Chapter 5 Cognitive Behavioral Therapy Integration

Chapter 5 Cognitive Behavioral Therapy Integration

The History Of Psychotherapy Is One Of Conflict And Change.

-Early history scientific findings were few and major means of discovery was individual case analysis (with personal disagreements and differences in interpretation).

-1950’s research methods were applied to psychotherapy  more objective, standard and rigorous

-Many practitioners believe true test of psychotherapy continues to rest in the logic of its theory and in the power of the clinicians persona; observations, rather than scientific findings

-In early development – disagreement between theorists and practitioners centered around what constitutes evidence of truth

-Different theoretical viewpoints and positions reached peak in 1980’s among scientists or practitioners

-Not disappeared, but more acceptance of scientific findings in contemporary practice and “evidence-based” practice has become the norm in medical and other treatment professions

-Today most psychotherapists accept (at least overtly) the value of scientific inquiry for establishing what works in tier field, but they differ widely in what they consider to be acceptable methods

-Practitioners tend to value naturalistic research designs over randomized clinical trials, n=1 studies over group designs and individualized over group measures of outcome.

-They tend to believe findings that favor the brand of psychotherapy they practice and those demonstrating that all approaches yield equivalent effects.

-Modern psychotherapists, like practitioners of the past, are often quick to reject scientific findings that disagree with their own theoretical value system

The Emergence of Eclectic and Integrationist Views

-Early days of psychotherapy theory development, once a theorist departed from mainstream views of a mentor, often treated as a Pariah (isolated)

-Often theorists did not know principles and practices of those in another theoretical school.

-Blend to alternative conceptualizations and theoretical approaches

-Since the 1980’s – field of psychotherapy has been charging in response to the emergence of integrationist and eclectic views

-Change stimulated only partially by status of scientific evidence

-Most since the development of eclectic psychotherapy as a set of coherent treatment models

-1980’s Practitioners suspicious of theory

-Over 400 different theories – conclusion that there was no single truth about psychopathology or psychotherapy

-Also, failure of scientific studies to indicate firmly any was superior

-In the last 20 years, mental health professional have made dramatic shifts in both directions and bases of their growth

-Now, changes are made in order to integrate new findings or perspectives more comprehensively to fit the treatment to the needs of the clients.

-Over the last several years, practitioners from a variety of orientations have been borrowing theories, techniques, and interventions from other approaches to enhance overall clinical efficiency

-Thorne’s eclectic psychotherapy – argued therapists’ training doomed them to a single method. Perspective not suited to varying conditions, personalities, and patients’ needs --. Left therapists poorly armed

-Goldstein and Stein (1976) suggested procedures selected should be based on scientific evidence of efficacy (drawn largely from Behavior therapy)

-4 Systematic views within the integrationist movement can be identified in contemporary psychotherapy practice:

1. Common-factors eclectism
2. Theoretical Integrationism
3. Technical eclectism
4. Strategic eclectism

-Haphazard ecleticism – unsystematic; little effort to define principles or define a replicable procedure for selecting and applying treatment; effectiveness bound to judgment and skill of particular therapist.

-Common-Factors Eclectism

• Relies on the identification pf factors that are common or similar across approaches
• It accepts the position that all effective psychotherapies rely on a common core of basic ingredients beyond which their distinctive effects are inconsequential or unpredictable
• These practitioners attempt to apply techniques or interventions that appear common in all successful treatments and propose that these techniques be applied to everyone.
• They posture scientific study
• This posture stands in contrast to the general tenet of ecletism embodying tailoring interventions to unique needs of each patient
• Common-factors therapists work to convey an accepting and non-threatening atmosphere where the patient may explore problems (like most relationship-oriented therapists).

-Theoretical Integrationism

• Attempts to amalgamate 2 or more extent theoretical viewpoints, leaving the definition of a specific techniques and procedures to the clinician.
• They see good theory as the road to good technique
• In psychotherapy, “integration” refers to harmoniously bringing together affective, cognitive, behavioral, and systems approach to psychotherapy under the roof of 1 theory and applying this theory and associated techniques to the treatment of individual, couple, or family
• Theoretical integrationism is the most theoretically abstract of the various systematic approaches

-Technical and strategic eclectism

• More clinically oriented and practical methods of applying psychotherapy
• Less abstract; more reliant on use of specific techniques, procedures, or principles.
• Attempts to define strategic (strategic eclectism) or develop menus of techniques (technical eclectism) quite independently of the theory that gave them birth.
• Neither is strongly concerned about validity of theories of personality and psychopathology
• Main focus is clinical efficacy of procedures

-Technical Eclectism – a menu of specific procedures is designed to fit a given person.

• All techniques have a finite range of applicability

-Strategic eclectism – identifies principles and goals, but leaves selection of techniques to the individual therapist.

• All assumed techniques can be used in different ways and can serve several different ends, depending on the therapist
• First and best known approach with technical eclectism is multimodal therapy by Lazarus

-Prescriptive Matching (PT) – a form of eclectism; at times resembles technical eclectism, but it also constructs principles of change. Objective is more coherent. Treatment based on comprehensive view of the patient’s presentation

-Cognitive therapy is quite amenable to eclectic principles as it relies of research findings

-Cognitive therapy postulates the presence of levels of cognition, but without extending beyond empirical observations to postulate how these levels are related treatment change

-Cognitive therapy has a tradition of emphasizing the importance of reliable observation and measurement in the assessment of the effects of treatment

-Cognitive therapy offers a reasonable platform from which one might begin a process of integration based on principles of change and the definition of strategies – a process that includes, but is not limited by, an already known array of technique interventions

Cognitive therapy- Integrative Framework

-For beginning – empirically based

-Used findings from formal research to establish its theoretical principles

-Allows flexibility of viewpoints and applications

-Cognitive therapy and Behavior therapy share commitment to scientific method and focus on ways of functioning

-Originally, Cognitive therapy was simply an integration of Cognitive and behavioral theories and techniques

-Cognitive therapy may be best defined as the application of a cognitive model of how a certain disorder is manifested and changed via a variety of techniques that focus on the dysfunctional beliefs and maladaptive information-processing systems characteristic of that disorder

-Cognitive therapy today – result of continuing evolutionary process – clinical application of this therapy, the integration of techniques characteristic of therapies other than behavioral ones often enhances overall treatment effectiveness

-Cognitive therapist may select interventions from a variety of theoretical viewpoints

Defensive processes

-Associated with psychodynamic theories

-May help patient avoid schema-related material through cognitive processes such as denial, repression of memories, depersonalization

-Emotional avoidance of painful schema-related material may take form of defensive number, dissociation or minimization of negative experiences.

-Behavioral defensive measures may take form of actual physical avoidance of situations likely to activate dysfunctional/painful schema

-In recent years, importance of sound therapeutic relations given greater emphasis

-Interpersonal processes now seen as important roads to the exploration and amelioration of dysfunctional interpersonal schemata, which typically receive their strongest developmental influence from early relationships

-Bowlby’s attachment theory has been incorporated by some cognitive treatment

-Safran and Segal (1990) indicate importance of CT to attend his/her own feelings and behaviors elicited by interactions with a patient (not referred to as counter-transference) and to avoid becoming involved in patient’s dysfunctional interpersonal cycle. They also, recommend that thoughts and feeling uncovered in this type of interaction be thoroughly explored

-Cognitive therapy approaches to treatment have been successful with a wide variety of conditions, problems, and disorders

Range of Effectiveness with Cognitive and Cognitive Behavioral Therapies

-Cognitive therapy – depression – uni-polar, major, minor, acute endogenous depression, anxiety, assertiveness, Somatic depressive symptoms, depressed and anxious mood for patients with alcoholism

-Cognitive therapy – does well in comparison to pharmacotherapy- to be at least equal and sometimes superior (for: phobias, specific fears, problems with anger and aggression, panic attacks, social skills training, personality disorders, addictive disorders)

-Making Cognitive therapy fit human complexity

-P. 157 Behavior Characteristics of patient resistance

-P. 158

-P. 159

-Resistance describes a transitory state and a trait-like quality in psychotherapy

-Thus, is a dispositional trait and an in-therapy state of oppositional behaviors (angry, irritable, suspicious behaviors)

-Involves both intrapsychic (image of self, safety and psychological integrity) and interpersonal (loss of interpersonal freedom or power imposed by another) factors.

-Therapist do their best to avoid disagreement with highly resistant patients; collaborative relationship important; Socratic questioning to be used carefully/cautiously, elicit feedback, direction and suggestions for exploration from patients

-Resistance states are a function of a particular constraints imposed by the treatment environment

-Resistance traits are manifested across situations

Internalization and Externalization

-Opposite poles on a dimension of patient’s coping styles

-Trait-like

-Externalization – such as escape or avoidance of the feared environment

-Internalization – behaviors that control internal experience (self-blame, compartmentalization, sensitization) such as anxiety.