1. Copyright © 2014. F.A. Davis Company Cognitive Therapy Chapter 19

2. Copyright © 2014. F.A. Davis Company Introduction The foundation on which cognitive therapy is established can be identified by the statement, “Men are disturbed not by things but by the views which they take of them.” Epictetus, 125 AD

3. Copyright © 2014. F.A. Davis Company Historical Background Cognitive therapy has its roots in the early 1960s research on depression conducted by Aaron Beck. Beck’s concepts have been expanded to include active, direct dialogues with clients and behavioral techniques such as reinforcement and modeling.

4. Copyright © 2014. F.A. Davis Company Lazarus’s and Folkman’s concept of personal appraisal of an event by an individual has also contributed to the cognitive therapy approach. Cognitive therapy is aimed at modifying distorted cognitions about a situation. Historical Background (cont.)

5. Copyright © 2014. F.A. Davis Company Indications for Cognitive Therapy Depression Panic disorder Generalized anxiety disorder Social phobia Obsessive-compulsive disorder Posttraumatic stress disorder Eating disorders Substance use disorders Personality disorders Schizophrenia Couple’s problems Bipolar disorder Illness anxiety disorder Somatic symptom disorder

6. Copyright © 2014. F.A. Davis Company Goals and Principles of Therapy The goal of cognitive therapy is for clients to learn to identify and alter the dysfunctional beliefs that predispose them to distort experiences. Cognitive therapy is highly structured and short-term, lasting 12 to 16 weeks.

7. Copyright © 2014. F.A. Davis Company Cognitive Therapy Is based on an ever-evolving formulation of the client and his or her problems in cognitive terms Requires a sound therapeutic alliance Emphasizes collaboration and active participation Is goal oriented and problem focused Initially emphasizes the present Goals and Principles of Therapy (cont.)

8. Copyright © 2014. F.A. Davis Company Cognitive Therapy (cont.) Is educative, aims to teach clients to be their own therapist, and emphasizes relapse prevention Aims to be time limited Uses structured therapy sessions Teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs Uses a variety of techniques to change thinking, mood, and behavior Goals and Principles of Therapy (cont.)

9. Copyright © 2014. F.A. Davis Company Basic Concepts “The general thrust of cognitive therapy is that emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues.” Wright, Beck, and Thase, 2008

10. Copyright © 2014. F.A. Davis Company Automatic thoughts are thoughts that occur rapidly in response to a situation and without rational analysis; sometimes called cognitive errors Some examples are: – Arbitrary inference – Overgeneralization – Dichotomous thinking – Selective abstraction – Magnification – Minimization – Catastrophic thinking – Personalization Basic Concepts (cont.)

11. Copyright © 2014. F.A. Davis Company 1.A client diagnosed with severe depression states, “When I wasn’t invited to my niece’s wedding, it was obvious that the in-laws did not think I was good enough to be included.” The nurse understands that this automatic thought is an example of which common cognitive error? A.Arbitrary inference B.Overgeneralization (absolute thinking) C.Dichotomous thinking D.Personalization Basic Concepts (cont.)

12. Copyright © 2014. F.A. Davis Company Correct answer: A – This client statement indicates the use of arbitrary inference. When arbitrary inference is used, the individual automatically comes to a conclusion about an incident without supporting facts. Basic Concepts (cont.)

13. Copyright © 2014. F.A. Davis Company Schemas (core beliefs): “ Cognitive structures that consist of the individual’s fundamental beliefs and assumptions, which develop early in life from personal experiences and identification with significant others. These concepts are reinforced by further learning experiences and, in turn, influence the formation of other beliefs, values, and attitudes.” (Beck and Weishaar, 2011) Schemas may be adaptive or maladaptive, general or specific, and positive or negative. Basic Concepts (cont.)

14. Copyright © 2014. F.A. Davis Company 2.A client states, “I just failed my college English course. I’ve never failed a class before so when my parents find out they are going to disown me. They’ll hate me and never forgive me for this.” The nurse recognizes this client’s statement as which type of automatic thought? A.Arbitrary influence B.Minimization C.Catastrophic thinking D.Personalization Basic Concepts (cont.)

15. Copyright © 2014. F.A. Davis Company Correct answer: C – Catastrophic thinking involves always thinking that the worst will occur without considering the possibility of more likely positive outcomes. By stating “…when my parents find out they are going to disown me. They’ll hate me and never forgive me for this,” the client is expressing the automatic thought of catastrophic thinking. Basic Concepts (cont.)

16. Copyright © 2014. F.A. Davis Company Techniques of Cognitive Therapy Didactic (Educational) Aspects Clients must be prepared to become their own therapist. The therapist provides information about cognitive therapy and provides assignments to reinforce learning. A full explanation about the correlation between distorted thinking and clients’ mental illness is provided.

17. Copyright © 2014. F.A. Davis Company Cognitive Techniques Recognizing Automatic Thoughts and Schemas – Socratic questioning – Imagery – Role play – Thought recording Techniques of Cognitive Therapy (cont.)

18. Copyright © 2014. F.A. Davis Company Cognitive Techniques (cont.) Modifying Automatic Thoughts and Schemas – Generating alternatives – Examining the evidence – Decatastrophizing – Reattribution – Daily recording of dysfunctional thoughts – Cognitive rehearsal Techniques of Cognitive Therapy (cont.)

19. Copyright © 2014. F.A. Davis Company 3.A nurse is using decatastrophizing techniques to help a client modify automatic thoughts and schemas. Which nursing statement could be used in this process? A.“First you must decide if this negative thought is valid.” B.“Let’s really look at that thought pattern. What evidence made you come to that conclusion?” C.“When you start to have a negative thought, start visualizing a pleasant experience.” D.“Let’s explore some other possibilities related to this thinking.” Techniques of Cognitive Therapy (cont.)

20. Copyright © 2014. F.A. Davis Company Correct answer: A – This nursing statement could be used during the technique of decatastrophizing. Decatastrophizing assists the client to examine the validity of a negative automatic thought. Even if some validity exists, the client is then encouraged to review ways to cope adaptively, moving beyond the current crisis situation. Techniques of Cognitive Therapy (cont.)

21. Copyright © 2014. F.A. Davis Company Behavioral Interventions It is believed that cognitions affect behavior and that behavior influences cognitions. The following procedures are directed toward helping the client learn more adaptive behavioral strategies that will in turn have a more positive effect on cognitions. – Activity scheduling – Graded task assignments – Behavioral rehearsal Techniques of Cognitive Therapy (cont.)

22. Copyright © 2014. F.A. Davis Company Behavioral Interventions (cont.) – Distraction – Relaxation exercises – Assertiveness training – Role modeling – Social skills training – Thought-stopping techniques Techniques of Cognitive Therapy (cont.)

23. Copyright © 2014. F.A. Davis Company Role of the Nurse Cognitive therapy techniques are within the scope of nursing practice. These concepts are often not a part of basic nursing education. It is important for nurses to understand the basic concepts of cognitive therapy as the scope of nursing practice continues to expand.