and/or discourage behaviors which would prove adaptive, c) the individual lacks the skills needed to engage in potentially adaptive behavior, or d) the environment reinforces dysfunctional behavior and/or punishes adaptive behavior. This view suggests that to change dysfunctional behavior it may be necessary to modify long-standing cognitions, to examine the individual's expectations regarding the consequences of his/her actions, to modify the individual's environment, or to help the individual master the cognitive or behavioral skills needed to successfully engage in more adaptive behavior.
It is interesting to note that when dysfunctional behavior is strongly maintained by dysfunctional cognitions, it may be necessary to modify the cognitions first, and that when dysfunctional cognitions are strongly maintained by the effects of dysfunctional behavior, it may be necessary to modify the dysfunctional behavior first. This suggests that if it is true that personality disorders are characterized by self-perpetuating cognitive-interpersonal cycles where dysfunctional cognitions strongly maintain dysfunctional behavior and dysfunctional behavior strongly maintains dysfunctional cognition, it may be difficult to find ways to intervene effectively. We argue that when a self-perpetuating cognitive-interpersonal cycle exists it may not be possible to effectively modify either cognitions or behavior in isolation and that a strategic intervention approach based on a clear conceptualization is likely to be necessary.”
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Unread November 12th, 2004, 10:35 PM
James Pretzer James Pretzer is offline
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Default Is CT defined by interventions designed to change cognitions? (Part 2)

Yes, I said that the targeting of cognitive content is warranted in the treatment of depression "because it works and works well" and I think that's a pretty good arguement. However, I don't mean to suggest that we should not continue to try to increase the effectiveness and try to find more effective approaches. A significant number of people do not benefit from CT. Some of these don't get an adequate trial of CT (i.e. they discontinue treatment prematurely) and others show little or no improvement despite an adequate trial of CT. You are completely right that our search for better treatments should not stop. If any of the "Third Wave" approaches turn out to be more effective than "standard" CT, I'll be arguing that we should either switch to those approaches or integrate them into CT.

In addition, we should do some research into the characteristics of individuals who terminate treatment prematurely or show a poor response to CT. I can remember a study or two that suggest that co-occurring Axis-II disorders may account for a substantial portion of these cases. Perhaps we're discovering that when there are co-occurring disorders (Axis-II, substance abuse, marital problems, etc.) we need to treat those problems as well rather than trying to treat the depression in isolation. (Remember that in those well-controlled outcome studies the treatment protocols focus on depression without much attention to co-morbid disorders.)

So why do I continue to emphasise the targeting of cognitive content in the treatment of depression when we have research suggesting that rumination that an important feature of depressive cognition? Because I've seen good evidence that CT based on targeting cognitive content is effective much of the time and I haven't seen good evidence that other treatment approaches are more effective. I've been keeping an eye on the "third wave approaches and will adopt them if they turn out to work better. If any studies showing that they work better have been published, I haven't seen them yet.

You suggest that my stance "raises the question as to why a therapy that seems to have been so clinically liberal in the past (even if this was theoretically incoherent in many ways) seems now to have have lost clinical flexibility when it comes to an apparently indisputable empirical finding". It sounds as though you may have misunderstood my position. I am not suggesting that CT should be inflexible or that we should only focus on changing cognitive content. I'm very much in favor of clinical flexibility and of adding new intervention techniques to CT (while remaining theoretically coherent). Personally, in addition to working to modify dysfunctional thoughts and beliefs, I also target depressive rumination, use a number of DBT techniques, use acceptance-based interventions, and am starting to use mindfulness more frequently. However, I don't buy the idea that we should abandon interventions that focus on cognitive content for some reason since those interventions are effective with many clients.
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Unread November 12th, 2004, 10:53 PM
James Pretzer James Pretzer is offline
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Default Can CT become a dinosaur?

CT certainly can become a dinosaur if we cease to learn and evolve. If new data, theoretical advances, and clinical innovation are ignored, CT will gradually become outmoded.

However, why should we cease to learn and evolve? There have been many advances since the seminal works were written nearly 30 years ago and fortunately we do not have to remain in the 1970s. All we need to do is to be open to new ideas, test them, and take the data seriously. If we do this, CT will evolve over time, retaining the features that prove effective and adopting new concepts, strategies, and techniques when they benefit our clients.
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Unread November 28th, 2004, 10:32 PM
James Pretzer James Pretzer is offline
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Default Empirical Support for "Third Wave" behavior therapy

Those who have been wondering about the empirical status of "third wave" approaches will find a recent review by Steve Hayes et al (2004) useful. Hayes and his colleagues review the empirical support for Dialectical Behavior Therapy(DBT), Acceptance and Committment Therapy (ACT), and Functional Analytic Psychotherapy (FAP) and conclude that DBT and ACT each "have a small but growing body of outcome research supporting these procedures and the theoretical mechanisms though responsible for them" while FAP "has a limited research base, but its central claim is well substantiated." The authors don't explain why they chose just these three approaches to review. A number of other "third wave" approaches have decent empirical support as well. However, it looks as though this article gives a good overview of the available evidence.

Note: My only complaint about proponents of "third wave" approaches (not Hayes et al, 2004) it that they often talk as though empirical support for "third wave" approaches somehow invalidates more established CBT & BT approaches. Obviously, the finding that these approaches work does not invalidate all the evidence that established CBT and BT approaches work well with a broad range of problems. If proponents of these approaches stuck to saying that they've come up with interesting new approaches which we all may be able to learn from, I'd have no quarrel at all. For some reason, they often seem compelled to argue that evidence of the effectiveness of their approaches somehow proves that all other approaches are wrong, or at least hopelessly outmoded.
Hayes, S. C., Masuda, A, Bissett, R., Luoma, J. & Guerro, L. F. (2004). DBT, FAP, and ACT: How empirically oriented are the new behavior therapy technologies? Behavior Therapy, 35, 35-54.
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