Rehabilitation in CBT

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1. Empirically tested
2. Problem is current (no retrospection needed)
3. Clients expected to be active and do something instead of talking
4. Change takes place without insight, clients learn through acting not understanding. Understanding may be the outcome of change, not otherwise.
5. Focus is on assessing overt and covert behavior directly, identifying the problem, and evaluating change.
6. Treatment interventions are individually tailored to specific problems experienced by clients.
- conducting assessment (behavior analysis) according to the ABC model (ABC: Antecedent events -> behavior -> consequences), identifying all parts of the ABC process and providing changes within "A".
- counselor more a consultant, a teacher than a therapist
- formulates treatment goals and plans, provides environment for experiment with new behavior, evaluates the success
- use of assessment tools, follow-up assessment)
extinctionwithholding reinforcement from a previously reinforced response (e.g. parents stop paying attention when child misbehaves).Relaxation Training (usually used in combination with other techniques; for rehabilitation counseling and therapy purposes):- Schult'z relaxation training - Jacobson's relaxation training - Guided imaginarySchultz's relaxation trainingrelaxation is based on imagining gravity and warmth of particular body parts.Jacobson's relaxation trainingprogressive muscle relaxation procedure, based on tensing and relaxing particular muscles.Guided imaginaryadded to training, e.g. safe place or inner wisdom.Techniques based on classic conditioning - to be used also in behavioral therapies- exposure therapy - systematic desensitization - in vivo exposure and flooding - EMBDRExposure therapyclient is contacted with situation or stimuli that he/she finds fearful.Systematic Desensitizationdeveloped by Wolpe, a form of exposure therapy, the client imagines step by step more and more anxiety-arousing situations, when at the same time the client is engaged in a behavior that competes with anxiety (e.g. relaxation training). Time consuming: interview, preparation of the list of stimuli, anxiety hierarchy, relaxation training, home training, creation of guided imaginary that includes hierarchy of stimuli, systematic desensitization, homework and follow-ups.In Vivo Exposure- live direct exposure to fearful stimuli, step by step according to their anxiety hierarchy (needs comprehensive preparation as well). Exposure can be stopped if client experiences very strong anxiety. e.g. client with arachnophobia, remaining relaxed, is first exposed to pictures of spiders, then to movies about spiders, then a sma$ terrarium with a spider is put in the corner of the office, client sits next to terrarium, client looks at therapist holding a spider, patient sits next to therapist holding a spider, patient touches the spider, patient hold the spider.Floodingin vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time, without engaging in any anxiety-reducing behaviors - the anxiety decreases on its own. Ethical questions about this technique... - e.g. a client who fears flighting embarks on a flight together with therapist and experiences severe anxiety but fina$y also relief and finds out that nothing bad happens during flight.EMDR- Eye Movement Desensitization and Processing technique - developed by Shapiro in treatment of clients who have experienced traumatic stress (PTSD), based on imaginal flooding (the exact trauma recollection), cognitive restructuring, and the use of rapid, rhythmic eye movements and other bilateral stimulation to treat. - Controversy: it's non-conclusive whether the rapid rhythmic eye movements are a healing factor or just they just defocus the client from emotions connected with trauma. - e.g. for sexual abuse victims, combat veterans, victims of crime, rape survivors, accident victims, and individuals dealing with anxiety, panic, depression, grief, addictions, phobias.Techniques based on social learning:Social Skills training Self-ModificationSocial Skills Training- Broad category of interventions applied to correct deficits clients have in interpersonal competencies. e.g. anger management, assertiveness training.Self-Modification- cost effective learning that includes strategies like self-monitoring, self-rewarding, self-contracting, stimulus control, self-as-model. - Based on complex preparation: selecting goals, translating goals into target behaviors, self- monitoring of current behavior, working out a plan for change, evaluating an action plan. - e.g. used in case of panic attacks, children fear of the dark, anxiety in social situations, smoking cessation, depression, behavioral rehabilitation in intellectual disabilities.Behavioral techniques - Pros- used in dealing with a lot of symptoms - symptoms removal - anxiety, depression, substance abuse, eating disorders, violence, sexual dysfunctions. - expanded to different rehabilitation settings; business, education, self-development trainings, couple and family interventions.Behavioral techniques - cons- doesn't change feelings or personality - ignores the important relational factors in counseling - does not provide insight - treats symptoms rather than causes - involves control and manipulation by the counselorBehavior counseling modifications - multimodal therapycomprehensive, systematic, holistic approach to behavior counseling developed by Lazarus, grounded in social learning and cognitive theory, technical eclecticism - techniques from different approaches (based on learning)Multimodal therapy - 7 areas of functioning (in assessment and interventions):BASIC ID B = behavior A = affective responses S = sensations responses I = images, imagination of self and others C = cognitions I = interpersonal relationships D = drugs, biological functions, nutrition and exerciseBehavior counseling modifications - mindfulness- a process that involves becoming increasingly observant and aware of external and internal stimuli in the present moment and adopting an open attitude toward accepting what is rather than judging the current situation. - e.g. in stress reduction, acceptance and commitment therapy.Behavior counseling modifications - DBT - Dialectical Behavior Therapy- a paradoxical treatment that helps clients to accept their emotions as well as to change their emotional experience. Observing emotions, being consciously aware of them and finally hanging on to an experience or to getting rid of it. - e.g. in depression treatment, border-line personality disorder (combined with psychoanalysis!)Cognitive-Behavior counseling models1. Ellis - rational emotive behavior counseling 2. Beck - cognitive counseling 3. Meichenbaum - cognitive behavior counselingREBT - rational emotive behavior therapy (Ellis)- brief counseling (1-10 sessions or 1-2 day marathons) - easy to use in rehabilitation settings - the ABC framework - similar to BASIC ID - focused on cognitive functioning - irrational beliefs - mustsREBT - rational emotive behavior therapy (Ellis) - Irrational beliefs = musts- concern self expectations towards others and gaining their acceptance - expectations towards others taking accepting stance - expectations of always receiving what the one wants.REBT techniques- Cognitive techniques - Emotive techniquesREBT Techniques - Cognitive technique- disputing methods: detecting ("shoulds", "musts", "oughts"), debating irrational, discriminating irrational from rational, cognitive restructuringREBT Techqniues - Emotive techniques- rational emotive imagery (of both wanted and unwanted scenarios and associated emotions). - humor (towards oneself), role-playing, shame-attacking exercises, sue of force and vigorBeck's cognitive counseling - example of CBT use in therapeutic setting- developed in treatment for depression - depressive cognitive triad: me, world, future - active, directive therapist stance, time-limited - focuses more on cognitive functioning and attributed meanings to certain events. - identifying and working out: automatic thoughts & cognitive distortionsAutomatic thoughtspersonalized thoughts that are triggered by specific stimuli and lead to uncomfortable emotional responseCognitive distortionserrors in reasoning leading to uncomfortable emotional reactions.Cognitive distortions:- arbitrary inferences - selective abstraction - overgeneralization - magnification and minimization - personalization - labeling and mislabeling - dichotomous thinkingCognitive dissonance - Arbitrary inferencesconclusions not based on evidence, e.g. catastrophizingCognitive dissonance - Selective Abstractionconclusion based on isolated evidence, e.g. self evaluation based on failures, not including successesCognitive dissonance - Overgeneralizationextreme conclusions based on a single case, e.g. always, never, everybodyCognitive dissonance - Magnification and minimizationmore or less serious evaluation of things that they deserve, e.g. being two times late at work means being fired),Cognitive dissonance - Personalization(attributing external causes to oneself, e.g. assuming that your boss is not satisfied with your work cause he was sullen in the morning),Cognitive dissonance - Labeling and mislabelinggiving labels based on single situations, e.g. "idiot" after failing examsCognitive dissonance - Dichotomous thinkingpolarized thinking, e.g. ones viewing yourself as the best and then as the worst in the same domain.Meichenbaum's cognitive behabior modifications (cbm)- aimed at changing client's self-verbalizations (self-statements affecting one's behavior) & cognitive restructuring - becoming aware of self-talk (instructional training) - teaching clients and role-playing - more direct and confrontational than REBT and CT - possible skill trainings with direct psycho-education - possible integration with social constructivist narrative approach3 phases of CBM1) self-observation 2) starting a new internal dialogue 3) learning new skills