29 terms

Cognitive Therapy

Psychiatric & Mental Health Nursing CH 20 Key Terms, Objectives, Core Concepts
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Cognitive
Relating to the mental process of thinking and reasoning
Cognitive Therapy
Cognitive therapy is a type of psychotherapy based on the concept of pathological mental processing. The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors.

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."
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.
- 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 cognition about a situation.
Indications for Cognitive Therapy
Was originally developed for use with depression. Today it is used for a broad range of emotional disorders:

- Depression
- Panic disorder
- Generalized anxiety disorder
- Social phobia
- Obsessive-compulsive disorder
- Posttraumatic stress disorder
- Substance abuse
- Personality disorders
- Schizophrenia
- Couple's problems
- Bipolar disorder
- Hypochondriasis
- Somatoform disorder
- Eating disorders
Principles of Therapy
Cognitive therapy
- Is highly structured and short term, lasting 12 to 16 weeks
- Cognitive therapy can be used in either individual or group treatment

1. Is based on an ever-evolving formulation of the client and his or her problems in cognitive terms
2. Requires a sound therapeutic alliance
3. Emphasizes collaboration and active participation
4. Is goal oriented and problem focused
5. Initially emphasizes the present
6. Is educative, aims to teach clients to be his or her own therapist, and emphasizes relapse prevention
7. Aims to be time limited
8. Uses structured therapy sessions
9. Teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs
10. Uses a variety of techniques to change thinking, mood, and behavior
Goals 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.
1. The client learns to monitor negative, automatic thoughts
2. Recognizes the connection between thoughts, emotions, behavior
3. Examines the evidence for and against distorted automatic thoughts
4. Substitutes more realistic interpretations for the biased thoughts
5. Identifies the dysfunctional beliefs that predispose him or her to distort experiences
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, & Thase, 2003)

- Basic Concepts include automatic thoughts and schemas or core beliefs.
Automatic Thoughts
Automatic thoughts— thoughts that occur rapidly in response to a situation and without rational analysis; sometimes called cognitive errors. These thoughts are often negative and based on erroneous logic.

Some examples are:
- Arbitrary inference
- Overgeneralization
- Dichotomous thinking
- Selective abstraction
- Magnification
- Minimization
- Catastrophic thinking
- Personalization
- Mind reading
- Change fallacy
- Fairness fallacy
- Global labeling
- Blaming
- Shoulds
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 & Weishaar, 2005)

- Schemas may be adaptive or maladaptive, general or specific, and positive or negative. Generally they fall in to two broad categories: those associated with helplessness and those associated with unlovability
Techniques of Cognitive Therapy
1. Didactic (educational) aspects
2. Cognitive techniques
3. Behavioral interventions
Didactic (educational) aspects
Clients must be prepared to become their own therapist.
Therapists provide 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.
Cognitive techniques
Strategies used in cognitive therapy include recognizing and modifying automatic thoughts (cognitive errors) and recognizing and modifying schemas (core beliefs).
Recognizing automatic thoughts and schemas
- Socratic questioning
- Imagery
- Role-play
- Thought recording
Modifying automatic thoughts and schemas
- Generating alternatives
- Examining the evidence
- Decatastrophizing
- Reattribution
- Daily recording of dysfunctional thoughts
- Cognitive rehearsal
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.
1. Activity scheduling
2. Graded task assignments
3. Behavioral rehearsal
4. Distraction
5. Miscellaneous techniques
* Relaxation exercises
* Assertiveness training
* Role modeling
* Social skills training
* Thought-stopping techniques
Cognitive-Behavioral Therapy
- General term for a group of therapy approaches with similarities
- Theoretical basis combines behavioral learning theory and cognitive psychology
- Effective for individuals with mood disorders, personality disorders, eating disorders, substance abuse, and controlled psychotic symptoms
- Treatment is brief and time-limited
- CBT may be used in group or individual therapy
- Stoicism is usually emphasized - calmly accepting personal problems and resolving them
- CBT is based on the idea that our thoughts cause our feelings and behaviors
- Therapeutic techniques include: keeping a journal of significant events and feelings, testing thoughts for a rational basis, facing situations that are feared, and trying new ways of behaving and reacting
- The therapist will assign homework and the patient will be an active participant in therapy
- Subtypes of CBT: Rational Emotive Therapy, Rational Behavior Therapy, Rational Living Therapy, Dialectic Behavior Therapy
Dialectic Behavior Therapy
designed specifically to treat people with self-harm
or self-destructive behaviors

- DBT assumes that these behaviors are learned coping techniques to handle intense negative emotions
- Therapy focuses on cognitive therapy, validation or acceptance of the patient, and change techniques
- The goal is to have the patients be in control of their own behavior, building an ordinary life, experiencing emotions fully without self-harm, and moving toward connection with others
Prochaska and DiClemente - Stages of Change
Motivational Interviewing
- A client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence
- A specific behavior is targeted (smoking, weight loss)
- Motivation to change is elicited from the client
- Open-ended questions, affirmations, and reflective listening are used
- Counseling strategies include looking back at past behavior, discussion of the stages of change, assessment feedback, exploration of values, looking forward, identifying pros and cons of changing a behavior, and planning change
Role of the Nurse
- Cognitive therapy and CBT techniques are within the scope of nursing practice. Nurses often use the stages of change model and motivational interviewing in 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.
SUMMARY & KEY POINTS
Cognitive therapy is founded on the premise that how people think significantly influences their feelings and behavior
SUMMARY & KEY POINTS
The concept was initiated in the 1960's by Aaron beck in his work with depressed clients. Since that time, it has been expanded for use with a number of emotional illnesses
SUMMARY & KEY POINTS
Cognitive therapy is short-term, highly structured, and goal-oriented therapy that consists of three major components: didactic, or educational aspects; cognitive techniques; and behavioral interventions
SUMMARY & KEY POINTS
The therapist teaches the client about the relationship between his or her illness and the distorted thinking patterns. Explanation about cognitive therapy and how it works is provided.
SUMMARY & KEY POINTS
The therapist helps the client to recognize his or her negative automatic thoughts (sometimes called cognitive errors)
SUMMARY & KEY POINTS
Once these automatic thoughts have been identified, various cognitive and behavioral techniques are used to assist the client to modify the dysfunctional thinking patterns
SUMMARY & KEY POINTS
Independent homework assignments are an important part of the cognitive therapist's strategy
SUMMARY & KEY POINTS
Many of the cognitive therapy techniques are within the scope of nursing practice
SUMMARY & KEY POINTS
As the role of the psychiatric nurse continues to expand, the knowledge and skills associated with a variety of therapies will need to be broadened. Cognitive therapy is likely to be one in which nurses will become more involved.
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